transactions 
OF THE 
[nternational medical congress TRANSACTIONS 
OF THE 
international medical congress 
* N 
PHILADELPHIA. 
1876. 
EDITED FOE. THE COHG-EESS 
BY 
JOHN ASHHURST, Je., A.M., M.D., 
FELLOW OF THE COLLEGE OF PHYSICIANS OP PHILADELPHIA, PROFESSOR OF 
CLINICAL SURGERY" IN THE UNIVERSITY" OF PENNSYLVANIA, SURGEON 
TO THE EPISCOPAL HOSPITAL AND TO THE CHILDREN’S HOSPITAL, 
CONSULTING SURGEON TO ST. CHRISTOPHER’S HOSPITAL AND 
TO THE HOSPITAL OF THE GOOD SHEPHERD, BTC. 
PHILADELPHIA: 
PRINTED FOR THE CONGRESS. 
1877. Entered according to the Act of Congress, in the year 1877, by 
CASPAR WISTER, M.D., Treasurer, 
in the Office of the Librarian of Congress. All rights reserved. 
PHILADELPHIA 
COLLINS, PRINTER, 
705 Jayne Street. PREFACE. 
K explanation of the delay which has attended the publication of the 
piesent volume, the Editor would invite attention to the diversified cha- 
racter of its contents, which has necessitated the sending of proof-sheets 
rnore than threescore authors, residing in all portions of the country, 
has thus required a much greater expenditure of time than would 
been needed under other circumstances. 
. _ le yolume contains all the Addresses delivered before the Congress 
hs General Sessions, and, with few exceptions, all the Papers read in 
Meetings of the several Sections, and by them recommended for pub- 
,'a 10ru Abstracts of the Discussions which ensued upon the reading 
the several papers, are also appended in many instances, and, it is 
e leved, will be found to add materially to the interest of the whole. 
A few papers have been withdrawn by their authors, and three have 
. een ornitted by the Committee of Publication: one on account of its 
to the work of the Section before which it was read, 
.nc op its fragmentary nature, the paper to which it was really but an 
lntioduction not having been furnished by the author; another on ae- 
o^t expense which would have attended the reproduction 
w n c^law^nS8 with which it was illustrated, and without which it 
fe tfi Ve koen valueless; and a third because, though it was referred 
pr . Committee by the Section before which it was read, yet the 
tion • t,n ®ecrefarJ? and several prominent members, of the Sec- 
take and1''3. lln^ *u declaring that it had been so referred by mis- 
wasi’tn was n°f designed for publication. One paper which 
have "bee^rneil(^ *'or Publication has not been received, and appears to 
e^ore fbe records of the Congress were placed in the 
are Therefo^8 WeFe considered f°° voluminous for the Transactions, and 
autho 6 °le’^ by condensed abstracts, one furnished by the 
been // otPer by the Secretary of the Section to which it had 
reiectin68011 Committee of Publication has not felt justified in 
been 011 the sole ground of want of merit, after it had 
which theora 6 yap by the Section which heard it read, and to 
but in i,6 resPouslbiHty of accepting or refusing it properly belonged; 
jas ice to itself, the Committee cannot avoid expressing the VI 
PREFACE. 
opinion that, in some few instances, the censorship exercised by the 
Sections might properly have been more rigid. 
To the actual proceedings of the Congress and of its several Sections, 
are prefixed Lists of the Officers and Members of the Congress, the 
Minutes of the General Sessions, the Address of Welcome of the Presi- 
dent, Professor Gross, and, in order to complete the history of the Con- 
gress, a brief account of its inception and of the Centennial Medical 
Commission, prepared by Dr. Hutchinson. 
Though authorized by a resolution of the Congress to call upon each 
delegate for a further contribution towards the expense of issuing the 
volume, the Committee of Publication determined, after mature delibe- 
ration, that it would be better not to make an additional assessment, 
but to endeavor, by the exercise of a careful supervision, to reduce the 
cost of the volume to the sum actually in hand from registration-fees 
and from subscriptions; this has been done, and the Committee has the 
satisfaction of terminating its labors with no deficit in the treasury. 
The Editor offers his sincere thanks to the other members of the Com- 
mittee of Publication for the cordial support which they have uniformly 
extended to him in the laborious, and occasionally ungrateful, duties of 
his office. For any errors which may be detected in his work, and he 
does not presume to hope that many such do not exist, he bespeaks the 
friendly indulgence of the reader; and, in bringing his task to a close, 
he ventures to express a hope that this volume, on which he has ex- 
pended more than a year of arduous labor, may be found to furnish a 
not unsatisfactory memorial of the meetings of that important body of 
which it records the acts—the First International Medical Congress of 
America. 
JOHN" ASHHUEST, Jr. 
2000 West DeLancey Place, 
Philadelphia, October, 1877. THE 
CENTENNIAL MEDICAL COMMISSION AND THE 
INTERNATIONAL MEDICAL CONGRESS. 
JAMES H. HUTCHINSOET, A.M., M.D., 
OF PHILADELPHIA. 
The project of holding an International Medical Congress in Phila- 
delphia, during the Centennial Anniversary of the Declaration of Independence 
the ITnited States, seems to have been entertained by the profession as early 
as and to have grown out of a resolution originally introduced by Dr. J. 
C*- Stetler, at a meeting of the Philadelphia County Medical Society, held in 
October of that year. This resolution proposed that a general conference of 
the different medical societies and colleges in the city should be held to deter- 
mine what part the medical profession should take in the approaching celebra- 
tion, which was just then beginning to excite general interest in the community. 
16 l°rili which the proposed celebration should assume, had not, however, been 
u y agreed upon, and the time at which it was to take place was still far off in 
le future. Moreover, its advocates had not yet succeeded in convincing our 
leople that it was destined to be one of the great events in our history. Under 
e. circumstances it is not surprising that Dr. Stetler’s resolution did not 
r immediate fruit, and that the subject was allowed to lie dormant for more 
Than a year. 
which UeS^011 Was5 however, reopened in January, 18T4, in the same society, 
c, then appointed a committee, consisting of Drs. L. Turnbull, J. Gr. Stetler, 
and M o ° 77 
x iara, to take the matter into consideration. This committee, in due 
a^the6^0^ avor ie ProJcct, and proposed the Fourth of July, 18T6, 
mci 1 1 U^on the Congress should begin its sessions. It recom- 
menc ct, also, that the other medical societies of the city should be requested 
° aPP°int committees to co-operate with that of the County Society in pre- 
panng a plan. At this time, p one other society responded to the request; 
fessio comrnittee soon after, finding that it did not fully represent the pro- 
take°U m e C'^T’ extcnded invitations to several prominent physicians to 
c t m deliberations. These invitations were in most instances 
ia 5, accepted. The committee, thus increased in numbers and influence, THE CENTENNIAL MEDICAL COMMISSION. 
organized on the 29th of March, 1815, as “The Centennial Medical Com- 
mission op Philadelphia,” with the following officers :—- 
President. 
Samuel D. Gross, M.D., LL.D., D.C.L. Oxon. 
Y ice-Presidents. 
Alfred Stille, M.D., LL.D. 
W. S. W. Ruschenberger, M.D., U. S. N. 
Caspar Wister, M.D. 
Treasurer. 
Recording Secretary. 
William B. Atkinson, M.D. 
Foreign Corresponding 
Secretary. 
Home Corresponding 
Secretary. 
Richard J. Dunglison, M.D. 
Daniel G. Brinton, M.D. 
It was at this time also decided that the Congress should meet in September, 
instead of in July, as originally suggested, and that it should continue in ses- 
sion for at least six days. It was, moreover, proposed that the mornings 
should be devoted to business and to the reading of discourses upon topics of 
general interest, and that in the afternoons the Congress should meet in Sec- 
tions for the discussion of scientific questions.1 After much discussion, it was 
determined that there should be nine Sections, as follows : (1) A Section on 
Medicine; (2) A Section on Biology; (3) A Section on Surgery; (4) A Sec- 
tion on Dermatology and S37 philography; (5) A Section on Obstetrics; (6) A 
Section on Ophthalmology; (1) A Section on Otology; (8) A Section on 
Sanitary Science ; and (9) A Section on Mental Diseases. The Commission 
further decided that the Sections should meet on Monday, Tuesday, Wednes- 
day, Thursday, and Friday afternoons of the week during which the Congress 
should be in session; that, on four of these afternoons, the deliberations of 
each Section should be opened by the reading of a paper upon a subject of 
scientific interest, by a gentleman specially chosen for that purpose, and that 
the paper should afterwards be submitted for discussion. The remaining after- 
noon was to be left free for the reception of voluntary papers. The elaboration 
of this plan, together with the choice of subjects to be discussed, was left to 
special committees. 
At the meeting of the Commission which was held on the 19th of April, 
1815, another and a successful effort was made to secure the co-operation of 
the other medical societies of the city 7', all of which appointed committees to 
1 The subjects finally chosen for the discourses, with the names of the gentlemen selected 
to deliver them, were as follows : 1. Medicine and Medical Progress, Dr. Austin Flint, 
of New York ; 2. Surgery, Dr. Paul F. Eve, of Tennessee ; 3. Obstetrics, Dr. TheophiluS 
Parvin, of Indiana ; 4. Therapeutics, Dr. Alfred Stille, of Pennsylvania (declined); 
5. Medical Jurisprudence, Dr. Stanford E. Chaille, of Louisiana; 6. Medical Biography, 
Dr. Joseph M. Toner, of the District of Columbia ; 1. Medical Institutions and Educa- 
tion, Dr. N. S. Davis, of Illinois ; 8. Medical Literature, Dr. L. P. Yandell, of Ken- 
tucky ; 9. Hygiene and Social Science, Dr. H. I. Bowditch, of Massachusetts ; 10. Mental 
Hygiene, Dr. John P. Gray, of New York; and 11. Medical Chemistry, Dr. Theo. G- 
Wormley. of Ohio. THE CENTENNIAL MEDICAL COMMISSION. 
IX 
confer with the Commission. From this time until the meeting of the Con- 
fess, the project had the warmest .support and sympathy of the whole body 
°f the profession in Philadelphia. 
The addition of so large a number of new members to the Commission, ren- 
dered that body rather unwieldy for the transaction of business, and a Com- 
mittee of Conference, consisting of members from the various delegations, was 
therefore chosen for the purpose of harmonizing, as far as possible, different 
views. This Committee, after a thorough review of the work previously done 
bT the Commission, reported that it would be inexpedient to make any mate- 
ri&l change in the plan already adopted. It recommended, however, in view of 
fhe large amount of labor likely to be imposed upon the secretaries, that two 
additional secretaries should be appointed. At the subsequent meeting of the 
Commission, Drs. William Goodell and Robert M. Bertolet were chosen 
to fill these positions, all the other officers being re-elected by acclamation. 
The Committee of Conference having done its work very satisfactorily, it 
Was thought well by the Commission that thenceforward the perfecting of the 
Plan of the Congress should be confided to a Committee op Arrangements,1 
consisting of the following gentlemen, wdio were chosen chiefly on account of 
fhc interest which they had shown in the project: Drs. S. D. Gross, Edward 
_ artshorne, Washington L. Atlee, Albert Fricke, Laurence Turnbull, W. W. 
eetb I. Minis Hays, J. Solis Cohen, N. L, Hatfield, A. K. Minich, Thomas 
Ceo. Morton, George Strawbridge, William Goodell, John S. Parry, R. G. 
Curtin, John H. Packard, James H. Hutchinson, Louis A. Duhring, Alfred 
die, William Thomson, and Daniel G. Brinton. Prof. Gross was chairman 
0f this Committee, and Dr. Wm. B. Atkinson acted as its secretary for the 
gieater part of the time during which it was in existence. The meetings of 
m Commission were after the appointment of this Committee very infrequent; 
16 larger body being called together only to decide questions of special im- 
portance. 
A large and influential Executive Committee was also formed about this 
G’ bore upon its roll the names of many of the most eminent men of 
in various parts of the Union. 
q oltlcr to secure as full a representation from foreign lands as possible, a 
the !IlTTee 0f Invitation was soon after appointed, to which was entrusted 
toeCUty of electing the medical societies abroad, which should be requested 
ber&eUf delegates to the Congress, and also of designating the individual mem- 
Mueh tllG profession! Toth in this and other countries, who, by the eminence 
lc 1 tbey had attained in medical science, were entitled to the compliment of 
torial invitatl°n. A large number of sucll invitations was sent, and those 
gentlemen in this country were with very few exceptions accepted. Unfor- 
A Coin 1 6 tlm Committee. two other Committees were appointed at this time, viz., (1) 
delewamg1^66 finance, whose duty it was to collect funds for the entertainment of the 
Caspar°vy- and A Coramittee of Publication. The first Committee consisted of Drs. 
Albert H IStBr’- 'Lenox Hodge, Levi Curtis, Thomas Geo. Morton, T. Hewson Bache, 
never call Jan!es Tyson, and Charles H. Burnett. The second Committee was 
the actione f to^etber’ anct the selection of a Committee of Publication was thus left for 
the Congress when it should assemble. X 
THE CENTENNIAL MEDICAL COMMISSION. 
Innately, the loss of time and the great expense involved in a journey to Ame- 
rica, prevented as many of our foreign brethren from entertaining the idea of 
attending the Congress as had been hoped ; but the letters which they sent in 
answer, courteously acknowledged the compliment offered, and were expressive 
of the regret felt by the writers in being obliged to decline the invitation.1 
In addition to the members specially invited, in our own country, it was 
finally agreed that delegates to the Congress should be received from the fol- 
lowing bodies : (1) The American Medical Association, one delegate for every 
State and Territory in the Union; (2) The Association of Medical Superin- 
tendents of American Institutions for the Insane, twenty delegates; (3) The 
State Medical Societies, each as many delegates as its State had representatives 
in the Congress of the United States ; (4) The Medical Staff of the Army, two 
delegates; (5) The Medical Staff of the Navy, two delegates ; (&) The Marine 
Hospital Service, two delegates ; (I) The American Public-Health Association, 
five delegates ; and (8) The American Association for the Cure of Inebriates, 
two delegates. All the members of the Centennial Medical Commission, includ- 
ing members of the Executive Committee, were considered delegates by virtue 
of their position in the Commission. 
The manner in which the officers of the Congress should be chosen, gave rise 
to some discussion in the Commission, some of the members holding that it 
would be a graceful compliment to bestow the Presidency upon a distinguished 
foreigner; but on the other hand, it was contended that it would be better to 
allow the Congress to select its own officers, and this view at length prevailed- 
It was made the duty of the President of the Commission to call the Congress to 
order when it should first meet, and, after welcoming the delegates, to appoint 
a Committee of Nominations, consisting of delegates from all parts of the 
world. 
It is, perhaps, needless to add, in concluding this short sketch of the labors 
of The Centennial Medical Commission of Philadelphia, and of its Com- 
mittees, that no pains were spared to render the visit of the delegates to the 
Congress a pleasant one, and that there is every reason to believe that the 
effort was not unsuccessful. 
1 An invitation was sent by the Commission, in September, 1875, to the International 
Medical Congress, then in session at Brussels, to hold its next meeting in Philadelphia' 
While this invrfalion was courteously declined, the Congress adjourned over until the year 
1877, in order to give all its members, who might wish to do so, an opportunity to attend 
the sessions of the Centennial Congress in this country, j OFFICERS OF THE CONGRESS. 
SAMUEL D. GROSS, M.D., LL.D., D.C.L. Oxon., 
PRESIDENT. 
OF PHILADELPHIA. 
/ 
SSIDENTS. 
Jollifpe Tuenell, P.R.C.S., Ireland. 
Gf Lange, M.D., Denmark. 
William H. Kingston, M.D., Canada. 
H. Miyake, M.D., Japan. 
Michael Rudnew, M.D., Russia. 
Prop. Hueter, M.D., Germany. 
Frederick Semeleder, M.D., Austriar" 
Johan lljort, M.D., Norway. 
R. F. Hudson, M.D., Australia. 
. Pierre Debaisieux, M.D., Belgium. • 
William Adams, F.R.C.S., England. 
Alexander R. Simpson, M.D., Scotland. - 
?AUI F- Eve, M.D., Tennessee. 
• L. Atlee, M.D., Pennsylvania. r 
J- E. Richardson, M.D., Louisiana. 
James p. White, M.D., New York, 
Nathan R. Smith, M.D., Maryland.- 
J- Toner, M.D., Dist. of Columbia. 
J” Johnson, M.D., Missouri. 
Hunter McGuire, M.D., Virginia. 
Jenry Gibbons, M.D., California. 
jtEorge L.Collins, M.D.,Rhode Island. 
Nathan S. Davis, M.D., Illinois. 
JOIIIS A* Hugas, M.D., Georgia. 
J. K. Bartlett, M.D., Wisconsin., 
HONORARY VICE-PRESIDENTS. 
Joseph K. Barnes, M.D., Joseph Beale, M.D., 
URGKON-GENERAL u.s. army. surgeon-general u.s. navy. 
TREASURER. 
Caspar Wister, M.D., 
OP PHILADELPHIA. 
SECRETARY-GENERAL. 
I. Minis Hays, M.D., 
OF PHILADELPHIA. 
secretaries op the meeting 
p ILLIAM B- Atkinson, M.D. 
vtCHARD J. Dunglison, M.D. 
Richard A. Cleemann, M.D. 
William W. Keen, M.D. 
R. M. Bertolet, M.D. COMMITTEE OF PUBLICATION. 
John Ashhuest, Jr., M.D. 
Ejchaed J. Dunglison, M.D. 
William Goodell, M.D. 
James H, Hutchinson, M.D. 
Caspae Wistee, M.D. 
JOHN ASHHURST, Jr., M.D., 
Chairman, and Editor or the Transactions. OFFICERS OF THE SECTIONS. 
SECTION ON MEDICINE, 
PRESIDENT. 
Alfred Stille, M.D., LL.D., 
OF PHILADELPHIA. 
R P. Howard, M.D 
OP MONTREAL. 
VICE-PRESIDENT S 
J. J. Woodward, M.D., 
SECRETARY. 
J. Ewing Meads, M.D., 
U. S. ARMY. 
OF PHILADELPHIA. 
SECTION ON BIOLOGY 
PRESIDENT. 
John 0. Dalton, M.D., 
OF NEWYORK. 
Austin Flint, Jr., M.D 
OF NEWYORK, 
VICE-PRESIDENTS. 
Francis W. Campbell, M.D., 
SECRETARY. 
James Tyson, M.D., 
OF MONTREAL. 
OP PHILADELPHIA. 
SECTION ON SURGERY. 
PRESIDENT. 
Joseph Lister, F.R.S., 
t . VICE-PRESIDENTS. 
U > A f'! 
op o ANT’ John Ashhurst, Jr., M.D., 
TTAWA. of PHILADELPHIA. 
OF EDINBURGH. 
SECRETARY. 
John H. Packard, M.D., 
OF PHILADELPHIA. 
SECTION on dermatology and syphilography, 
PRESIDENT. 
James 0. White, M.D. 
OF BOSTON. 
g -p VICE-PRESIDENTS. 
0P copekhaq^S’'o'’ Edward Shippen, M.D., 
U. S. NAVY. 
SECRETARY. 
Arthur Yan Harlingen, M.D., 
OF PHILADELPHIA. XIV 
OFFICERS OF THE SECTIONS. 
SECTION ON OBSTETRICS. 
PRESIDENT. 
Egbert Barnes, M.D., 
VICE-PRESIDENTS. 
OF LONDON. 
Alexander E. Simpson, M.D., 
OF EDINBURGH. 
William H. Btford, M.B. 
OF CHICAGO. 
William Goodell, M.D., 
SECRETARY. 
OF PHILADELPHIA. 
SECTION ON OPHTHALMOLOGY. 
PRESIDENT. 
R. Brudenell Carter, F.R.0.5., 
OF LONDON. 
William Thomson, M.D 
OF PHILADELPHIA. 
VICE-PRESIDENTS. 
Henry W. Williams 
M.D., 
SECRETARY. 
OF BOSTON. 
John Green, M.D., 
OF ST. LOUIS. 
SECTION ON OTOLOGY, 
PRESIDENT. 
Clarence J. Blake, M.D., 
OF BOSTON. 
YICE-P RESIDENT. 
Albert H. Buck, M.D. 
OF NEW YORK. 
H. N. Spencer, M.D., 
OF ST. LOUIS. 
SECRETARY. 
SECTION ON SANITARY SCIENCE. 
PRESIDENT. 
Stephen Smith, M.D., 
VICE-PRESIDENT. 
John S. Billings, M.D 
OF NEW YORK. 
U. S. ARMY. 
Ezra M. Hunt, M.D., 
OF METUCHEN, NEW JERSEY 
SECRETARY. 
SECTION ON MENTAL DISEASES. 
PRESIDENT. 
John P. Gray, M.D., LL.D., 
OP NEW YORK. 
E. Grissom, M.D., 
OF NORTH CAROLINA. 
VICE-PRESIDENTS. 
Isaac Ray. M.D 
OP PHILADELPHIA. 
SECRETARY. 
Walter Kempster, M.D., 
OF WINNEBAGO, WISCONSIN. LIST of delegates and invited members, 
REGISTERED DURING THE MEETING OF 
THE CONGRESS. 
NAME. DELEGATE PROM 
• Abbott, M.D., Manchester, N. H. State Medical Society. 
Rliam Adams, F.R.C.S., London, England. Medical Society of London. 
Agnew, M.D., New York, N. Y. State Medical Society. 
• ayes Agnew, M.D., Philadelphia, Pa. Centennial Commission, 
j lißtson Allen, M.D., Philadelphia, Pa. Centennial Commission. 
’ • Anawalt, M.D., Greensburg, Pa. State Medical Society. 
illiam Anderson, M.D., Indiana, Pa. State Medical Society. 
BRam B. Arnold, M.D., Baltimore, Md. Medical and Chirurgical Fa- 
r culty of Maryland, 
SIrHURS,r5 Jr., M.D., Philadelphia, Pa. Centennial Commission, 
jM' Atkinson, M.D., Philadelphia, Pa. Centennial Commission. 
TLEE’ M.D., Lancaster, Pa. State Medical Society. 
H ApHINGTON B Atlee, M.D., Philadelphia, Pa. Centennial Commission. 
Pr\n YR>ES’ Fort Wayne, Indiana. State Medical Society. 
HenCISLAC°N, Haven, Conn. American Medical Association. 
yy1LRY ahnson, M.1)., Salem, N. C. State Medical Society. 
Baieey, M.D., Albany, N. Y. State Medical Society. 
A. g * Bakrr, M.D., Lansing, Mich. State Medical Society. 
BoRDY(;UjpWrN’ Jacksonville, Fla. State Medical Society. 
John RE ARReri M.D., New York, N. Y. State Medical Society. 
Robert Vp Hublin, Ireland. Surgical Society of Ireland. 
ARNes, M.D., F.R.C.P., London, Eng- Royal Medical and Chirnrgi- 
[land. cal Society, and Obstetrical 
Bregorio iw Society °* London* 
- Rroeta, M.D., San Luis Potosi, Medical Society of San Luis 
Roberts B\r [Mexico. Potosi. 
Edwin W P TIIolow! M-D.,Cincinnati, Ohio. State Medical Society. 
J. K. Bart ARTLEtt? M.D., Milwaukee, Wis. State Medical Society. 
J. M. BarTtLETT’ Milwaukee, Wis. State Medical Society. 
RLETcHERTpN’ Philadelphia, Pa. Centennial Commission. 
P. W. Be ar EACH’ London, England. Invited member. 
C. E. Bear*™’ Vincennes5 Ind. State Medical Society. 
M,D.? Ottawa, Ohio. State Medical Society. LIST OF DELEGATES AND INVITED MEMBERS. 
XVI 
NAME. DELEGATE FROM 
John Bell, M.D., Montreal, Canada. Medico-Chirurgical Society of 
Montreal. 
R. M. Bertolet, M.D., Philadelphia, Pa. Centennial Commission. 
John S. Billings, M.D., IT. S. A., Washington, American Public-Health Asso- 
[D. C. ciation. 
Clarence J. Blake, M.D., Boston, Mass. Invited member. 
A. Blitz, M.D., Nashville, Tenn. State Medical Society. 
F. Bogart, M.D., Sweetwater, Tenn. State Medical Society. 
Robert Bolling, M.D., Chestnut Hill, Pa. Centennial Commission. 
Aug. C. Bournonyille,M.D., Philadelphia, Pa. Centennial Commission. 
Henry I. Bowditch, M.D., Boston, Mass, American Medical Association. 
Richard C. Brandeis, M.D., Louisville, Ky. State Medical Society. 
John L. Bray, M.D., Chatham, Ont. Canada. Western and St. Clair Medical 
Society. 
A. L. Breysacher, M.D., Little Rock, Ark. State Medical Society. 
Geo. E. Brickett, M.D., Augusta, Me. State Medical Society. 
Charles E. Briggs, M.D., St. Louis, Mo. State Medical Society. 
John H. Brinton, M.D., Philadelphia, Pa. Centennial Commission. 
Wm, Brodie, M.D., Detroit, Mich. State Medical Society. 
George W. Broome, M.D., Moberly, Mo. State Medical Society. 
W. H. Brouse, M.D., Prescott, Ont. Canada. Canada Medical Association, 
D. Tilden Brown, M.D., New York, N. Y. Association of Medical Super- 
intendents of American In- 
stitutions for the Insane. 
James H. Brownfield, M.D., Fairmount, W.Ya. State Medical Society. 
Geo. D. Bruce, M.D., Pittsburg, Pa. State Medical Society. 
T. Lauder Brunton, M.D., F.R.S., London, Medical Society of London. 
[England. 
Peter Bryce, M.D., Tuscaloosa, Ala. State Medical Society. 
Albert H. Buck, M.D., New York, N. Y. Centennial Commission. 
Frederick J. Buck, M.D., Philadelphia, Pa. Centennial Commission. 
L. Duncan Bulkley, M.D., New York, N. Y. Centennial Commission. 
F. J. Bumstead, M.D., New York, N. Y. Centennial Commission. 
Francis Burdick, M.D., Johnstown, N. Y. State Medical Society. 
C. H, Burnett, M.D., Philadelphia, Pa. Centennial Commission. 
Robert Burns, M.D., Philadelphia, Pa. Centennial Commission, 
David Burpee, M.D., Philadelphia, Pa. Centennial Commission. 
George Burr, M.D., Binghamton, N. Y. State Medical Society. 
W. Burt, M.D., Paris, Ont. Canada. Branch County Medical Asso- 
ciation. 
Samuel C. Busey, M.D., Washington, D. C. Medical Society of the District 
of Columbia. 
W. Webster Butterfield, M.D., Indianapolis, State Medical Society. 
[lnd. 
James D. Button, M.D., Auburn, N. Y. State Medical Society. 
Wm. H. Byford, M.D., Chicago, 111. State Medical Society. 
A. W. Calhoun, M.D., Atlanta, Ga. State Medical Society. list of delegates and invited members. 
XVII 
■p NAME. DELEGATE FROM 
W. Campbell, M.D.,Montreal, Canada. Invited member. 
lenry Fraser Campbell, M.D., Augusta, Ga. State Medical Society. 
J-A. Campbell, M.D., Grafton, W. Ya. State Medical Society. 
eeliam Cannier, M.D., Toronto, Canada, Canadian Medical Association. 
OHN Carpenter, M.D., Pottsville, Pa. State Medical Society. 
• seph Carson, M.D., Philadelphia, Pa. American Medical Association. 
°bert Brudenell Carter, F.R.C.S., London, Royal Medical and Chirurgi- 
[England. cal Society, and Pathologi- 
cal Society of London. 
-Nk D. Castle, M.D., Philadelphia, Pa. Centennial Commission. 
-g AllD T. Caswell, M.D., Providence, R. I. Centennial Commission. 
gT ’ Catlin, M.D., West Meriden, Conn. State Medical Society. 
c aneord E. Chaille, M.D.,New Orleans, La. Centennial Commission. 
Earence B. Church, M.D., Ottawa, Canada. Ottawa Medico-Chirurgical 
E W n Society. 
' Lark, M.D., Grinnell, lowa. State Medical Society. 
ARD A. Cleemann, M.D., Philadelphia, Pa. Centennial Commission, 
j ’ ogswell, M.D., Bradford, Mass. State Medical Society. 
Ab CLIS Pohen’ At.D., Philadelphia, Pa. Centennial Commission. 
Ge Coles, M.H., Newark, N. J. State Medical Society. 
Ja-E ewis Collins, M.D., Providence, R. I. State Medical Societ}-. 
Em\Eb Co^linss AI.D., Philadelphia, Pa. Centennial Commission. 
PRpR ARD L°x, M.D., Battle Creek, Mich. State Medical Society. 
(jg VN(^IS L. Cunningham, M.D., Richmond, Ya. State Medical Society. 
R. CUPPLES’ San Antonio, Texas. State Medical Society, 
j * IjRTINi M.D., Philadelphia, Pa. Centennial Commission. 
urwen, M.D., Harrisburg, Pa. Association of Medical Super- 
j intendents, etc. 
j Losta, M.D., Philadelphia, Pa. Centennial Commission. 
John Alton’ New York, N. Y. American Medical Association. 
18’ Cincinnati, Ohio. State Medical Society. 
Richauj} T) AVIs’ ALD., Chicago, 111. American Medical Association. 
Pierre p) AVY’ L.R.C.S, London, England. Medical Society of London. 
Charles FBaisieuxs M.D., Louvain, Belgium. Belgian Government. 
John R H1^NIS°N’ Denver, Col. State Medical Society. 
Henry I) -p.Ksox’ H.D., Kingston, Out. Canada. Canada Medical Association. 
Stephen Syracuse, AT. Y. State Medical Society. 
J- Lewis Halifax, Nova Scotia. Dominion Medical Association, 
Greensville1 T)1’ erdt0’ a. State Medical Society. 
Thomas MDr °Well’ ALD., Galveston, Texas. State Medical Society.- 
Thomas S Philadelphia, Pa. Centennial Commission. 
Louis A Hug Y\ Hutherfordton, N. C. State Medical Society. 
J. J- Dugdale^M nD’’ AllgUsta’ Ga‘ State Meclical Society. 
’ 1 *’ Montreal, Canada. Medico-Chirurgical Society of 
Louis A. Dumping At Montreal. 
H. J. DunglisoiTAT Philadelphia’ Pa- Centennial Commission. 
B ’ 1 Philadelphia, Pa. State Medical Society. LIST OF DELEGATES AND INVITED MEMBERS. 
NAME. DELEGATE FROM 
Alexander Dunlap, M.D., Springfield, Ohio. American Medical Association- 
Charles W. Earle, M.D., Chicago, 111. State Medical Society. 
S. Y. Earle, M.D., St. John, N. B. Canada Medical Association. 
J. C. Eastman, M.D., Hampstead, N. 11. State Medical Society. 
James H. Eldredge, M.D.,East Greenwich, R.I. State Medical Society. 
William Elmer, M.D., Bridgeton, N. J. Centennial Commission. 
S. Engelsted, M.D., Copenhagen, Denmark. Medical Society of Copenha- 
gen. 
J. A. Estlander, M.D., Helsingfors, Finland. Invited member. 
Joseph A. Eve, M.D., Augusta, Ga. State Medical Society. 
Paul P, Eye, M.D., Nashville, Tenn. Centennial Commission. 
David S. Fairchild, M.D., Ames, lowa. State Medical Society. 
Cyrus Falconer, M.D., Hamilton, Ohio. State Medical Society. 
P. J. Farnsworth, M.D., Clinton, lowa. State Medical Society. 
A. G-. Field, M.D., Des Moines, lowa. State Medical Society. 
William Finlay, M.D., Edinburgh, Scotland. Obstetrical Society of Edin- 
burgh. 
Emil Fischer, M.D., Philadelphia, Pa. Centennial Commission. 
George Jackson Fisher, M.D., Sing Sing, N.Y. State Medical Society. 
Simon Fitch, M.D., St. John, N. 8., Canada. Invited member. 
Thomas Davis Fitch, M.D., Chicago, 111. State Medical Society. 
Thomas M. Flandreau, M.D., Rome, N. Y. State Medical Society. 
Austin Flint, M.D., New York, N. Y. American Medical Association- 
Austin Flint, Jr., M.D., New York, N. Y. State Medical Society. 
Daniel E. Foote, M.D., Belvidere, 111. State Medical Society. 
William H. Ford, M.D., Philadelphia, Pa. Centennial Commission. 
William Fox, M.D., Madison, Wis. State Medical Society. 
Albert Fricke, M.D., Philadelphia, Pa. Centennial Commission. 
John Frissell, M.D., Wheeling, W. Ya. State Medical Society. 
F. T. Fuller, M.D., Raleigh, N. C. Association of Medical Super- 
intendents, etc. 
Anatolede Gaine, M.D., St. Petersburg, Russia. Invited member. 
Frederic Henry Gerrish, M.D., Portland, Me, State Medical Society. 
Henry Gibbons, M.D., San Francisco, Cal. Centennial Commission. 
William Goodell, M.D., Philadelphia, Pa. Centennial Commission. 
H. Earnest Goodman, M.D., Philadelphia, Pa. Centennial Commission. 
Thomas W. Gordon, M.D., Georgetown, Ohio. State Medical Society. 
M. W. C. Gori, M.D., Amsterdam, Holland. Invited member. 
J. W. S. Gouley, M.D., New York, N. Y. State Medical Society. 
J. A. Grant, M.D., Ottawa, Canada. Canada Medical Association- 
John P. Gray, M.D., Utica, N. Y. State Medical Society. 
John Green, M.D., St. Louis, Mo. Centennial Commission. 
Traill Green, M.D., Easton, Pa. Centennial Commission. 
Wm. Warren Greene, M.D., Portland, Me. State Medical Society. 
.Samuel D. Gross, M.D., Philadelphia, Pa. Centennial Commission. 
,S. W. Gross, M.D., Philadelphia, Pa. Centennial Commission. LIST OF DELEGATES AND INVITED MEMBERS. 
XIX 
NAME. DELEGATE FROM 
Francis M. Gunnell, M.D., U.S.N., Washing- Medical Staff, U. S. Navy. 
[ton, D. C. 
osiah Hale, M.D., Owensboro, Ky. State Medical Society. 
iiarles C. Hamilton, M.D., Cornwallis, Nova Canada Medical Association. 
_ [Scotia. 
ank Hastings Hamilton, M.D., New York, American Medical Association, 
j [N. Y. and State Medical Society. 
I) r ®AMilton? M.H., Columbus, Ohio. State Medical Society. 
Fi ‘ Hand, M.D., St. Paul, Minn. State Medical Society, 
p Hansen, M.D., Copenhagen, Denmark. Invited member. 
Harles J, Hare, M.D., F.R.C.P., London, Royal Medical and Chirurgi- 
[England. cal Society, and Pathologi- 
n cal Society of London, 
p oRge C. Harlan, M.D., Philadelphia, Pa. Centennial Commission. 
LISHa Harris, M.D., New York, N. Y. American Public-Health Asso- 
rt elation. 
B pES Harrison, M.D., University of Ya. State Medical Society. 
‘ Hart, M.D., Marietta, Ohio. State Medical Society. 
KEw Hartman, M.D., Baltimore, Md. Medical and Chirurgical Fa- 
jr culty of Maryland. 
]y Hartshorne, M.D., Haverford Coll., Pa. Centennial Commission, 
j w Hatfield, M.D., Philadelphia, Pa. Centennial Commission. 
\y jINIB Hays, M.D., Philadelphia, Pa. Centennial Commission. 
' Hddens, M.D., St. Joseph, Mo. State Medical Society. 
Ai rES Heitzmann> M.D., Hew York, N. Y. Invited member. 
ander Allan Henderson, M.D.,Ottawa, Ottawa Medico-Chirurgical 
George pTT [Canada. Society^ 
qllap ’ Hersey, M.D., Manchester, N. H. State Medical Society. 
Addin*58 Hewht, M.D., Red Wing, Minn. State Medical Society. 
ALBERELpi Ewson’ H.D., Philadelphia, Pa. Centennial Commission. 
R P ' Heyl, M.D., Philadelphia, Pa. Centennial Commission. 
Wm h lEt>RETH? M.D., Wheeling, W. Ya. State Medical Society. 
Homer IXgst°n, M.D., Montreal, Canada. Invited member. 
Johan Ijj ' ITchcook, M.D., Kalamazoo, Mich. State Medical Society. 
Edward RT Christiania, Norway. Medical Society of Christiania. 
Holder, M.D., P.R.C.S., Toronto, Invited member. 
H. Lenox Hod ■ , [Canada. 
John T Rod Philadelphia, Pa. Centennial Commission, 
John H IT GEN’ H.D., St. Louis, Mo. American Medical Association. 
T. R HoL^ISrER’ H.D., Chicago, 111. State Medical Society. 
LiMEs, M.D.} Chatham, Ont. Canada. Western and St. Clair Medical 
0. A H at Association. 
R. P. H^1’ * Lewiston, Me. State Medical Society. 
JqHN q H.D., Montreal, Canada. Invited member. 
Stephen pLTrBARD’ H-D., Ashtabula, Ohio. State Medical Society. 
R. p. Huds UEBAR:d’ M.D., New Haven, Conn. Centennial Commission. 
- -D., Ballarat, Australia. Medical Society of Victoria. XX 
LIST OF DELEGATES AND INVITED MEMBERS. 
NAME. DELEGATE FROM 
Prof. Hueter, M.D., Griefswald, GermanjL Med. Yerein fur Griefswald. 
C. H, Hughes, M.D., St. Louis, Mo. Association of Medical Super- 
intendents, etc. 
E. W. Hughes, M.D., Grenada, Miss. State Medical Society. 
J. C. Hughes, M.1)., Keokuk, lowa. State Medical Society. 
Edward R. Hun, M.D., Albany, X. Y. State Medical Society. 
Ezra M. Hunt, M.H., Metuchen, X. J. State Medical Society. 
William Hunt, M.D., Philadelphia, Pa. Centennial Commission. 
John C. Hupp, M.D., Wheeling, W. Ya. Centennial Commission. 
A. Hurd, M.1)., Findlay, Ohio. State Medical Society. 
W. S. Huselton, M.D., Allegheny Citj’-, Pa. State Medical Society. 
Alexander Hutchins, M.H., Brooklyn, X. Y. State Medical Society. 
James H. Hutchinson, M.H., Philadelphia, Pa. Centennial Commission. 
Joseph C. Hutchison, M.D., Brooklyn, X. Y. State Medical Society. 
Frederick Hyde, M.D., Cortland, X. Y. State Medical Society. 
Josias A. Ireland, M.D., Louisville, Ky. State Medical Societjv 
Wm. Irvin, M.D., Breakneck, Pa. State Medical Societ}r. 
T. Ishigouro, M.H., Tokio, Japan. Japanese Government. 
J. B. S. Jackson, M.1)., Boston, Mass. State Medical Society. 
Harvey Jewett, M.D., Canandaigua, X. Y. State Medical Society. 
P. A. Jewett, M.D., Xew Haven, Conn. State Medical Society. 
A. H. Johnson, M.D., Salem, Mass. State Medical Society. 
11. A. Johnson, M.D., Chicago, 111. American Public-Health Asso- 
ciation. 
John C. Johnson, M.D., Blairstown, X. J. State Medical Society. 
Christopher Johnston, M.D., Baltimore, Md. Centennial Commission. 
Samuel J. Jones, M.D., Chicago, 111. State Medical Society. 
L. S. Joynes, M.D., Richmond, Ya. State Medical Society. 
W. W. Keen, M.D., Philadelphia, Pa. Centennial Commission. 
Walter Kempster, M.D., Winnebago, Wis. Association of Medical Super- 
intendents, etc. 
H. X. Kendall, M.D., Quincy, 111. State Medical Society. 
J. G. Kerr, M.D., San Francisco, Cal. Invited member. 
E. L. Keyes, M.H., Xew York, X. Y. Invited member. 
S. B. Kieffer, M.D., Carlisle, Pa. State Medical Society. 
G. Kimball, M.H., Lowell, Mass. Invited member. 
C. B. King, M.D., Allegheny City, Pa. State Medical Society. 
R. A, Kinloch, M.D., Charleston, S. C. State Medical Society. 
Charles J. Kipp, M.D., Xewark, X. J. Invited member. 
Thomas S. Kirkbride, M.D., Philadelphia, Pa. Centennial Commission. 
Daniel H. Kitchen, M.D., Xew York, X, Y. Association of Medical Super- 
intendents, etc. 
Herman Knapp, M.D., Xew York, X. Y. Invited member. 
W. A. Koukol de Yasnopolsky, M.D., Invited member. 
[St. Petersburg, Russia, 
C. Lange, M.D., Copenhagen, Denmark. Medical Society of Copenha- 
gen. LIST OF DELEGATES AND INVITED MEMBERS. 
XXI 
NAME. DELEGATE FROM 
Lemoine, M.D., St. Louis, Mo. State Medical Society. 
James Leslie, M.D., Hamilton, Ont. Canada. Hamilton Medical and Surgi- 
cal Society. 
James H. Letcher, M.D., Henderson, Ky. State Medical Society. 
an S. Lindsley, M.D., Nashville, Tenn. State Medical Society. 
Joseph Lister, F.R.S., Edinburgh, Scotland. University of Edinburgh, and 
Medico-Chirurgical Society 
of Edinburgh. 
Reward G. Loring, Jr., M.1)., New York, N. Y. Invited member. 
ILljam T. Lusk, M.H., New York, N. Y. Invited member. 
Jeered A. Lutkins, M.D., Jersey City, N. J. State Medical Society. 
_ Homas Lyon, M.D., Williamsport, Pa. State Medical Society. 
HN Deep Macdonald, M.D., Hamilton, Hamilton Medical and Surgi- 
[Ont. Canada. cal Society. 
rp Ijjl,laM J. McDowell, M.1)., Portsmouth, 0. State Medical Society. 
Heodore A. McGraw, M.D., Detroit, Mich. Centennial Commission, 
y UNter McGuire, M.D., Richmond, Ya. State Medical Society. 
y°HN Mr. Mcllhany, M.D., Warrenton, Ya. State Medical Society, 
yJIIN Mackie, M.D., New Bedford, Mass. State Medical Society. 
a. McKinnon, M.D., Selma, Ala. State Medical Society. 
i°Mas p. McLean, M.D., Goderich, Ont. County of Huron Medical As- 
p. [Canada. sociation. 
Tr McNary, M.D., Princeton, Ky. State Medical Society. 
T rf' ADI)IN5 M.D, Nashville, Tenn. American Medical Association. 
S* Ml M.D., Waco, Texas. State Medical Society. 
ARKs, M.D., Milwaukee, Wis. State Medical Society. 
lUs Mason, M.D., Prairie-du-Chien, Wis, State Medical Society. 
’°dore L. Mason, M.D., Brooklyn, N. Y. American Association for Cure 
of Inebriates, 
p p S Mastin, M.D., Mobile, Ala. Centennial Commission. 
eAL7RY’ Philadelphia, Pa. Centennial Commission. 
J p^E * Mears, M.D., Indianapolis, Ind. Centennial Commission. 
James EARS’ M.D., Philadelphia, Pa. Centennial Commission. 
Marcos ITK:EN Meigs, M.D., Philadelphia, Pa. Centennial Commission. 
DE J. Melero, M.D., Havana, Cuba. La Real Sociedad Economica 
de Amigos del Pais, Ha- 
ll. p. \r vanna. 
Tiioh a EERIMANi M.D., Chicago, 111. State Medical Society. 
Sp *Miohablb. M.D., Richmond, Ya. State Medical Society. 
Andre * Miner, M.D., Buffalo, N. Y. State Medical Society. 
pRANcW M.D., Philadelphia, Pa. Centennial Commission. 
H. Miyv INoL M.D., Boston, Mass. State Medical Society. 
John Tokio, Japan. Japanese Government. 
1 onmonier, M.D., Baltimore, Md. Medical and Chirurgical Fa- 
M. Moore un p , oulty of Maryland. 
Geo. R. ’ I*’ Uoehester, N. Y. American Medical Association. 
orehouse, M.D., Philadelphia, Pa. Centennial Commission. XXII 
LIST OF DELEGATES AND INVITED MEMBERS. 
NAME. DELEGATE FROM 
Thomas G-. Morton, M.D., Philadelphia, Pa. Centennial Commission. 
Alexander B. Mott, M.D., New York, N. Y. Invited member. 
R. B. Mowry, M.D., Allegheny City, Pa. Invited member. 
Pall F. Munde, M.D., New York, N. Y. Invited member. 
H. J. Murphy, M.D., Chatham, Out. Canada. Western and St. Clair Medi- 
cal Association. 
George Murray, M.D., New Glasgow, Nova Medical Society of Nova 
[Scotia. Scotia. 
Robert I). Murray, M.D., Keywest, Fla. Centennial Commission. 
S. Nagayo, M.D., Tokio, Japan. Japanese Government. 
Andrew Nebinger, M.D., Philadelphia, Pa. Centennial Commission. 
William B. Neftel, M.D., New York, N. Y. Invited member. 
Charles 11. Nichols, M.D., Washington, D. C. Association of Medical Super- 
intendents, etc. 
R. J. Nunn, M.D., Savannah, Ga. State Medical Society. 
John A. Octerlony, M.8., Louisville, Ky. State Medical Society. 
Michael O’Hara, M.U., Philadelphia, Pa. Centennial Commission. 
Wm. Oldright, M.D., Toronto, Canada. Canada Medical Association. 
11. L. Orth, M.D., Harrisburg, Pa, State Medical Society. 
J. W. D. Osgood, M.D., Greenfield, Mass. State Medical Society. 
George A. Otis, M.D., U. S. A., Washington, American Medical Association. 
[D. C. 
John E. Owens, M.D., Chicago, 111. State Medical Society. 
John H. Packard, M.D., Philadelphia, Pa. Centennial Commission. 
Wm. H. Pancoast, M.D., Philadelphia, Pa. Centennial Commission. 
Edward H. Parker, M.D., Poughkeepsie, N. Y. State Medical Society. 
Joseph Parrish, M.D., Burlington, N. J. American Association for Cure 
of Inebriates. 
Theophilus Paryin, M I),, Indianapolis, Ind. State Medical Society. 
R. S. Payne, M.D., Lynchburg, Ya. State Medical Society. 
Enoch Pearce, Jr., M.D., Steubenville, Ohio. State Medical Society. 
E. R. Peaslee, M.D., New York, N. Y. Centennial Commission. 
William Pepper, M.D., Philadelphia, Pa. Centennial Commission. 
W. 11. Philips, M.D., Kenton, Ohio. State Medical Society. 
Gideon L. Platt, M.D., Waterbury, Conn. State Medical Society. 
A. M. Pollock, M.D., Pittsburg, Pa. American Medical Association* 
J. 11. Pooley, M.D., Columbus, Ohio. State Medical Society. 
Charles 11. Porter, M.D., Albany, N. Y. State Medical Society. 
1). R. Porter, M.D., Kansas City, Mo. State Medical Society. 
Isaac G. Porter, M.D., New London, Conn, Invited member. 
Wm. G. Porter, M.D., Philadelphia, Pa. Centennial Commission. 
Alfred C. Post, M.D., New York, N. Y. Invited member. 
Edwin Powell, M.D., Chicago, 111. State Medical Society. 
Hayid Prince, M.D., Jacksonville, 111. State Medical Society. 
J. S. Prout, M.D., Brooklyn, N. Y. Invited member. 
Samuel S. Purple, M.D., New York, N. Y. Invited member. 
Sumner Putnam, M.D., Montpelier, Yt. State Medical Society. LIST OF DELEGATES AND INVITED MEMBERS. 
xxiii 
NAME. DELEGATE FROM 
R* Rawson, M.D., Buenos Ayres, Argentine Medical Association of Buenos 
[Republic. Ayres. 
Haac Ray, M.D., Philadelphia, Pa. Association of Medical Super- 
intendents, etc. 
H S. Rayeield, M.D., Jefferson, Texas. State Medical Society. 
H. Read, M.D., Norwalk, Ohio. State Medical Society. 
rn 77 7 * 
1 Ho mas B, Reed, M.D., Philadelphia, Pa. Centennial Commission. 
James T. Reeve, M.8., Appleton, Wis. State Medical Society. 
James E. Reeves, M.D., Wheeling, W. Ya. Centennial Commission. 
Alexander P. Reid, M.D., Halifax, Nova Medical Society of Nova 
[Scotia, Canada. Scotia. 
Holey S. Reynolds, M.D., Louisville, Ky. State Medical Society. 
EoRqe A. Rex, M.D., Philadelphia, Pa. Centennial Commission, 
rp SEph O. Richardson, M.D., Philadelphia, Pa. Centennial Commission. 
Richardson, M.D., New Orleans, La. Centennial Commission, 
j. * Richardson M.D., Montrose, Pa. State Medical Society. 
V Rhihe, M.8., Camden, N. J. State Medical Society. 
• R* Risley, M.D., Philadelphia, Pa. Centennial Commission. 
COB Roberts, M.D., Philadelphia, Pa. Centennial Commission. 
• Robertson, M.D., Edinburgh, Scot- Medico-Chirurgical Society of 
[land. Edinburgh. 
j,AVrD Robertson, M.D., Milton, Out. Canada. Canada Medical Association. 
p' R°billard, M.D., Montreal, Canada. Invited member. 
ames D. Robison, M.D., Wooster, Ohio. State Medical Society. 
Ho mas P. Rochester, M.D., Buffalo, N. Y. State Medical Society. 
Robert E. Rogers, M.D., Philadelphia, Pa. Centennial Commission. 
J' * Rosebrugh, M.D., Toronto, Canada. Canada Medical Association. 
• Rosebrugh, M.D., Hamilton, Canada. Hamilton Medical and Snrgi- 
j cal Society. 
Tor ES R°ss, M.D., Toronto, Canada. Canada Medical Association. 
« onji r» r> ’ 
jg . ‘ K°ss, M.D.,Williamsburg, Pa. State Medical Society. 
MiCh M.D., Montreal, Canada. Invited member. 
y/Y Rhhnew, M.D., St. Petersburg, Russia. Russian Government. 
‘ Rhschenberger, M.D., U. S. N., Centennial Commission, 
Gordon W r> [Philadelphia, Pa. 
JRa PiLT ‘ Rhssell, M.D., Hartford, Conn, State Medical Society. 
John Winchendon, Mass. State Medical Society. 
Thom vs P V-LSSEII’ M.D., Mt. Yernon, Ohio. State Medical Society. 
Thomas E IJSSEIl’ M.D., Oshkosh, Wisconsin. State Medical Society. 
J Ward Satterthwaite, M.D., New Centennial Commission. 
Williams* [York, N. Y. 
Le\vls a A^Ery5 M.D., Bryn Mawr, Pa, State Medical Society. 
Henry s' AYRe’ H.D., New York, N. Y. Centennial Commission. 
James m GHell’ H. 1)., Philadelphia, Pa. Centennial Commission. 
W. Scot’* yCOTT’ St. Louis, Mo. State Medical Society. 
eve^antG Ghi°- State Medical Society. 
eguin, M.D., New York, N. Y. American Medical Association XXIV 
LIST OF DELEGATES AND INVITED MEMBERS. 
NAME. DEIjEGATE FROM 
Amos Seip, M.D., Easton, Pa. State Medical Society. 
Frederick Semeleder, M.D., Vienna, Austria. Invited member. 
N. Senn, M.D., Milwaukee, Wis. State Medical Society. 
Leopold Seryais, M.D., Antwerp, Belgium. Belgian Government. 
Edward 0. Shakespeare, M.D., Philadelphia, Centennial Commission. 
[Pa. 
Charles Shepard, M.D., Grand Rapids, Mich. State Medical Society. 
B. F. Sherman, M.D., Ogdensburg, N. Y. State Medical Society. 
Edward Shippen, M.D., U.S.N., Philadelphia, Medical Staff, United States 
[Pa. Navy. 
J. H. Shout, M.D., Las Yegas, New Mexico. Medical Society of New 
Mexico. 
George E. Shuttleworth, M.D., Lancaster, Invited member. 
[England. 
Alexander R. Simpson, M.D., Edinburgh, University of Edinburgh, and 
[Scotland, Obstetrical Society of Edin- 
burgh. 
Wharton Sinkler, M.D., Philadelphia, Pa. Centennial Commission. 
Henry M. Skillman, M.D., Lexington, Ky. State Medical Society. 
Albert H. Smith, M.D., Philadelphia, Pa. Centennial Commission. 
Ashbel Smith, M.D., Houston, Texas. State Medical Society. 
David P. Smith, M.D., Springfield, Mass. State Medical Society. 
Eugene Smith, M.D., Detroit, Michigan. State Medical Society. 
Heber Smith, M.D., Stapleton, N. Y. United States Marine-Hospital 
Service. 
J. Lewis Smith, M.D., New York, N. Y. Centennial Commission. 
Joel W. Smith, M.D., Charles City, lowa. State Medical Society. 
Joseph R. Smith, M.D., U. S. A., Fort Monroe, Medical Staff, United States 
[ Y a. Army. 
Francis G. Smyth, M.D., Philadelphia, Pa. Centennial Commission. 
Edwin M, Snow, M.D., Providence, R. I. Centennial Commission. 
S. Fleet Speir, M.D., Brooklyn, N. Y. Invited member. 
H. N. Spencer, M.D., St. Louis, Mo. State Medical Society. 
Edward R. Squibb, M.D., Brooklyn, N. Y. State Medical Society. 
A. J. Steele, M.D., St. Louis, Mo. State Medical Society. 
Lewis H, Steiner, M.D., Frederick City, Md. American Public-Health As- 
sociation, and Medical and 
Chirurgical Faculty ofMary- 
land. 
George T. Stevens, M.D., Albany, N. Y. Invited member. 
James A. Steuart, M.D., Baltimore, Md. Medical and Chirurgical Fa- 
culty of Maryland. 
J. L. Stewart, M.D., Erie, Pa. State Medical Society. 
Alfred Stille, M.D., Philadelphia, Pa. Centennial Commission. 
Joseph A. Stilwell, M.D., Brownstown, Ind. State Medical Society. 
Barton Warren Stone, M.D., Hopkinsville, Association of Medical Super- 
[Ky. intendents, etc. LIST OF DELEGATES AND INVITED MEMBERS, 
XXV 
name. delegate from 
George Strawbridge, M.D., Philadelphia, Pa. Centennial Commission. 
S. S. Stryker, M.D., Philadelphia, Pa. Centennial Commission. 
Absalom B. Stuart, M.D., Winona, Minn. State Medical Society. 
D. F. Stuart, M.D., Houston, Texas. State Medical Society. 
G. E. Sussdorfp, M.D., Macon, Georgia. State Medical Society. 
George Sutton, M.D., Aurora, Ind. State Medical Societ}'. 
Joseph Swartz, M.D., Duncannon, Pa. State Medical Society. 
V. H. Taliaferro, M.D., Atlanta, Ga. State Medical Society. 
B. W. Taylor, M.D., Columbia, S. C. State Medical Society. 
M. A. Taylor, M.D., Austin City, Texas. State Medical Society. 
R. W, Taylor, M.D., New York, N. Y. Centennial Commission. 
Lake J. Tefft, M.1)., Syracuse, N. Y. State Medical Society. 
S. H. Tewksbury, M.D., Portland, Me. State Medical Society. 
■William Thomson, M.D., Philadelphia, Pa. Centennial Commission. 
James Thorburn, M.D., Toronto, Canada. Invited member. 
F. Walton Todd, M.D., Stockton, Cal. State Medical Society. 
S. S. Todd, M.D., Kansas City, Mo. State Medical Society. 
Joseph M. Toner, M.D., Washington, D. C. American Public-Health As- 
sociation. 
Edward H. Trenholme, M.D., Montreal, Medico-Chirurgical Society of 
[Canada. Montreal. 
Jolliffe Tufnell, F.R.C.S., Dublin, Ireland. Surgical Society and Patholo- 
gical Society of Ireland. 
Horace Tupper, M.D., Bay City, Mich. State Medical Society. 
Charles S. Turnbull, M.D., Philadelphia, Pa. Centennial Commission. 
Laurence Turnbull, M.D., Philadelphia, Pa. State Medical Society. 
Edward Berriam Turnipseed, M.D., Colum- State Medical Society. 
[bia, S. C. 
James Tyson, M.D., Philadelphia, Pa. Centennial Commission. 
G. Underwood, M.D., Pittston, Pa. State Medical Society. 
William H. Yanßuren, M.D., New York, N. Y. Invited member. 
Joseph H.Yandeman,M.D., Chattanooga,Tenn. State Medical Society. 
S. Oakley Yanderpoel, M.D., Stapleton, N. Y. State Medical Society. 
Arthur Yan Harlingen, M.D., Philadelphia, Centennial Commission. 
[Pa. 
Thomas H. Yan Yalzah, M.D., Lewiston, Pa. State Medical Society. 
Theodore R. Yarick, M.D., Jersey City, N. J. Centennial Commission. 
Alexander M. Yedder, M.D., Schenectady, State Medical Society. 
[N. Y. 
H. D. Yosburgh, M.D., Lyons, N. Y. State Medical Society. 
Clement A. Walker, M.D., Boston, Mass. Association of Medical Super- 
intendents, etc. 
James P. Walker, M.D., Mason City, 111. State Medical Society. 
Charles D. Watson, M.D., Covington, Ind. State Medical Society. 
Wm. Watson, M.D., Dubuque, lowa. State Medical Society. 
\y. Murray Weidman, M.D., Reading, Pa. State Medical Society. 
Faneuil D. Weisse, M.D., New York, N. Y. Centennial Commission. XXVI 
LIST OF DELEGATES AND INVITED MEMBERS. 
NAME. DELEGATE FROM 
James C. White, M.D., Boston, Muss. Centennial Commission. 
James P. White, M.D., Buffalo, N. Y. State Medical Society. 
Luther C. White, M.T)., Yan Buren, Ark. State Medical Society. 
George Wilkins, M.D., Montreal, Canada. Canada Medical Association. 
I)e Forest Willard, M.D., Philadelphia, Pa. Centennial Commission. 
E. Williams, M.D., Cincinnati, Ohio. State Medical Society. 
Henry W. Williams, M.D., Boston, Mass. Invited member. 
J. M. Willis, M.D., Waco, Texas. State Medical Society. 
Ellwood Wilson, M.D., Philadelphia, Pa. Centennial Commission. 
F. X. Wise, M.D., Covington, Ky. Invited member. 
Caspar Wister, M.D., Philadelphia, Pa. Centennial Commission. 
Horatio C. Wood, Jr., M.T)., Philadelphia, Pa. Centennial Commission. 
H, D. Wood, M.D., Angola, Ind. State Medical Society. 
Alfred H. Woodill, M.D., Halifax, Xova Halifax County Medical So- 
[Scotia. ciety. 
Ashbel Woodward, M.D., Franklin, Conn. State Medical Society. 
J. J. Woodward, M.D., U. S. A., Washington, Medical Staff, United States 
[D. C. Army. 
John M. Woodworth, M.H., Washington, D. C. Centennial Commission. 
Algernon Woolverton, M.D., Hamilton, Ont. Hamilton Medical and Surgi- 
[Canada. cal Society. 
Theo. G. Wormley, M.D., Columbus, Ohio. Centennial Commission, 
Fred. H. Wright, M.D., Toronto, Ont., Canada. Canada Medical Association. 
Henry P. Wright, M.D., Ottawa, Canada. Ottawa Medical Chirurgical 
Society. 
R. F. Wright, M.D., Dalton, Ga. State Medical Society. 
Lunsford P. Yandell, M.D., Louisville, Ky. State Medical Society. 
H. P. Yeomans, M.D., Mt. Forest, Ont. Canada. Canada Medical Association. TABLE OF CONTENTS. 
Preface 
The Centennial Medical Commission and the International Medical Congress. 
By James H. Hutchinson, A.M., M.D., of Philadelphia .... vu 
List of Officers of the Congress 
List of Officers of Sections XIU 
List of Delegates and Invited Members xx 
List of Illustrations • xxxu 
Address of Welcome. By S. D. Gross, M.D., LL.D., D.C.L. Oxon., President 
of the Centennial Medical Commission » 
Minutes of the General Sessions xxxvu 
Notice 
addresses. 
I. R Address on Medicine and Medical Progress in the United States. By Am™ 
Flint, M.D., Professor of the Principles and Practice of Medicine, and Clinical 
Medicine, in Bellevue Hospital Medical College, New A ork . . • • 1 
11. Address on Hygiene and Preventive Medicine. By Henry I. Bowditch, M.D., 
President of the, State Board of Health of Massachusetts . • • • Zi 
111. Address on Medical Chemistry and Toxicology. By Theo. G. Wormley, M.D., 
Ph.D., LL.D., Professor of Chemistry and Toxicology m Starling Medical Pol- 
lege, Columbus, Ohio ' 
IY. Address on Surgery. By Paul F. Eve, M.D., Professor of Operative and Clinical 
Surgery in the University of Nashville 
V. Address on Medical Biography. By J. M. Toner, M.D., of Washington, D. 0. 91 
YI. Address on Obstetrics. By Theophilus Parvin, M.D., Professor of Obstetrics 
and the Medical and Surgical Diseases of Women, College of Physicians and 
Surgeons of Indiana * 18 
YII. Address on Medical Jurisprudence. With Notes and a Bibliographical Appen- 
dix. By Stanford E. Chaille. A.M., M.D., Professor of Physiology and 1 atho- 
logical Anatomy in the Medical Department of the University ol Louisiana . 167 
VIII. Address on Mental Hygiene. By John P. Gray, M.D., LL.D., Medical 
Superintendent of the New York State Lunatic Asylum. Utica; Professor ot 
Psychological Medicine and Jurisprudence in Bellevue Hospital Medical College, 
New York 
IX. Address on American Medical Literature. By Lunsford Pitts Yandell, M.D., 
of Louisville, Kentucky • • • • • • 2-3 
X Address on the Progress of Medical Education in the United States of America, 
during the Century commencing in 1776. By N. S. Davis, A.M., M.D., of _ 
Chicago, Illinois .....••••••■• 233 
XI. Address on the Medical Staff of the United States Army, and its Scientific Work. 
By J. J. Woodward, M.D., Surgeon, United States Army .... 286 CONTENTS. 
SECTION ON MEDICINE. 
ART. PAGE 
XII. Typho-Malarial Fever; is it a Special Type of Fever? By J. J. Woodward, 
M.D., Surgeon, United States Army 305 
XIII. Are Diphtheritic and Pseudo-Membranous Croup Identical or Distinct Affec- 
tions ? By J. Lewis Smith, M.D., Physician to the Infant Hospital, New 
York, etc 341 
XIY. Do the Conditions of Modern Life favor specially the Development of Nervous 
Diseases? By Roberts Bartholow. M.A., M.D., Professor of the Theory and 
Practice of Medicine in the Medical College of Ohio 366 
XY. Contribution to the Etiology of Epilepsy. By William B. Neftel, M.D., of 
New York . 378 
XYI. The Influence of High Altitudes on the Progress of Phthisis. By Charles 
Denison, A.M., M.D., of Denver, Colorado ....... 387 
XYII. On the Treatment of Simple Ulcer of the Stomach. By M. Le Docteur H. 
Lebert, of Yevey; formerly Professor of Clinical Medicine at Zurich and 
Breslau. Translated by Charles Winslow Dulles, M.D., of Philadelphia . 424 
XYIII. Cases of Pernicious Progressive Ansemia, with some Observations upon the 
Ante-and Post-mortem Conditions observed in that Affection. By R. P. Howard, 
M.D., L.R.C.K., Professor of Medicine in the McGill University, Canada . . 432 
XIX. Alcohol in its Therapeutic Relations as a Pood and as a Medicine. By Ezra 
M. Hunt, M.D., of Metuchen, N. J 452 
XX. Report of Investigations made under the Direction of Professor Rudnew at the 
Institute of Pathological Anatomy of St. Petersburg. Communicated by Pro- 
fessor Rudnew 462 
SECTION ON BIOLOOY. 
SECTION ON BIOLOOY. 
XXI. The Microscopy of the Blood. By Christopher Johnston, M.D., of Balti- 
more, Md. 467 
XXII. The Excretory Function of the Liver. By Austin Flint, Jr., M.D., Pro- 
fessor of Physiology and Physiological Anatomy in the Bellevue Hospital Medi- 
cal College, New York 489 
XXIII. Report of Investigations made under the Direction of Professor Zayarikini, 
at the Institute of Normal Histology of St. Petersburg. Communicated by 
Professor Rudnew 503 
XXIY. On Fungous Growths in Solutions for Hypodermic Medication, and their 
Prevention by Salicylic Acid. By Joseph G. Richardson, M.D., Attending 
Physician to the Presbyterian Hospital, Philadelphia 506 
XXY. The Mechanism of Joints. By Harrison Allen, M.D., Professor of Com- 
parative Anatomy and Zoology in the University of Pennsylvania, Surgeon to 
the Philadelphia Hospital, Surgeon to St. Joseph’s Hospital, etc. . . . 510 
SECTION ON SURGERY. 
SECTION ON SURGERY. 
XXYI. Antiseptic Surgery. By John T. Hodgen, M.D., Professor of Surgical 
Anatomy and of Fractures and Dislocations in the St. Louis Medical College, 
St. Louis, Mo 518 
XXYII. Antiseptic Surgery. Report of Remarks made before the Surgical Section, 
during the Adjourned Discussion on Dr. Hodgen’s Paper. By Joseph Lister, 
F.R.S., Professor of Clinical Surgery in the University of Edinburgh. (Presi- 
XXYIII. The Treatment of Aneurism. By W. H. Yan Buren, A.M., M.D., Pro- 
fessor of the Principles and Practice of Surgery in the Bellevue Hospital Medical 
College, New York 545 
dent of the Section.) 535 
XXIX. The Pathology and Treatment of Morbus Coxarius. By Lewis A, Sayre, 
M.D., Professor of Orthopaedic Surgery and of Fractures and Dislocations in the 
Bellevue Hospital Medical College, New York, etc 575 CONTENTS, 
XXIX 
ART. _ ... . PAGE 
XXX. Report of a Case of Sub-periosteal Excision and Disarticulation of the entire 
Inferior Maxillary Bone for Phosphorus Necrosis. By John W. S. Gouley, M.D., 
Professor of Diseases of the Genito-Urinary System in the Medical Department 
of the University of New York, Surgeon to Bellevue Hospital, etc. . . . 605 
XXXI. The Causes and Geographical Distribution of Calculous Diseases. By 
Claudius H. Mastin, M.D., of Mobile, Alabama 609 
XXXII. Subcutaneous Division of the Neck of the Thigh-Bone for Anchylosis at the 
Hip-Joint. By William Adams, F.R.C.S., President of the Medical Society of 
London, etc. . 624 
XXXIII. Remarks upon Penetrating Wounds of the Abdomen, with the Suggestion 
of a change of Practice in such Cases. By L. A. Dugas, M.D., LL.D., Pro- 
fessor of Surgery in the Medical College of Georgia 631 
XXXIY. On Opening the Sac in Herniotomy. By Frederick Hyde, M.D., of Cort- 
land, New York 634 
XXXY. Some Comments on the History of Nitrous-Oxide Gas as an Anaesthetic, 
and on the Analgesic Effects of Rapid Breathing. By Addinell Hewson, M.D., 
Surgeon to the Pennsylvania Hospital, Philadelphia 642 
XXXYI. Observations on the Temperature of Osteo-sarcoma. By Prof. J. A Est- 
lander, M.D., of Helsingfors, Finland 658 
XXXVII. On Stone in the Bladder in Finland. By Prof. J. A. Bstlander, M.D., 
of Helsingfors, Finland ........... 662 
SECTION ON DERMATOLOGY AND SYPHILOGRAPHY. 
XXXYIII. Variations in Type and in Prevalence of Diseases of the Skin in Different 
Countries of Equal Civilization. By James 0. White, M.D., Professor of Der- 
matology in Harvard University 665 
XXXIX. Verrugas, a Disease Peculiar to Peru. By George A. Ward, M.D., 
Medical Director of the Oroya Railway. [Communicated by the Secretary.] . 685 
XL. Are Eczema and Psoriasis Local Diseases of the Skin, or are they Manifestations 
of Constitutional Disorders? By L. Duncan Bulklry, A.M., M.D., Physician 
XLI. The Virus of Venereal Sores, its Unity or Duality. By Freeman J. Bum- 
stead, M.D., late Professor of Venereal Diseases in the College ot Physicians 
and Surgeons, New York . . . . . . . . • ■ . /08 
to the Skin Department, Demilt Dispensary, New York, etc 691 
XLII. Leprosy as Observed in the Sandwich Islands. By Frank H. Enders, M.D., 
Government Physician. [Communicated by the Secretary.] .... 711 
XLIII. On the Treatment of Seborrhoea. By C. Heitzmann, M.D., of New York 
City 
XLIV. The Treatment of Syphilis, with Special Reference to the Constitutional 
Remedies appropriate to its Various Stages, the Duration of their Use, and the 
Question of their Continuous or Intermittent Employment. By Edward L. 
Keyes, M.D., Professor of Dermatology in the Bellevue Hospital Medical 
College, New York 726 
XLV. The Treatment of Syphilis. By Charles R. Drysdale, M.D., Senior Physi- 
cian to the Metropolitan Free Hospital, Physician to the Bolsover Street Lock 
Hospital, London. [Communicated by the Secretary.] ..... 741 
XLVI. Measures adopted in Denmark to Prevent the Spread of Venereal Disease. 
By S. Engelsted, M.D., Physician-in-Chief to the Copenhagen Hospital . . 745 
SECTION ON OBSTETRICS. 
XLVII. The Causes and Treatment of Non-Puerperal Hemorrhages of the Womb. 
By William H. Byford, M.D., Professor of Obstetrics and Diseases of Women 
in the Chicago Medical College 762 
XLVIII. The Mechanism of Natural and of Artificial Labor in Narrow Pelves. By 
William Goodell, A.M., M.D., Clinical Professor of the Diseases of Women 
and of Children in the University of Pennsylvania 777 XXX 
CONTEXTS. 
ART. . . . . PAGE 
XLIX. The Management of Convulsions, in Children, depending upon a High Tern- 
perature of the Body. By T. IC. Holmes, M.H., of Chatham, Ontario, Canada . (96 
L. Ovariotomy by Enucleation. By Julius F. Miner, M.D., Professor of Special 
LI. The Treatment of Fibroid Tumors of the Uterus. By Washington L. Atlee, 
M.D., of Philadelphia 808 
and Clinical Surgery in the Medical Department of the University of Buffalo . 801 
LII. The Three Most Important Obstetrical Instruments. By T. Lazarewitch, 
M.D., Professor of Clinical Midwifery and Diseases of Women, and Director of 
the Gynaecological Clinique, in Kharkoff, Russia. [Communicated by the Secre- 
tary.] 827 
Fill. On the Nature, Origin, and Prevention of Puerperal Fever By W. T Lusk 
M.D., Professor of Obstetrics and Diseases of Children in the Bellevue Hospital 
Medical College, New York 829 
LIT. On Electrolysis, with Special Reference to the Treatment of Ovarian Cysts. 
By Frederick Semeleder, M.D., of Vienna 859 
LY. Paracentesis, Aspiration, and Transfusion. By Simon Fitch, A.M., M.D. 
Edin., of St. John, New Brunswick, Canada 862 
LYI. Uterine Hemorrhage during Gestation. By E. H. Trenholme, M.D., 8.C.L., 
Professor of Midwifery and Diseases of Women and Children in Bishop’s College, 
Montreal; Attending* Physician to the Woman’s Hospital; Fellow of the Obstet- 
rical Society of London, etc 870 
LYII. Chronic Inversion of the Uterus. By James P. White. M.D., Professor of 
LYIII. Case of Retroversion of the Gravid Uterus; Treatment by Puncture; Reco- 
very. By Thomas F. Rochester, M.D., Professor of Principles and Practice of 
Obstetrics in the Medical Department of the University of Buffalo . . ■ 873 
Medicine in the Medical Department of the University of Buffalo . ' • 890 
SECTION ON OPHTHALMOLOGY. 
SECTION ON OPHTHALMOLOGY. 
LIX On the Comparative Value of Caustics and Astringents in the Treatment of 
Diseases of the Conjunctiva, and on the best mode of applying these Remedies 
By Henry W. Williams, A.M., M.D., Professor of Ophthalmology in Harvard 
University • • ' • • 1 ' • 
LX. On Tumors of the Optic Nerve. By H. Knapp, M.D., of New York . . 905 
LXI. Orbital Aneurismal Disease and Pulsating Exophthalmia; their Diagnosis and 
Treatment. By E. Williams, M.D., Professor of Ophthalmology in Miami 
Medical College, Cincinnati . . 912 
LXII. Spontaneous Cure of Congenital Pulsating Exophthalmos. By George C. 
Harlan, M.D., Surgeon to Wills Hospital, Ophthalmic and Aural Surgeon to 
the Children’s Hospital, Philadelphia . 921 
LXIII. Are Progressive Myopia and Conus (Posterior Staphyloma^due to Heredi- 
tary Predisposition, or can they be induced by Defect of Retraction acting 
through the Influence of the Ciliary Muscle? By Edward L. Loring, Jr., M.D., 
of New York . • • • • • • • * ‘ ‘ * 
LXIY. On the Relations between Corneal Diseases and Refractive Lesions of the 
Bye. By George T. Stevens, M.D., of Albany, N. Y 942 
SECTION ON OTOLOGY. 
SECTION ON OTOLOGY. 
LXV. The Importance of Treatment of Aural Diseases in their Early Stages, espe- 
cially when arising from the Exanthemata. By Albert H. Buck, M.D., o ew 
York ' 
LXYI. On the Best Means of Testing the Hearing. By Charles H. Burnett, M. D., 
Aural Surgeon to the Presbyterian Hospital, Philadelphia . • • 
LXYII. The Function and Utility of the Artificial Drum-Membrane. By H. N. 
Spencer. M.D., of St. Louis 1 CONTENTS. 
XXXI 
ART. , PAGE 
LXYIII. Modifications of the Methods of Treating Chronic Non-Suppurative Inflam- 
mation of the Eustachian Tube and Middle Ear. By Samuel J. Jones, A.M., 
M.D., Professor of Ophthalmology and Otology in the Chicago Medical College 988 
LXIX. On the Best Mode of Testing the Hearing of School Children, and of Pro- 
viding for the Instruction of Partially Deaf Children. By Clarence J. Blake, 
M.D., Instructor in Otology in Harvard University 992 
LXX. On Aural Vertigo with Variable Hearing. By Charles H. Burnett, M.D., 
Aural Surgeon to the Presbyterian Hospital, Philadelphia .... 1000 
LXXI. On the Several Methods of Educating, and on the Selection of Proper 
Schools for, the Deaf and Dumb. By Laurence Turnbull, M.D., Fellow of 
the American Association for the Advancement of Science; Aural Surgeon to 
Jefferson College Hospital; Physician to the Department of Diseases of the Bye 
and Ear, Howard Hospital, Philadelphia ........ 1004 
LXXII. On Bathing, Swimming, and Diving, as Causes of Aural Disease. By 
Laurence Turnbull, M.D., Fellow of the American Association for the Ad- 
vancement of Science; Aural Surgeon to Jefferson College Hospital; Physician 
to the Department of Diseases of the Eye and Bar, Howard Hospital, Phila- 
delphia .............. 1008 
SECTION ON SANITARY SCIENCE, 
LXXIII. The Present Condition of the Evidence concerning “Disease-Germs.” By 
Thomas E. Satterthwaite, M.D., of New York 1011 
LXXIV. Vital Statistics of Buenos Ayres. By G. Rawson, M.D., of Buenos 
Ayres 1029 
LXXV. The General Subject of Quarantine, with Particular Reference to Cholera 
and Yellow Fever. By John M. Woodworth, A.M., M.D., Supervising Surgeon- 
General, United States Mercantile Marine-Hospital Service .... 1059 
LXXVI. A Universal Pharmacopoeia. By Edward R. Squibb, M.D., of Brooklyn 1072 
LXXVII. The Relations of the Pharmacist to the Medical Profession. By Ezra 
M. Hunt, M.D., of Metuchen, New Jersey 1075 
SECTION ON MENTAL DISEASES. 
LXXVIII. The Microscopic Study of the Brain. By Walter Kempster, M.D., 
Physician and Superintendent of the Northern Hospital for the insane, Oshkosh, 
Wisconsin 1083 
LXXIX. The Responsibility of the Insane for their Criminal Acts. By Isaac Ray, 
M.D., of Philadelphia . . . , ... . . . • • 1097 
LXXX. The Simulation of Insanity by the Insane. By C. H. Hughes, M.D., late 
Superintendent and Physician of the Missouri State Lunatic Asylum . .1110 
LXXXI. On the Best Mode of Providing for the Subjects of Chronic Insanity. By 
Charles H. Nichols, M.D., Superintendent of the Government Hospital for 
the Insane, Washington, D. 0. . . . . • • • • • 1127 
Index 1145 LIST OF ILLUSTRATIONS. 
PAGE 
Cell Wall of Eed Blood-Corpuscles. Figs. 1 and 2. (Dr. J. G. Eichardson) . . 488 
Stercorine from Normal Human Feces, (Dr. Austin Flint, Jr.) .... 496 
PatLology and Treatment of Morbus Coxarius. Figs. 1-22. (Dr. L. A. Sayre) 577-596 
Ovariotomy by Enucleation. (Dr. Julius F. Miner) 803 
Paracentesis, Aspiration, and Transfusion. Figs. 1-6. (Dr. Simon Fitch) . . 866 
Chronic Inversion of the Uterus. Figs. 1-6. (Dr. James P. White) . . 880-884 
Progressive Myopia and Conus, Fig. 1 and Tables 1-4. (Dr. Edward G. Loring, 
Jr.) 927-930 
Methods of Treating Inflammation of the Eustachian Tube, etc. Figs. 1-6. (Dr. 
Samuel J. Jones) 989-990 ADDRESS OF WELCOME. 
BY 
S. D. GROSS, M.D., LL.D., D.C.L. Oxon., 
PRESIDENT OF THE CENTENNIAL MEDICAL COMMISSION. 
Gentlemen of the International Medical Congress:— 
My colleagues have confided to me, as President of the Centennial Medical 
Commission, the agreeable and honorable duty of opening this International 
Medical Congress, so long the object of their solicitude and earnest labor. In 
their name, then, as well as in my own and in that of the entire American medical 
profession, whose great heart this day throbs in unison with ours, I extend to you 
the right hand, and bid you a thrice cordial welcome to the “ City of Brotherly 
Love.” The occasion which has brought us together this morning is one of no 
ordinary kind ; it is one also which has been long and, I may add, anxiously 
anticipated. It might, perhaps, seem ungracious if I were to tell you how 
much time and labor have been bestowed by the Commission, through its 
Committee of Arrangements, upon the organization of the Congress ; how 
often it has met to devise plans and interchange views; how earnestly and 
thoughtfully it has performed its work; in a word, how faithfully and con- 
scientiously it has discharged the great trust confided to it by the different 
medical bodies of the city and county of Philadelphia, in which, nearly two 
years ago, the Congress originated. Not a little embarrassment has often 
attended our progress; and it has, therefore, not been without a profound sense 
of relief, such as a weary traveller may be supposed to experience at the end of 
a long and tedious journey, that at length we have found that our task has been 
brought to a successful close. If the organization is less complete than to some 
of you it may seem to be, no blame will, I am sure, be ascribed to the Commis- 
sion on account of any shortcomings. There might, possibly, have been wiser 
and more experienced heads at work ; but warmer hearts, or more conscientious 
men, never were, I venture to affirm, engaged in a noble enterprise. Such, 
then, as the work is, we cordially submit it to your consideration, satisfied that 
it will be accepted by you in the same kindly spirit in which it is tendered, and 
that any deficiencies which may mar its character will be duly rectified by your 
superior wisdom. 
It is at all times a source of gratification to welcome friends, especially when 
they are united by the bonds of a common brotherhood; but on this occasion, 
so pregnant with important events, the feeling is vastly heightened by the fact 
that we have assembled around us brethren not only from every section of this 
great continent, but from various foreign climes—from the British Dominion, 
from England, Ireland, and Scotland, from France, Belgium, and Germany, 
from Russia, Sweden, Norway, and Finland, from Greece, from China and ADDRESS OF WELCOME. 
Japan, from Australia, from Mexico and South America, and, I had almost 
said, from every country in the world. It is interesting to know that some ot 
these delegates come here accredited by their respective governments. The 
invitations sent out by the Commission covered every prominent medical society 
and every distinguished medical man in the four quarters of the globe. Ihe 
object was to bring together representative men from all nationalities to par- 
ticipate in our proceedings, and to affoi’d us the benefits of their wisdom, and 
the results of their experience and scientific investigations. If all these, or 
even a respectable minority of these, representative men could have been here, 
what a glorious spectacle would be presented in this hall this morning ! Men 
laying aside for a while their ordinary pursuits, crossing vast continents and 
perilous seas, congregating to unite with us in celebrating our first Medical 
Centennial, in interchanging cordial salutations, in delibeiating upon the best 
means of promoting the dearest and holiest interests of our profession, and in 
laying their contributions, the accumulations of years of study and observation, 
upona common altar for fixe common good! In its wide range, the present 
Congress is without a parallel. Similar bodies have repeatedly met, but none 
on so grand a scale, or with such a cosmopolitan outlook. 
In organizing the Congress, the Commission may have been guilty of undue 
partiality towards its own country; and yet, perhaps, such a tendency was, 
after all, only natural. However this may be, certain members felt an irre- 
sistible desire to show the world what the country, since the establishment ot 
our independence as a free and sovereign people, had accomplished tor scientific 
medicine. For this purpose, topics illustrative of the progress and present 
condition of the different branches of medicine in the United States, have been 
assigned, as subjects for addresses, to gentlemen ot acknowledged rank in the 
profession in different sections of the Union. These exercises will, it is believed, 
add greatly to the interest of the occasion. Time was, and that not at all remote, 
when we had no medical literature—no medical science—and but few medical 
schools when we were utterly helpless, and wholly dependent upon the aid 
derived from our European brethren, especially the English, whose language, 
practice, and habits, we naturally made our own. The poverty of the country, 
in these respects, cannot be better illustrated than by the fact that we had no 
native works on medicine and the collateral sciences until after the commence- 
ment of the present century. Many of you will recall the words of the great 
English lexicographer who, in 1169, in speaking to a friend of the American 
colonies, exclaimed : “ Sir, they are a race of convicts, and ought to be thankful 
for anything we allow them short of hanging.” The Abbe Ilaynal, writing in 
the latter part of the last century, declared that America had not yet produced 
a single man of genius; and the question of a celebrated English writer: “ Who 
reads an American book, or goes to an American play, ox looks at an Ameiican 
picture or statue ?” uttei’ed at a more recent period, is still fresh in the memory 
of many of the present race of men. The discourses which wdll be delivered be- 
fore you on the progress of American Medicine, will serve to show that the pro. 
fession of the Uxxited States has earxxed for itself an enviable reputation, and that 
it is fully abreast of all the other pursuits that adorn the human mind and shed 
lustre upon the scientific character of the nation. They will serve to show that 
we have passed the stage of medical provincialism, and that we stand upon a ADDRESS OF WELCOME. 
XXXV 
lofty platform, to which we need not he ashamed to invite the representative 
men of the profession of foreign countries, however illustrious, or however ad- 
vanced in the arts of civilization. 
The different Sections, organized by the Commission, must speak for them- 
selves. It is in them that the work of the Congress is mainly to be done, in 
them that the interchange of scientific ideas is to be perfected, and from them 
that the meeting is to derive its chief glory as an international body of edu- 
cated and enlightened men. 
It will be recollected that attempts have been made of late years, in different 
quarters, to establish a uniformity of scientific nomenclature, of weights, mea- 
sures, and records of disease for the medical profession in all parts ot the 
civilized world. The plan, if carried out, could not fail to advance, in an emi- 
nent degree, the interests of medical science ; and I am happy to be able to 
state that it is proposed to discuss the subject fully in one of the Sections. 
We are upon the threshold of a new centennial era. One hundred years 
have passed away since the grand old bell upon Independence Hall announced 
to the world the birth of a new nation and liberty, not only to our own citizens, 
but to all the peoples of the earth. The century that has just elapsed is the 
most wonderful in all that pertains to human progress, to discovery, to inven- 
tions, to improvements, to refinement and intellectual culture; in short, to ail 
that exalts and ennobles human nature, in its various aspects and phases, that 
has been vouchsafed to man since God said “ Let there be light.” The science 
of medicine has been completely revolutionized within our day. The saying, 
« Old things are passed away ; behold all things are become new,” has literally 
been fulfilled. The microscope, chemical analysis, clinical observation, and ex- 
periments upon the inferior animals, are leading on the medical mind with won- 
drous velocity in the pursuit of knowdedge, and are daily adding new facts to our 
stock of information far beyond what the wildest fancy could ha’se conceived, 
even a third of a century ago. Dogmatism, once so dominant in the schools, 
has ceased to exist, and no unacknowledged theories are any longer received or 
entertained by the scientist. Facts, resting upon the broad basis of observation 
and experiment, repeated and varied in a thousand ways, alone are relied upon 
as worthy of acceptance and as safe guides in practice. Hippocratic medicine 
is the order of the day. Everything bows before its divine behests. 
In every corner of the habitable globe, penetrated by the light of civilization, 
busy, active minds, endowed with high culture and actuated by the noblest 
resolves, are at work, exploring the mysteries of disease, and devising means or 
methods of treatment for the relief of suffering, and the prolongation of life. 
The busy bee was never more industriously engaged in gathering honey from the 
flower of the field than the modern physician is in gathering knowledge at the 
bedside of the sick, and garnering it for future use. Much of what is considered 
by many as established, must be reviewed in the light of modern science; new 
avenues must be opened; and the ball, composed of myriads of threads more 
delicately formed than any ever spun by Penelope, must be pushed onward and 
upward by the united efforts of the medical profession in all parts of the world. 
How far the Centennial International Medical Congress shall promote these 
desirable objects, time alone can determine. It may safely be predicted that, if 
it do not fulfil all the promises of hope that are expected from it, it will at all ADDRESS OF WELCOME. 
events accomplish a vast deal of useful work, and thus afford the world an earn- 
est of its interest in the advancement of scientific medicine, and in international 
unity and kindly feeling. Science can have no higher mission than that of 
strengthening the bonds and securing the co-operation of its votaries in various 
portions of the globe, assembled to deliberate upon everything calculated to 
promote its holiest interests. 
Among the many objects of an International Congress, not the least is the 
interchange of kindly feelings on the part of its members, the foimation ol new 
friendships, and the cementing of old ties. It is well that men ot different 
nationalities should occasionally come together, to look at one anothei, to shake 
hands, and to see how they stand in public estimation, as well as in theii own ; 
what the world thinks of them, and what they think of the woild; what they 
have done to further the interests of scientific progress, to lighten the burdens 
of human suffering, and to extend the boundaries of human happiness. All 
these and many other things, which need not to be here specified, are objects 
well worthy of engaging earnest attention on such an occasion as this. 
It has often occurred to me that, if these international reunions were more 
frequent and more largely attended, they would be a vast deal more serviceable 
in preventing war and international misunderstandings than any arbitrations 
that could be inaugurated for the settlement of international difficulties. Much 
of the pleasant feeling at present existing between the United States and Europe 
is due to the enlarged intercourse which has been going on since the establish- 
ment of steam navigation between the two countries, and the consequent inter- 
change of hospitality and courtesy on the part of their citizens. It is, therefore, 
to be hoped that this may be only one of many such reunions on this side ot 
the Atlantic. 
It needs hardly to be stated that the medical profession and the citizens of 
Philadelphia will do all that they can to make your time pass pleasantly, as well 
as profitably, during your sojourn among us. Cards of invitation will be issued 
to you to inspect the various institutions of interest in and around the city; 
and after the work of the Congress is over, the International Exposition will 
no doubt claim, as it assuredly deserves, the earnest attention of every member 
of this body. And now that the labor of the Centennial Medical Commission 
is completed, it only remains for the Congress, which I now declare open, to 
perfect its organization by the election of officers for its own government. To 
facilitate this object the Commission has appointed a committee on nomina- 
tions, consisting of thirteen members, nine American and foui foieign, whose 
duty it will be to report the result of their deliberations at the earliest possible 
moment this morning. MINUTES. 
The Congress assembled at noon of Monday, September 4, 18T6, in the Chapel 
of the University of Pennsylvania. Dr. Samuel D. Gkoss, President of the 
Centennial Medical Commission, called the Congress to order, and introduced 
the Right Reverend William Bacon Stevens, D.D., LL.D., Bishop of the 
Protestant Episcopal Church in the Diocese of Pennsylvania, who opened the 
session with prayer. Dr. W. S. W. Rusciienbergbr, U. S. N., one of the Vice- 
Presidents of the Centennial Medical Commission, having been then called to 
the Chair, Dr. Gross read an Address of Welcome (see page xxxiii.), after which 
he announced the appointment of the following Committee of Nomination : 
William Adams, Esq., of England; Prof. Engelsted, of Denmark; Prof. 
Hueter, of Germany; Prof. Rudnew, of Russia; Dr. J. A. Grant, of Canada; 
Dr. H. I. Bowditch, of Massachusetts; Prof. L. A. Dugas, of Georgia; Prof. 
J. T. Hodgen, of Missouri; Prof. Christopher Johnston, of Maryland; Prof, 
Austin Flint, of New York; Dr. W. S. W. Ruschenberger, U. S. Navy; Dr. 
J. R. Smith, U. S. Army ; Dr. Edwin M. Snow, of Rhode Island. 
Dr, Austin Flint, of New York, then delivered an Address on Medicine 
and Medical Progress in the United States (see page 1). 
The Committee of Nominations presented the following partial report of 
nominations for Officers of the Congress :—• 
President—Dr. S. D. Gross, Philadelphia. 
Vice-Presidents—Dr. Paul F. Eve, Tennessee ; Jolliffe Tufnell, Esq., Ireland ; Dr. W. L. 
Atlee, Pennsylvania; Dr. 0. Lange, Denmark ; Dr. T. G. Richardson, Louisiana ; Dr. W. H. 
Kingston, Canada; Dr. J. P. White, New York ; Dr. H. Miyake, Japan ; Dr. N. R. Smith, 
Maryland; Dr. M. Rudnew, Russia; Dr. J. M. Toner, District of Columbia; Dr. Hueter, 
Germany ; Dr. J. B. Johnson, Missouri; Dr. F. Sernele'der, Austria ; Dr. Hunter McGuire, 
Virginia; Dr. Johan Hjort, Norway; Dr. G. L. Collins, Rhode Island; Dr. R. F. Hudson, 
Australia ; Dr. H. Gibbons, California; Dr. Pierre De Baisieux, Belgium ; Dr. N. S. Davis, 
Illinois; William Adams, Esq., England; Dr. L. A. Dugas, Georgia; Dr. A. R. Simpson, 
Scotland; Dr. J. K. Bartlett, Wisconsin. 
Honorary Vice-Presidents—Dr. Joseph K. Barnes, Surgeon-General U. S. A.; Dr. 
Joseph Beale, Surgeon-General U. S. N. 
Secretary-General—Dr. I. Minis Hays, Philadelphia. 
Secretaries of Meeting—Drs. William B. Atkinson, R. J. Dunglison, R. A. Cleemann, 
W. W. Keen, R. M. Bertolet. 
Section on Medicine—President, Dr. Alfred Still 6, Philadelphia; Secretary, Dr. J. 
Ewing Mears, Philadelphia. 
Section on Biology—President, Dr. J. C. Dalton, New York; Secretary, Dr. James 
Tyson, Philadelphia. 
Section on Surgery—President, Joseph Lister, Esq., Edinburgh; Secretary, Dr. J. H. 
Packard, Philadelphia. . 
Section on Dermatology and Syphilography—President, Dr. J. C. White, Boston ; 
Secretary, Dr. A. Van Harlingen, Philadelphia. 
Section on Obstetrics—President, Dr. Robert Barnes, London; Secretary, Dr. William 
Goodell, Philadelphia. 
Section on Ophthalmology—President, R. Brudenell Carter, Esq., London ; Secretary, 
Dr. John Green, St. Louis. 
Section on Otology—President, Dr. L. Turnbull, Philadelphia; Secretary, Dr. H. N. 
Spencer, St. Louis. XXXV1U 
MINUTES. 
Section on Sanitary Science—President, Dr. Stephen Smith, New York; Secretary, Dr. 
E. M. Hunt, New Jersey. 
Section on Mental Diseases—President, Dr. J. P. Gray, Utica; Secretary, Dr. W. 
Kempster, Wisconsin. 
The report was accepted, and the nominations confirmed. 
Hr, Gross then assumed the chair as President of the Congress. He thanked 
that body for the honor conferred upon him, and said that no other would be 
dearer to him during the remainder of Ids life than that of presiding over its 
deliberations. He considered it not solely an honor bestowed on him, but a 
tribute to the profession of Philadelphia, which had been instrumental in 
organizing this Congress. 
On motion the Congress then adjourned until Tuesday at 10 A.M. 
The President called the Congress to order at 10 A.M. The minutes of the 
preceding day were read and approved. The Secretary-General presented a 
list of nearly three hundred delegates who had been registered up to this date. 
Reports were then received from the various Sections, and, on motion, the 
conclusions adopted by them, after debate upon the topics assigned for dis- 
cussion, were taken up seriatim, and adopted by the Congress, as follows: 
From the Section on Medicine;— The Section considered the question, 
“ Typho-Malarial Fever; is it a Special Type of Fever?” The debate was 
opened by J. J. Woodward, M.H., Surgeon U. S. A,, and the following conclu- 
sion was adopted by the Section : 
Second Hay’s Session. 
Typho-malarial fever is not a special or distinct type of disease, but the term may be 
conveniently applied to the compound forms of fever which result from the combined influ- 
ence of the causes of the malarial fevers and of typhoid fever. 
From the Section on Hermatology and Syphilography ;—The considera- 
tion of the subject, “ Variations in Type and in Prevalence of Diseases of the 
Skin in different countries of equal civilization,” was introduced by James C. 
White, M.D., of Boston, and the following conclusions were adopted:— 
1. Certain obscure affections, the etiology of which is little if at all understood, even in 
those parts of Europe to which they are mostly confined, may be regarded as practically 
non-existent among us—such are prurigo, pellagra, and lichen exudativus ruber. 
2. Certain diseases, directly connected with and dependent upon poverty and habits of 
personal uncleanliness, are less prevalent in the United States than in those parts of Europe 
of which we have sufficient statistical information for comparison. Examples of this class 
are the animal parasitic affections especially. 
3. Some cutaneous affections of grave character, which are dependent upon or a part of 
serious constitutional disorders, are of less frequent occurrence and of milder type amongst 
us than in Europe in general, or those parts of it where they are endemic. Lupus, the 
sypliilndermata, and leprosy are the most marked instances of this class. 
4. Certain disorders of the skin, especially those of its glandular system, and those 
connected more immediately with its nervous system, are apparently more prevalent with 
us than in Europe. The most notable examples of the former are seborrhoea, acne, and 
possibly the heat rashes ; of the latter, herpes, urticaria, and pruritus. 
In addition to the above-mentioned conclusions, the following additional proposition was 
adopted by the Section : 
5. The type of certain acute congestive and nervous diseases of the skin is more severe 
in this country than abroad. 
From the Section on Ophthalmology:—A discussion on “The Compara- 
tive Value of Caustics and Astringents in the Treatment of Diseases of the 
Conjunctiva, and the best mode of applying them,” was introduced by Henry 
W. Williams, M.D., of Boston, and the following conclusions were adopted by 
the Section ; 
1. In a considerable number of essentially transient affections of the conjunctiva, and in 
pterygium or other growths, no active treatment by caustics or astringents is required. 
2. When disease affects only a limited portion of the conjunctiva, as in phlyctenular 
inflammation, the mildest stimulating or astringent remedies are usually sufficient. MINUTES. 
XXXIX 
3. In the acute and chronic forms of general conjunctivitis, astringents are, as a rule, 
safer as well as more efficacious than caustics, and are therefore better adapted to the 
requirements of the general practitioner. 
From the Section on Otology:—The subject of the “Importance of Treat- 
ment of Aural Diseases in their early stages, especially when arising from 
the Exanthemata,” was presented by Dr. Albert H. Buck, of New York, 
and the following conclusions were adopted by the Section:— 
1. Chronic Otorrhosa is at the present time a very common disease, due in most cases to 
the want of proper treatment during the acute stage of the affection. 
2. It is by no means a harmless affection. 
3. It may be fairly classed as a preventable disease; at least among those who possess a 
healthy constitution. 
4. Paracentesis of the membrana tympani, if resorted to during the first few days of the 
acute attack, and if not carried out too timidly, i. e., if a free incision be made and not a 
mere prick, is almost a sure preventive of the subsequent chronic disease. 
5. The profession at large, and especially the medical schools, should give the subject 
more earnest thought than they have in the past. 
From the Section on Sanitary Science :—“ The Present Condition of the 
Evidence concerning Disease-germs,” was reported upon by Dr. Thomas E. 
Satterthwaite, of New York, and the following conclusions were adopted:— 
1. As far as inquiry has been made as to the results of the active principles in infective 
diseases, it is probable that in a certain number the matter is particulate or molecular in 
form, and, in the instances named, in no sense a soluble substance. 
2. In regard to the causes of septicaemia, pyaemia, puerperal fever, erysipelas, aod 
hospital gangrene, and of cholera, smallpox, the carbuncular diseases of men and animals, 
typhoid and relapsing fevers, and diphtheria, there is not satisfactory proof that they are 
necessarily connected with minute vegetable organisms. 
3. The real nature of these causes is still uncertain. 
Dr. Laurence Turnbull, of Philadelphia, announced that, with a desire to 
give the posts of honor to gentlemen from a distance, he had resigned the 
position of President of the Section on Otology, and that Dr. Clarence J. 
Blake, of Boston, had been chosen by the Section to preside over its delibera- 
tions. 
Dr. T. Gr. Richardson, of New Orleans, moved that the Congress should 
hold itself in no way responsible for the conclusions adopted by the Sections, 
but that the whole responsibility in the matter should rest with the Sections 
themselves. 
On motion of Dr. N. S. Davis, of Chicago, this resolution was amended, so 
that, upon the submission of the reports of the Sections to the Congress, the 
question should be merely upon their acceptance and reference for publication. 
On motion of Dr. William Brodie, of Michigan, the previous action of the 
Congress in adopting the conclusions reported by the several Sections, was 
reconsidered, and the reports accepted and referred to the Committee of Pub- 
lication. 
The Secretary-General then read letters of greeting from the Imperial 
Society op St. Petersburg, Russia, and from the University op Christi- 
ania, Norway. He also read the following letter from Dr. J. S. Billings, 
U. S. Army : 
War Department, Surgeon-General’s Office. 
Washington, D. 0., July 31, 1876. 
Sir: By direction of the Surgeon-General, U. S. Army, I have the honor to forward 
herewith to your address six (6) copies of a specimen fasciculus of a catalogue of the 
library of this office, and to request that they may be presented to the International Medi- 
cal Congress. While the object in view in forming this library has been to make a collec- 
tion of sufficient extent and completeness to meet the wants of the physicians of the United 
States, an attempt is being made to prepare a catalogue and index of its contents, whose 
practical usefulness shall not be confined to this country, but shall be, as far as the material MINUTES. 
available will permit, international and cosmopolitan. The manuscript of the entire work 
is so nearly completed that the printing can be commenced next spring if Congress shall 
see fit to give the necessary authority. 
Very respectfully, your obd’t servant, 
John S. Billings, 
Assist. Surgeon U. S. Army, in charge of Library. 
Whereupon Dr. Austin Flint, of New York, offered the following preamble 
and resolutions, which were adopted:— 
Whereas, The institution of a National Library containing all the important bibliogra- 
phical and periodical publications relating to medicine and the collateral sciences, in the 
past and present time, is of importance, not alone to the medical profession, but to persons 
in other pursuits who may desire to refer to works treating ot topics embraced in these 
departments of knowledge, and also concerns greatly the public welfare in so far as this is 
involved in the elevation of the standard of medical education ; and 
Whereas, Through the wisdom of the National Legislators of the United States Govern- 
ment, a medical library has been established, containing, at the present time, about 40,000 
volumes, and about the same number of single pamphlets; and 
Whereas, Experience has already shown the practical advantages of the present library, 
and, at the same time, the great need of its being made more complete by increasing at 
least tenfold the number of publications which it now contains ; and 
Whereas, In order to render such a library available for reference, especially to medical 
men and others residing at a distance, a catalogue wherein publications are classified after 
the names of authors and subjects, the scope of each publication being stated, is indispen- 
sable ; and 
'Whereas, Such a catalogue of the National Medical Library has been prepared under 
the direction of the Surgeon-General of the United States Army by Assistant Surgeon 
J. S. Billings, copies of a specimen fasciculus having been forwarded for examination by 
the members of the International Medical Congress ; therefore, 
Resolved, First. That the members of this International Medical Congress regard with 
great interest the institution of a National Medical Library in the City of Washington, 
and respectfully petition the Congress of the United States to provide tor additions to the 
number of volumes and periodical publications, until the library is made as complete as 
possible. 
Second. That in view of the necessity of what is known as a raisonnS. in 
order to render the library properly available for reference, this International Medical 
Congress urges the importance of an early completion and publication of such a catalogue. 
Third. That the Specimen Fasciculus of the Catalogue, which is stated to be nearly 
ready for the press, affords evidence of great labor and care, and the arrangements for con- 
venience of reference it is believed will prove in all respects satisfactory. 
Fourth. That those of the delegates to this International Medical Congress who are 
citizens of the United States, and other members of the Medical Profession in this country, 
are urged individually to exert their influence to secure the enlargement of the library, and 
the speedy publication of the Catalogue. 
The Committee of Nominations then presented the following supplementary 
report, which was accepted, and the nominations confirmed : 
Committee of Publication (with power to choose its chairman and an editor)—Dr. John 
Ashhurst, Jr., Dr. Richard J. Dunglison, Dr. William Goodell, Dr. Janies H. Hutchinson, 
Dr. Caspar Wister, all of Philadelphia. 
Treasurer—Dr. Caspar Wister, Philadelphia. 
Section on Medicine-Dr. R. P. Howard, Canada; Dr. J. J. Woodward, U. S. Army. 
Section on Biology—Dr. Austin Flint, Jr., New York; Dr. F. W. Campbell, Canada. 
Section on Surgery—Dr. J. A. Grant, Canada ; Dr. J. Ashhurst, Jr., Philadelphia. 
Section on Dermatology and Syphilography—Dr. S. Engelsted, Copenhagen ; Dr. B. 
Shippen, U. S. Navy. 
Section on Obstetrics—Dr. Alexander R. Simpson, Edinburgh; Dr. W. H. Byford, 
Illinois. 
Vice-Presidents of the Sections. 
Section on Ophthalmology—Dr. William Thomson, Philadelphia ; Dr. Henry W. Wil- 
liams, Boston. 
Section on Otology—Dr. A. H. Buck, New York. 
Section on Sanitary Science—Dr. J. S. Billings, U. S. Army. 
Section on Mental Diseases—Dr. E. Grissom, North Carolina; Dr. I. Ray, Philadelphia. MINUTES. 
Dr. Henry I. Bowditch, of Massachusetts, then read an Address on Hy- 
giene and Preventive Medicine (see page 21), Vice-President Paul F. Eve, 
of Tennessee, occupying the Chair; and afterwards Dr. Theo. G. Wormley, 
of Ohio, delivered an Address on Medical Chemistry and Toxicology (see 
page 49). 
The Congress then adjourned until Wednesday at 10 A. M. 
The Congress met at 10 A. M.; the President in the Chair. The minutes 
of the previous day were read and approved. 
On motion of Dr. John L. Atlee, of Lancaster, Pa., the Secretary was in- 
structed to transmit copies of the Address of Dr. Bowditch, when printed, to 
the Governor of each State and Territory, with the request that it be trans- 
mitted to the Legislature of such State or Territory ; and, on motion of Dr. 
Trenholme, of Montreal, the government of the Dominion of Canada and 
those of its several provinces were included in the terms of the resolution. 
On motion of Dr. Traill Green, of Easton, Pa., Dr, Worm ley’s Address 
was referred to the Committee of Publication, and the name of Dr. Wormley’s 
wife, who had assisted him in his labors, was ordered to be entered on the 
rolls of the Congress. 
The Secretary-General reported 382 names of delegates on the register. He 
announced the reception of a telegram from the National Temperance Asso- 
ciation, respectfully inviting an expression of opinion from the Congress 
regarding the use of alcohol. 
Lhe Secretary-General also I’ead invitations to the members of the Congress 
to visit the following institutions: The Academy of Natural Sciences of 
Philadelphia, Dr. W. S. W. Ruschenberger, President; The University of Penn- 
sylvania, Dr. Robert B. Rogers, Dean; The Jefferson Medical College, Dr. 
John B. Biddle, Dean ; The Pennsylvania Hospital; The College of Physicians 
of Philadelphia; and The Archteological Association; and from Dr. William 
Pepper, Medical Director of the Centennial Exposition, extending courtesies 
to visiting members. These invitations were, on motion, accepted. 
An invitation was also read from the Council of the National Forest Asso- 
ciation to attend its convention about to assemble at Cape May, N. J., on 
September 7 and 8. 
Third DxiY’s Session. 
The Secretaries of Sections then reported the conclusions adopted by their 
several Sections as follows: 
By the Section on Biology:—The consideration of “The Excretory Func- 
tion of the Liver,” was opened by Dr. Austin Flint, Jr., and the following 
conclusions were adopted:— 
1. Cholesterine exists in health in the bile, Wood, and nervous matter, also in the crystal- 
line lens, the spleen, and meconium. 
2. Cholesterine is formed for the most part in the nervous matter, from which it is passed 
into the blood. The blood gains cholesterine in its passage through the brain. Its forma- 
tion is constant, and it is always found in the blood. 
3. Cholesterine is separated from the blood by the liver, and discharged with the bile. 
It pre-exists in the blood, serves there no useful purpose, and, if allowed to accumulate, 
blood poisoning results. 
4. The bile has two separate and distinct functions, one connected with nutrition, to 
which the so-called biliary salts, glycocholate and taurocholate of soda, contribute; these 
do not exist preformed in the blood, but are products of secretion. The second function of 
the bile is excretory, connected with depuration or excretion ; this is accomplished by the 
removal of the cholesterine which it obtains from the blood. 
5. Normal feces do not contain cholesterine. The latter substance is represented by 
stercorine, formerly called sSroline, into which it is converted in its passage down the intes- 
tine. The conversion of cholesterine into stercorine does not, however, take place when 
digestion is arrested or when it is not necessary, as is shown by the presence of cholesterine 
in its own form in the feces during fasting, and in the meconium. 
6. The difference between the two varieties of jaundice, one mild and the other severe, MINUTES. 
is dependent on obstruction of the bile-ducts in one instance, with reabsorption of the 
biliary coloring matters, while in the other there is retention of cholesterine in the blood 
in consequence of destruction of the parenchyma of the liver. 
7. That condition of the blood dependent upon the presence of cholesterine in the blood 
is called cholestercemia. It is characterized by symptoms referable to the brain, and may 
or may not be attended with jaundice. 
8. Cholesteraemia does not occur in every disorder of the liver, because, even when a 
part of the organ is disorganized, there may remain a part still capable of performing the 
functions of excreting cholesterine. 
9. In cases of simple jaundice, even when feces are decolorized, there is no accumulation 
of cholesterine in the blood. 
10. Cholesterine bears the same relation to the liver that urea does to the kidneys. 
By the Section on Dermatology and Syphilography :—The debate on the 
question, “Are Eczema and Psoriasis Local Diseases, or are they Manifesta- 
tions of Constitutional Disorders?” was opened by Dr. L. Duncan Bulkley, 
of New York, and the following conclusions were adopted;— 
1. Eczema and psoriasis are distinct diseases. The former is to be clearly distinguished 
from artificial dermatitis, and the latter from the eruptions of syphilis, scaly eczema, and 
leprosy. 
2. Eczema and psoriasis cannot own a double causation or nature at one time local and 
at another constitutional; but, with other diseases, may have a twofold cause, a predis- 
posing and an exciting. 
3. Eczema and psoriasis in many of their features resemble the accepted constitutional 
diseases more than they do those recognized as local. 
4. Eczema is most properly likened to catarrh of the mucous membranes; it is very 
probable that some attacks called catarrh are eczema and psoriasis of the mucous tissue. 
5. Both eczema and psoriasis resemble gout and rheumatism in certain respects, and are 
dependent upon a somewhat similar, although as yet unknown, constitutional cause; much 
of the skin lesion must be looked upon as the local result or remains of the diseases. 
6. There as yet exists no microscopical or physiological proof that eczema and psoriasis 
are the sole result of local cell disorder, either congenital or acquired, or due alone to per- 
verted nerve action. 
7. Local causes play a very important part in the etiology of eczema. They are probably 
inoperative in psoriasis. 
8. Local treatment is often insufficient alone to remove the lesions of eczema and psoriasis, 
and cannot prevent or delay relapses ; its success does not necessarily demonstrate the local 
nature of these affections. 
9. Constitutional treatment, alone and singly, can cure many cases of eczema and 
psoriasis, and prevent or delay relapses in a certain proportion of cases; under constitu- 
tional treatment is included every agency not properly classed among local measures. 
10. The total weight of evidence and argument is that eczema and psoriasis are both 
manifestations of constitutional disorders and not local diseases of the skin. 
By the Section on Obstetrics:—The discussion of “ The Mechanism of 
Natural and of Artificial Labor in Narrow Pelves,” was introduced by Dr. Wil- 
liam Goodell, of Philadelphia, and the following conclusions were adopted by 
the Section:— 
1. The unaided first-coming head and the aided after-coming head observe in a flat pelvis 
precisely the same general laws of engagement and of descent. Hence, version here means 
art plus nature. 
2. The forceps, however applied in a flat pelvis, antagonizes more or less with the natu- 
ral mechanism of labor. Hence, the forceps here means art versus nature. 
3. The aided and the unaided first-coming head observe in a uniformly narrowed pelvis 
precisely the same laws of engagement and of descent. But version violates these laws. 
Hence, the forceps here means art plus nature; version, art versus nature. 
4. At, or above, the brim of a flat pelvis, the fronto-raastoid, or even the frouto-occipital, 
application of the forceps interferes less with the moulding of the head, and violates the 
natural mechanism of labor less, than the biparietal application. • 
5. In the flat pelvis, the vectis aids the natural mechanism of labor, and, therefore, meets 
the indications belter than the forceps. 
By the Section on Mental Diseases :—The consideration of the subject of 
the “Responsibility of the Insane for Criminal Acts,” was introduced by Dr. 
Isaac Ray, of Philadelphia, and the following conclusions were adopted by 
the Section:— MINUTES. 
1. There is at present a manifest tendency to hold the insane responsible for criminal 
acts. 
2. This tendency is unjust, unphilosophical, and contrary to the teachings of pathology, 
which clearly point out that insanity is but the expression of disease. 
The Section on Medicine also submitted the following resolutions for the 
action of the Congress, and on motion of Dr. Brodie, of Michigan, they were 
adopted : 
Resolved, That the International Medical Congress of 1876 recognizes the advantages 
which would accrue from the introduction of a gradual uniformity in the multiple and hete- 
rogeneous elements of physic, as posology, nomenclatures, etc., and in the means and records 
of medical observation. 
Resolved, That, in consequence, this Congress authorizes the President to appoint three 
delegates to the International Congress of 1877, with the special mission of presenting a 
schedule of the means of uniformity in physic actually applicable in all countries, and an- 
other of those which could soon be made acceptable by the profession at large. 
Resolved, That the said delegates be advised to invite the co-operation of the men who 
have already worked for the same cause at the International or National Medical or Phar- 
maceutical Congresses of Paris, Vienna, St. Petersburg, Brussels, and Buffalo. 
Under the above resolutions, the following delegates were subsequently ap- 
pointed by the President: Dr. Henry I. Bowditch, of Boston, Dr. J. J. Wood- 
ward, U. S. A., of Washington, and Dr. E. Seguin, of New York. 
Dr. Paul F. Eve, of Tennessee, then delivered an Address on Surgery (see 
page 73), Dr. Rudnew, of St. Petersburg, Russia, Vice-President, occupying 
the Chair; after which Dr. J. M. Toner, of the District of Columbia, delivered 
an Address on Medical Biography (see page 91), while Dr. L. A. Dugas, of 
Georgia, Vice-President, occupied the Chair. 
On motion the Congress then adjourned until Thursday at 10 A.M. 
[On Wednesday evening, at 7.30 P.M., Dr. J. J. Wooward, U. S. Army, de- 
livered in the Lecture Room of Jefferson Medical College an Address on The 
Medical Staff of the United States Army, and its Scientific Work (see page 
286).] 
Fourth Day’s Session. 
The Congress met at 10 A. M., the President in the Chair. The minutes of 
the previous day were read and approved. The Secretary-General reported 
422 names of delegates on the Register. 
Dr. H. I. Bowditch, of Boston, presented the following preamble and reso- 
lutions, which were adopted : 
Whereas, The work already accomplished by the officers commoted with the Bureau of 
the Surgeon-General of the United States Army, in the establishment of a medical library, 
and in the preparation of its complete and unique catalogue, in the formation of an ana- 
tomical museum from which important scientific results have already been obtained, and 
which have been not only a source of honor to these United States, but of value to foreign 
lands wherever science is cultivated ; and, 
Whereas, This Congress learns with regret that, owing to the lack of a sufficient clerical 
force and of pecuniary means, not only some of the work already in progress has been sus- 
pended, but that other work of equal value cannot be undertaken, although ample mate- 
rials for the same are now lying unused in the Surgeon-General’s office; therefore, 
Resolved, That a committee of three be appointed to prepare a memorial to be presented 
to the Congress of the United States, at the earliest day possible, at its next session, urging 
efficient support to these most important works. 
Resolved, That it is desirable that said memorial should be signed by the President, 
Vice-Presidents, and Secretary-General of this body. 
The President appointed Drs. Bowditch, of Boston, Rudnew, of St. Peters- 
burg, and N. S. Davis, of Chicago, as the Committee to prepare this Memorial. 
(in motion of Dr. J. P, White, of Buffalo, New York, it was ordered that 
the printed pamphlet containing Dr. Bovvditch’s Address on Hy'giene and 
Preventive Medicine be sent to the Presidents of State and Territorial Medical MINUTES. 
Societies and Sanitary Boards of the United States, and of the Societies and 
Sanitary Boards of the Dominion of Canada. 
The conclusions adopted by the several Sections were then reported as fol- 
lows ; 
By the Section on Surgery :—The subject of the “ Medical and Surgical 
Treatment of Aneurism,” was introduced by Dr. William 11. Yan Buren, of 
New York, and the following conclusions were adopted:— 
1. Tufnell’s treatment of aneurism, by rest, position, and restricted diet, offers a valuable 
resource in thoracic and abdominal aneurisms. .. 
2. It should always be tried in innominate, subclavian, subclavio-axillary, and iliac aneu- 
risms, before resorting to measures attended by risk to life. . . 
3. For aneurisms of the subclavian and iliac arteries, the Hunterian operation, with oui 
present means of preventing secondary hemorrhage, is not justifiable. 
4. For reasons formally set forth by Holmes and Henry Lee, the old operation camnot 
properly be formally substituted for the Hunterian operation in these cases, but should be 
held in reserve for special cases. ... 
5. It is the most safe and surgical resource in gluteal aneurism, if the circulation can be 
commanded by the hand in recto. 
6. The mode of cure by embolism, aimed at in the method of manipulation, is a not untre- 
quent explanation of what is called spontaneous cure of aneurism. 
7. The value of Esmarch’s bandage in the treatment of aneurism is probably not fully 
estimated. , „ . ~ , 
8. In view of the promising features presented by the cases of Levis and Bryant, in which 
horse-hair was introduced into an aneurismal tumor, the.repetition of this operation, or the 
substitution for horse-hair of Lister’s prepared catgut or other animal substances, may be 
properly tried. 
By the Section on Dermatology and Syphilography:—The consideration 
of the subject of “The Virus of Venereal Sores; its Unity or Duality,” was 
opened by Dr. F. J. Bumstead, of New York, and the following conclusions 
were adopted by the Section:— 
1. The virus of venereal sores is dual. . ... 
2. Venereal sores may be due to the inoculation of the syphilitic virus, and also to the 
inoculation of products of simple inflammation. 
3. These two poisons may be inoculated simultaneously. . 
4 (Additional.) The present state of science has demonstrated that suppurating inflam- 
matory lesions resembling chancroids may be produced on various portions of the body by 
inoculation with simple pus from various lesions. 
By the Section on Otology:—Dr. 11. N. Spencer, of St. Louis, opened a 
discussion of the question, “In what Percentage of Cases do Artificial Drum- 
membranes prove of Practical Advantage?” The following were the conclu- 
sions adopted by the Section : 
1. Of the various forms of artificial drum-membrane in use, the cotton pellet is prefera- 
ble for its greater simplicity and its easier introduction, for the greater uniformity of its 
effect, and the comparative safety in its employment. 
2. It has an advantage over all other forms of artificial drum-membrane in that, in addi- 
tion to the functional gain which may be derived, there may be added its value as a means 
of treating the tympanum, and this therapeutical use of the artificial membrane has a gieat 
future in otology. . , 
3. The continued use of the artificial drum-membrane as a means of improving the hear- 
ing is indicated in rare conditions which can only be determined by the aural surgeon. 
By the Section on Sanitary Science:—“ The General Subject of Quaran- 
tine, with Particular Reference to Cholera and Yellow lever,” was consideied 
by Dr. J. M. Woodworth, of the U. S. Marine Hospital Service, and the fol- 
lowing conclusions were adopted by the Section:— 
1. The supervision of ocean travel ought to be directed to securing good sanitary condi- 
tions of vessels at all times, out of as well as in port. 
2. A system of Port Sanitation should be adopted and administered for each country or 
place, separately, modified in particular cases by taking into account the liability of the 
port to infection, the period of incubation of the disease, the length of time consumed in 
the voyage, and the measures enforced by the vessel en route. MINUTES. 
3 ln some countries the detention of passengers and crews of ships hailing from infected 
norts is unwarranted, but for such time only as is necessary to complete the period ot incu- 
bation of cholera or yellow fever, counting from the date ot departure from an in ec e po. , 
or of landing from an infected vessel; but in no instance should passengeis 01 sai ois e 
held for observation on board an infected vessel, and such vessel should not e e amec 
bevond the period required for inspection and thorough disinfection and cleansing. 
4. Recognizing the fact that the morbific causes of infectious diseases may sometimes 
elude the most vigilant sanitary supervision of shipping, the importance ot wisely-direc e 
internal sanitary measures can scarcely be over-estimated. ...... . P _ 
5. As far as America is concerned, it is desirable that prompt and authoritative informa- 
tion should be had of the shipment of passengers or goods from districts infected with 
cholera or yellow fever, thereby insuring the thorough disinfection of infected articles. 
6 The endemic homes of cholera and yellow fever are the fields which give the greatest 
promise of satisfactory results to well-directed and energetic sanitary measures and to 
this end an international sentiment should be awakened, so strong as to compel the caie- 
less and offending people to employ rational means ol prevention. 
By the Section on Mental Diseases ;—The consideration of the subject of 
the u Simulation of Insanity by the Insane,” was opened by Dr. C. 11. Hughes, 
of St. Louis, Mo., and the following conclusion was adopted by the Section 
It is not onlv not impossible for the insane to simulate insanity for a purpose in any but 
its gravest forms of profound general mental involvement, but they actually do simulate 
acts and forms of insanity for which there exists no pathological warrant that we can dis- 
cover in the real disease affecting them. 
On motion of Dr. T. G. Richardson, of Louisiana, Dr. J. J. Woodward, 
U. S. A., was requested to repeat his lecture of the previous evening, as many 
of the members had failed to read the announcement of the lecture on the Pro- 
gramme, and had, therefore, been absent. 
& Dr Theophilus Paryin, of Indiana, then delivered an Address on Obstetrics 
(see pao-e 1B8), Dr. H. Miyake, of Tokio, Japan, Vice-President, occupying the 
Chair, and, after a very brief recess, Dr. Stanford E. Chaille, of Louisiana, 
delivered an Address on Medical Jurisprudence (see page 161), while Dr. J. I. 
White of Buffalo, New York, Vice-President, occupied the Chair. 
The Congress then adjourned until 10 A.M. on Friday. 
The Congress met at 10 A.M., the President in the Chair. The minutes of 
the preceding day were read and approved. The Secretary-General reported 
430 names of delegates on the Register. 
Eifth Day’s Session. 
On motion of Dr. Paul F. Eve, of Nashville, it was 
Resolved, That no papers or addresses read before this body, and ordered to be printed, 
shall be furnished either in abstract or otherwise for publication in any journal prior to 
the publication of the Transactions. 
The conclusions adopted by the several Sections were then reported as fol- 
lows : 
By the Section on Biology:—The consideration of “The Mechanism of 
Joints,” was introduced by Dr. Harrison Allen, of Philadelphia, and the 
following conclusions were adopted by the Section ; 
1. Starting with the idea that joints are of dynamic and static values, it is shown that 
in most movable joints the ball-and-socket arrangement predominates. V\ hen the ball is 
supported bi7 the socket, as at the occipito-atloid articulation, rest is suggested. But when 
the ball is suspended from the socket, as at the temporo-maxillary articulation, motion is 
Articular surfaces are of three kinds : axial, actinic, and lateral. Ihe axial or 
primary surfaces are those situated upon proximal and distal ends of a bone in the line ot 
its longitudinal axis. The actinic or secondary (rarely seen) are those placed in a line 
which Is deflected from the longitudinal axis. The lateral or tertiary are those situated 
upon the sides of the shaft or body of a bone, and serve for articulation with corresponding 
surfaces of other bones. . 
3. Axial surfaces, it is believed, are static; actinic surfaces are dynamic ; while lateral MINUTES. 
surfaces have subordinate degrees of value—some of them being adventitious. The outer 
femoral condyle is active in extension = static; the inner femoral condyle is active in 
flexion == dynamic; but the lateral facets have no independent action. 
4. Joints are fixed or locked at extremes of flexion and extension, and are most relaxed 
at the intervals between these extremes. 
5. When a facet is actively employed, it enters into a combination with which the entire 
limb is in harmony. Hence, in the study of any one facet, its relations to all others ot its 
kind, as well as to the bones, muscles, and fascia? of its limb, become essential.^ 
6. A correct knowledge of the symptomatology and treatment of diseases ot the joints is 
dependent upon a true conception of the complex nature of articular surfaces. 
By the Section on Surgery:—Dr. Lewis A. Sayre, of New York, opened 
the discussion of the subject of the “Treatment of Coxalgia.” The Section 
adopted the following conclusions : 
1. Morbus coxarius is a disease most frequently met with in early childhood, or the age 
of reckless indifference. . , 
2. It is almost always of traumatic origin, and not necessarily connected with a vitiated 
constitution. 
3. Rest and freedom from pressure of the parts involved, while at the same time the rest 
of the body is allowed free exercise in the open air, and a nutritious diet, is the best treat- 
ment that has yet been devised for this disease. 
4. If this plan of treatment be adopted in the early stages of this disease, the majority 
of cases will recover, with nearly if not quite perfect motion, and without deformity. 
5. In the advanced second stage of the disease, when absorption of the effused fluid can- 
not be produced, then it is better to puncture or aspirate the joint and remove its contents, 
than to leave it to rupture by ulceration. 
6. In the third stage of the disease, when the treatment recommended in this paper has 
been properly applied without satisfactory improvement, but progressive caries continues, 
the exsection of the diseased bone is not only justifiable, but in many cases absolutely 
necessary. . 
7. That the operation of exsection of the hip is easily performed, and in itself attended 
with little or no danger. 
8. That after exsection of the hip-joint in cases of progressive caries, the recovery is 
much more rapid and certain, and infinitely more perfect, as to form, motion, and the use- 
fulness of the joint and limb, than when left to the slow process of nature. 
[Note.—In the second conclusion, the Section does not unanimously coincide.] 
By the Section on Dermatology and Syphilography :—After a debate, 
opened by Dr. E. L. Keyes, of New York, on “ The Treatment of Syphilis 
with special reference to the Constitutional Remedies appropriate to its 
various stages ; the Duration of their Use, and the question of their Continuous 
or Intermittent Employment,” the Section adopted the following:— 
Negative conclusions, for which there would seem to be no foundation in fact: 
1. Syphilis commencing mildly needs but little treatment, and does not require mercury. 
2. Mercury given internally is necessarily debilitating. 
3. Mercury is only useful in secondary syphilis. 
4. lodide of potassium is of considerable value in secondary syphilis. 
5. lodide of potassium is of no value unless preceded by the use of mercury. 
6. lodide of potassium acts by liberating mercury which has been lying latent. 
Positive conclusions, which, in the present state of our knowledge, may be affirmed; 
1. Mercury is an antidote to the syphilitic poison, and of service in controlling all its 
symptoms in all, even the latest stages of the disease ; its power over gummata being least, 
and not to be relied upon. 
2. Mercury in minute doses is a tonic. 
3. lodine cures certain symptoms of syphilis, but does.not prevent relapses. 
4. Mercury, long continued uninterruptedly, as far as practicable, in small doses from the 
time of the earliest eruption, constitutes the best treatment of syphilis. 
By the Section on Ophthalmology:—A discussion on the question, “Are 
Progressive Myopia and Posterior Staphyloma due to Hereditary Predisposi- 
tion, or can they be induced by Defects of Refraction, acting through the 
Influence of the Ciliary Muscle ?” was opened by Dr. E. G. Lorinq, Jr., of 
New York, and the following conclusions were adopted by the Section:— 
1. From the fact that so many children are myopic, whose parents are not near-sighted, 
while the myopia increases directly with the amount of increased tension of the eyes, and MINUTES. 
from the fact that an interchange of refraction may occur, whereby an eye which is not 
congenitally myopic may become so in spite of hereditary tendency against it, it would 
seem to follow that hereditary predisposition, though undoubtedly a potent cause, is not 
only not the sole cause, but that it is not even the predominating cause. 
2. The action of the ciliary muscle, taken by itself, exerts but little influence on the pro- 
duction of myopia, and still less on the formation of the cone. 
[Note.—Of these conclusions, the first was adopted by the Section unanimously, and 
the second by a majority of fifteen to seven.] 
Dr. N. S. Dayis, of Chicago, offered the following preamble and resolutions, 
which were adopted : 
Whereas, This Congress marks an era in the history of medicine in the United States of 
America, the addresses as delivered presenting a summary of progress in the various de- 
partments which will be of great historical value in all coming time ; and 
Whereas, It is highly probable that these addresses, in connection with the many very 
valuable papers read and discussed in the Sections, will require for their early and proper 
publication more funds than are at present in the hands of the Treasurer for the purpose; 
therefore, 
Resolved, That the Committee of Publication be authorized and instructed, as soon as 
practicable after the final adjournment of the Congress, to ascertain the probable cost of 
publishing the full Transactions in a style appropriate for the work, and, if the money on 
hand be found deficient, to address a circular letter to the American members of the 
Congress, asking for such additional sum, not exceeding $lO for each of such members, as 
will supply the deficiency; and that said committee be authorized to withhold the volume 
or volumes, when published, from any member who may neglect to pay the additional sum 
required. 
Resolved, That the Committee of Publication be authorized and requested to exercise a 
careful and liberal discretion in preparing and revising the proceedings and reported dis- 
cussions in the several Sections, for publication in the Transactions of the Congress. 
The Secretary General announced the receipt of communications from the 
Woman’s National Christian Temperance Union, and from the Friends Tem- 
perance Union of New York, respectfully inviting an expression of opinion 
from the Congress concerning the use of alcohol. 
On motion of Dr. N. S. Davis, these were referred to the Section on Medi- 
cine. 
On motion of Dr. J. M. Toner, of Washington, D. C., the communication 
previously received from the National Temperance Association "was similarly 
referred. 
After a recess of ten minutes, Dr. J. P. Gray, of Utica, N. Y., read an Ad- 
dress on Mental Hygiene (see page 205), Dr. Hunter McGuire, of Virginia, 
Vice-President, occupying the Chair; and afterwards Dr. Lunsford P. Yan- 
dell, of Louisville, Kentucky, delivered an Address on Medical Literature (see 
page 223), while Dr. T. G. Richardson, of Louisiana, Vice-President, occupied 
the Chair. 
On motion, the various addresses read before the Congress were referred to 
the Committee of Publication, and the Congress then adjourned until 10 A. M. 
on Saturday. 
Sixth Day’s Session. 
The Congress met at 10 A. M., the President in the Chair. The minutes of 
the preceding day were read and approved. The Secretary-General reported 
44T names of delegates on the register (see page xv.), and, on motion of Dr. 
Toner, these were all confirmed as members of the Congress, 
The Secretary-General read a request from Dr. Rudnew, of Russia, asking 
the privilege of access to the minutes and proceedings of the Congress, with 
a view of reporting them on his return to Russia, which was granted. 
The Section on Medicine recommended that the Secretary be directed to 
send, in reply to the various Temperance Associations which had sent com- 
munications to the Congress, the following conclusions which had been ap- 
proved by the Section, and which were contained in a paper read before it by xlviii 
MINUTES. 
Dr. E. M. Hunt, of New Jersey, entitled “Alcohol in its Therapeutic Rela- 
tions as a Food and as a Medicine.” 
1. Alcohol is not shown to have a definite food value by any of the methods of chemical 
analysis or physiological investigation. _ , 
2. Its use as a medicine is chiefly that of a cardiac stimulant, and often admits 01 sub- 
3. As a medicine, it is not well-fitted for self-prescription by the laity, and the medical 
profession is not accountable for such administration, or tor the euoimous evils aiising 
4. The purity of alcoholic liquors is, in general, not as well assured as that of articles 
used for medicine should be. The various mixtures, when used as medicines, should ha\e 
a definite and known composition, and should not be interchanged promiscuously. 
On motion of Dr. J. P. White, of Buffalo, it was 
Resolved, That the Centennial Medical Commission of Philadelphia is hereby tendered 
the cordial thanks of this Congress for the most excellent manner in which its members 
have discharged the arduous duties devolved upon them, and by which our pleasure and 
profit have been so much enhanced. . 
Resolved, That the President and other Officers of the International Medical Congress 
of 187G are’hereby tendered the cordial thanks of the Congress for the excellent manner in 
which they have discharged the arduous duties devolved upon them, and by which our 
pleasure and profit have been so much enhanced. 
Resolved, That the Officers and Trustees of the University of Pennsylvania are hereby 
tendered our cordial thanks for the very liberal use of their excellent buildings for the 
meetings of this International Medical Congress. 
Resolved, That the Officers and Trustees of the Jefferson Medical College are hereby 
tendered the cordial thanks of this Congress for the use of their lecture-room for the most 
interesting lecture of Dr. J. J. Woodward, U. S. A. 
Resolved, That the cordial thanks of the International Medical Congress are especially 
due to Drs. Thomson, Wilson, and Strawbridge, and to Messrs. Henry C. Lea and J. B. 
Lippiucott, for their generous hospitality. 
On motion of Dr. H. I. Bowditch, of Boston, the following resolution was 
adopted : 
Resolved, That we, a brotherhood of physicians from the North, South, Last, and M est 
of this country, hereby tender to our associates from other lands our most earnest wishes 
that they may have safe and happy returns to their homes, and we would suggest the hope 
that they will carry back many pleasant memories ol this fraternal meeting, now closing, 
and which has been, most appropriately, held in this generous and noble city of Philadel- 
phia. 
Dr. J. A. Grant, of Ottawa, Canada, stated that at a meeting of the mem- 
bers of the Canadian medical delegates, held yesterday, the following resolu- 
tions were adopted unanimously:— 
Resolved, That the Canadian members of the International Medical Congress desire to 
express their sense of the great consideration and urbanity with which they have been 
treated by the officers and members of the Centennial Medical Commission, and beg, by 
this resolution, to tender their warm thanks for the same. _ 
Resolved, That the Canadian members of the International Medical Congress most cor- 
dially join with the other members of the Congress in thanking physicians and citi- 
zens of Philadelphia for the generous hospitality extended to its members throughout the 
present session. 
Dr. Charles J. Hare, of London, read the following expression of congrat- 
ulation from the delegates of Great Britain:— 
The delegates from Great Britain to the International Medical Congress of Philadelphia 
beg to congratulate the President and the several committees on the complete success of the 
Congress, on the high value of the various addresses presented to it, and on the forward 
impulse which it has given to the progress of medicine in the widest sense of that word. 
They desire at the same time to express in the strongest and warmest terms their sense of 
and their thanks for the unmeasured kindness and courtesy and the unbounded hospitality 
with which they have been received on this Centennial occasion, and to add that they will 
carry back with them a most grateful recollection of that warm right hand of fellowship 
which has been so warmly extended to them by their brethren of the United States. 
Signed on behalf of the British delegates by Charles J. Hare, M.D. Cantab., F.R.C.P., MINUTES. 
late Professor of Clinical Medicine in University College, and Physician to University 
College Hospital; R. Brudenell Carter, F.R.O.S. Eng., Hunterian Professor of Surgery 
to the Royal College of Surgeons of England; William Adams, F.R.C.S., President of 
the Medical Society of London. 
Dr. L. A, Sayre, of New York, offered the following:— 
Resolved, That this International Medical Congress requests its President, Professor 
Samuel D. Gross, to sit for his portrait, and that the Committee of Publication be in- 
structed to have the same engraved and printed as a frontispiece to the Volume of Transac- 
tions. Adopted.1 
The Secretary-General stated that a circular had been received announcing 
that an International Medical Congress would be held in Geneva in September, 
1877. 
Dr. N. S. Davis, of Illinois, then delivered an Address on Medical Educa- 
tion and Medical Institutions (see page 265), Dr. Henry Gibbons, of California, 
Vice-President, occupying the Chair. 
Dr. Gross, President, announced that the official programme of the Congress 
had been completed. No new business being presented, he addressed the 
Congress as follows : 
Gentlemen : Before I put the question of the final adjournment of the Con- 
gress, I desire to say a few parting words. First and foremost, I must be 
permitted again to thank 3Tou for the great honor which you have done me in 
electing me as your presiding officer. It is the last honor which I can reasona- 
bly expect from my professional brethren, who have always been so kind to me 
in the bestowal of their favors and of their good opinion. For these courtesies 
I shall never cease to be grateful, for they have served to cheer me in my 
labors, and have been as a balm to my soul. 
The International Medical Congress of 1876 is about to pass into history as 
a thing of the past; but, although its exercises are at an end, its work will live 
and form an interesting era in our profession as marking the reunion of a great 
body of men in the Centennial year of American Independence. We have 
listened to a number of valuable and instructive discourses, illustrative of the 
progress of American medicine and surgery ; have been engaged in profitable 
debates affecting some of the most vital interests of society; have performed 
a large amount of earnest work in the Sections; have met at the festive board; 
have clasped hands, and have formed warm and, as I trust, lasting friendships, 
all without any discord, one unkind expression, or even one word of misun- 
derstanding. Altogether, we have every reason for self-congratulation. When 
another Centennial century shall have passed away, the men who shall then 
be upon the stage will not fail to commemorate our meeting, and to bless us 
for what has been done this week in the interests of humanity and of medical 
science. In dissolving this meeting, as I now do, permit me to invoke upon 
our labors the choicest blessings of Almighty God, and to wish each and all of 
you a safe return to your homes, and a happy reunion with your families and 
friends. May we not hope that you may long, if not forever, retain pleasant 
memories of our meetings in this Chapel, and that in your leisure moments 
your minds may occasionally revert to those of us from whom you are about 
to separate ? 
The Congress then adjourned sine die. 
I. MINIS HAYS, M.D., 
Secretary-General. 
William B. Atkinson, M.D., 
Richard J. Dunglison, M.D., 
Richard A. Cleemann, M.D., 
William W. Keen, M.D., 
R. M. Bertolet, M.D., 
Secretaries 0f the 
*eC7etaries °J 1,16 
meetmg‘ 
1 [ln deference to Prof. Gross’s expressed wish, the portrait is omitted.—Editor.] 
D NOTICE. 
The Committee of Publication thinks it proper to say that the Con- 
gress is to be held in no way responsible for the statements, reasonings, 
or opinions set forth in the various papers published in its Transactions. ADDRESSES. 
ADDRESS ON MEDICINE AND MEDICAL PROGRESS IN THE 
UNITED STATES. 
BY 
AUSTIN FLIRT, M.D., 
PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE, AND CLINICAL MEDICINE, IN 
BELLEVUE HOSPITAL MEDICAL COLLEGE, NEW YORK. 
An important object of the Philosophy of History is the study of 
agencies concerned in originating and modifying past events. From this 
standpoint I propose to survey “Medicine and Medical Progress in the 
United States” during the past one hundred years. Whence were derived 
influences affecting the progress of Medicine in this Centennial period ? 
I shall submit certain historical-facts and reflections in answer to this 
inquiry. Another object of the Philosophy of History, of greater prac- 
tical importance, is the study of agencies with reference to future events. 
Regarding Medicine in the latter aspect, the inquiry arises, by what in- 
fluences is the progress of Medicine in our country to be promoted? 
This inquiry opens up a wide range of thought, to which some incidental 
reference is all that the limits of my discourse will permit. 
Medicine, as I use the term in this discourse, distinguishes a province 
of knowledge and art from Surgery and Midwifery. In this restricted 
sense it denotes the province called in former times “the theory and 
practice of physic.” I assume that medicine has steadily progressed in 
our country during the past one hundred years; the rapidity, at different 
periods, during this space of time, and the extent of will natu- 
rally enter into reflections upon the influences affecting it. The scope of 
the term progress, as applied to Medicine, claims preliminary explanation. 
In what consists, and what are the criteria of, medical progress in this 
country, in past time? This question cannot be summarily answered ; 
the answer will lead at once to the influences affecting the progress which 
has taken place, and to those which tend to its promotion now and here- 
after. ... . . , . 
The most striking evidence of progress is a great discovery, the practical 
benefits of which are immediate and palpable. Discoveries entitled to 
this distinction, within the past century, are vaccination, auscultation, 
and the separate functions of different components of the nervous sys- 
tem. Tliis brief list cannot be much lengthened. Pre-eminently great 
discoveries in medicine are so distributed in respect of intervals, as to 
bear the impress of special gifts vouchsafed by Providence. We can 
boast of but one discovery which belongs in this category, the annihila- 
tion of pain by anaesthetic inhalations. It is true the brilliancy of this 
discovery is especially conspicuous in its applications to surgery ; but the 2 
FLINT, 
benefits conferred on medicine are not vastly inferior, and would alone 
entitle it to rank with discoveries to be characterized as pre-eminently 
Evidence of progress equally obvious, although less striking, is affoided 
by enlargement of the boundaries ot knowledge in different directions, 
iUnder this head are embraced all facts relating to the nature of diseases, 
their anatomical characters, their causation, their discrimination from 
each other, their natural history, the principles of treatment, the relative 
value of remedial or curative agents,the introduction of new lemedies 01 
therapeutical methods and effective measures of prophylaxis, ivot stop- 
ping to consider in these relations the history of Medicine in the united 
States during the past Centennial period, I pass to another aspect of 
The progress of Medicine in any country is shown by the prompt 
recognition of advancements in knowledge and improvements ongi- 
natimr in other countries. After, for example, Harvey’s great discovery, 
tardiness of its recognition in any country betokened lack ot progress. 
So with regard to discoveries of every grade, and improvements great 
or small, it is proof of progress when they are promptly recognized in 
countries other than those in which they originated. Readiness in the 
importation of knowledge is thus a criterion, as it is, of course, a means 
of progress. I need not add that the rapid diffusion throughout a country 
of knowledge, either imported or of native growth, is both a criterion and 
a means of progress. Further, a spirit of progress is shown by the prompt 
recognition and diffusion, not alone of actual advancements in knowl- 
edge and real improvements, but of doctrines and novelties which fail to 
stand the test of time. Thus, in the eighteenth century, a spirit of pro- 
gress must have been wanting wherever but little was known of the 
theories of Stahl, Hoffmann, and Boerhaave. This statement is not incon- 
sistent with the belief that the prevalence of these theories impeded 
advancement in actual knowledge of medicine and leal impiovements in 
medical practice. , , 
With these explanations of the term progress in Medicine, let us sur- 
vey the medical history ot the United States. 
We celebrate in this anniversary the lapse of a hundred years of our 
existence as an independent people. A hundred years is but a small 
space in the life-history of a nation. We have passed through infancy; 
we are hardly beyond adolescence, and, as we hope and believe, senescence 
is far in the future. Our infantile and our adolescent condition are, of 
course, to be taken into account in our reflections upon the influences 
affecting the progress of Medicine. 
When in 1776, by a Csesarean section, we were separated from the 
mother country, Medicine existed in a state ready for progressive devel- 
opment and growth. The number of educated and able physicians was 
by no means insignificant. Conspicuous among these weie Rush, Moigan, 
Shippen, Thomas Bond, of Philadelphia ; John and Samuel Baid, Petei 
Middleton, Richard Bailey, Jacob Ogden, Cadwallader Golden, of Hew 
York; Benjamin Gale, of Connecticut; Joseph Warren, William Aspm- 
wall, and the centennarian Holyoke, of Massachusetts. At our nation s 
birth, the lives and labors of these men and their coadjutors had a poten- 
tial influence in determining the commencing progress of Medicine. 
Medical education had an embryonic existence in two medical schools, 
■one in Philadelphia and the other in Hew York, and there were germi- 
nations of medical literature. ADDRESS ON MEDICINE. 
3 
In the history of American Medicine prior to the Revolution we find 
in operation a source of influence which has largely affected medical 
progress in this country during the last hundred years, namely, the re- 
cognition and adoption of advancements, real or apparent, in other 
countries. A striking instance in the colonial period was the introduc- 
tion of the inoculation of smallpox by Zabdiel Boylston in 1771. Boyls- 
ton inoculated his son about two months after the date of the inoculation, 
at the instance of Lady Mary Wortley Montague, of her daughter, and 
without knowledge of the latter fact. Boylston himself inoculated 
two hundred and forty-seven persons within a year after his first inocu- 
lation, whereas, in England, during that period, and prior to the inocu- 
lation of the daughters of the Princess Caroline, it had been practised 
in only twenty cases. Virulent as was the opposition on this side of the 
Atlantic, Boylston’s life even being endangered, the practice in England 
was still more violently opposed. Its sinfulness was proclaimed from 
the pulpit, it being likened on one occasion to the smiting of Job with 
boils by Satan, “ the deluded preacher,” quoting from Boylston’s biogra- 
pher (Thacher), “ wishing to have it understood that the Devil was the 
first inoculator, and that poor Job was his first patient.” 
The Revolutionary struggle, while it suspended teaching in medical 
schools, labors in literature, and studies requiring tranquil leisure, doubt- 
less gave an impetus to medical as well as surgical progress. It enlarged 
opportunities for, and enforced closer attention to, the observation of 
certain diseases; it enhanced the urgency of prompt and successful 
methods of treatment; it opened up the subject of hospitals, and it stimu- 
lated to measures of prophylaxis. Herein is, in some degree, a compen- 
sation for the barbarism of warl It is not surprising, then, that, with 
the antecedent history of American Medicine, medical progress was re- 
newed with much activity after the achievement of independence. As 
illustrations of this activity, after the war had ended (1783), and prior 
to the beginning of the 19th century, two rival medical schools in Phila- 
delphia had gone into operation, coalesced, and been united with the 
University of Pennsylvania, the faculty then consisting of Rush, Kuhn, 
Wistar, Shippen, Benjamin Smith Barton, and James Hutchinson; the 
Philadelphia Dispensary for the relief of the sick poor, the first institu- 
tion of its kind in the United States, had been established ; the trustees 
of Columbia College in Hew York had organized a medical school, which, 
however, from local difficulties, had not accomplished much ; a medical 
department of Harvard University had been instituted, with John War- 
ren, Waterhouse, and Aaron Dexter as professors; medical societies had 
been incorporated in Massachusetts, Yew Jersey, and Yew Hampshire, and 
the publication of the “Medical Repository,” a quarterly journal, which 
lived to the completion of twenty-three volumes, had been commenced. 
It is worthy of note that, prior to this century, Dr. Ezekiel Hersey, of 
Hinghara, Massachusetts, had bequeathed a thousand pounds, his widow 
the same sum, his brother, Dr. Abner Hersey, of Barnstable, and Dr. 
John Cuming, of Concord, each five hundred pounds, to be applied to 
the support of a Professor of Anatomy and Surgeryin the Harvard Medi- 
cal College. The sum of one thousand pounds toward the support of an 
additional professor had been bequeathed by William Erving, Esq., of 
Boston, It would have been pleasant to have cited these examples as 
precedents of many similar contributions for the promotion of medical 
education; but, it must be confessed,the subsequent history of Medicine 
in the United States furnishes little to boast of in this regard. It is, how- 4 
FLINT, 
ever, a question, the discussion of which would he here out of place, how 
far the interests of Medicine in this country would have been advanced 
by the endowment of professorships in medical colleges. As an illustra- 
tion of interest in medical progress felt by persons not members of the 
profession, in 1798 Ward Boylston secured to the Harvard 
School a fund yielding an annuity, for annual prizes for competitive dis- 
sertations on medical subjects, of one hundred and thirty-three dollars. 
These prizes are continued at the present day. The same public-spirited 
citizen of Boston founded the medical library which bears his name, and 
contributed in various ways to the promotion of medical education. 
Another conspicuous illustration was the active co-operation of the great 
Franklin in founding and in the management of the Medical College of 
Philadelphia. Franklin was president of the board of trustees, and the 
meetings were held at his house until within a few months of his death. 
During the period in our history of which I am now speaking, Cullen 
was the master-spirit in Medicine. Hot content with being an expounder 
of the doctrines of Boerhaave, or a follower of his commentator Yan 
Swieten, he promulgated a system of his own. Fie had the boldness to 
abandon giving lectures in the Latin language. His teachings, with 
those of his able colleagues Monro, Gregory, Black, Young, and Home, 
had made Edinburgh the centre of medical education. The College of 
Philadelphia, which in 1791 was merged in the Medical Department of 
the University of Pennsylvania, had been modelled after the school in 
Edinburgh, the latter having been modelled after the famous school of 
Leyden. All the professors of the Philadelphia College had graduated 
at Edinburgh. Hence, in this period of our history, the Cullenian sys- 
tem was adopted, although, as will presently be seen, its supremacy was 
not long maintained. It is evidence of activity at this period that an 
American edition of Cullen’s work entitled “First Lines of the Practice 
of Physic” was published in 1781, his lectures on the Materia Medica 
having been published in Philadelphia in 1775.1 Bush, in a letter to 
Cullen, written in 1783, said, in relation to the American edition of the 
“First Lines,” that it “had a rapid sale and a general circulation 
throughout the United States. It was read with peculiar attention by 
the physicians and surgeons of our army, and in a few years regulated 
in many things the practice in our hospitals.” He added : “ Thus, sir, 
you see you have had a hand in the revolution, by contributing indi- 
rectly to save the lives of the officers and soldiers of the American 
army.” 
I have cited illustrations enough to show the activity of medical pro- 
gress prior to the nineteenth century. The experience acquired in the 
war of the Revolution, the enthusiasm arising from the sense of national 
independence, the number of American physicians who had completed 
their medical education in European schools and imbibed the spirit of 
master minds in the profession, the pressing need of educated and skilful 
practitioners—these were potential influences affecting the progress of 
Medicine in the early days of the Republic. 
Let me refer in this connection to the position held by the city in which 
we are assembled, in her relations to the progress of Medicine in the 
United States. At the time of the Revolution, Philadelphia was distin- 
guished for her able and learned physicians and surgeons. They inau- 
1 For these and other facts relating to the history of this period, I am indebted to Car- 
son’s History of the Medical Department of the University of Pennsylvania. ADDRESS ON MEDICINE. 
5 
gurated systematic medical instruction on this continent prior to the 
Revolutionary war, and again directly peace was declared. At the 
time to which our survey of the history of Medicine has extended, 
Philadelphia was the acknowledged seat of medical education. This 
pre-eminence she has held from that time to the present. In the number 
of medical men who have been educated at her schools ; in the great 
preponderance of her medical literature, and in her large proportion of 
the distinguished representatives of the different departments of Medi- 
cine, she has had no compeer in the new world. To the influence of her 
example is to be attributed much of the activity of progress in other 
cities of the Union. If, in the future, she should cease to preserve the 
relative position which she now deservedly holds, it will be, in no small 
measure, from the spirit of honorable emulation awakened and sustained 
by her admirable example. In saying what I have said, I feel that I may 
assume to speak in behalf of the medical profession of the United States. 
It was most fitting that an International Medical Congress, in celebra- 
tion of our centennial anniversary, should assemble in the city of Phila- 
delphia. 
We have now to inquire concerning influences affecting medical pro- 
gress after the commencement of the nineteenth century. At the end 
of the first quarter of this century, there were at least twenty colleges in 
active operation, distributed among sixteen of the States of the Union, 
the number of students in the year 1825 exceeding two thousand. Of 
these twenty colleges, six'may be distinguished as Metropolitan, being 
situated in Boston, Hew York, Baltimore, or Philadelphia. Let us do 
justice to the so-called Provincial schools as affecting medical progress. 
They furnished formal instruction to many who were unable to bear 
the expenses of long journeys and a residence in metropolitan towns. 
A considerable proportion of students then, as now, pursued their stu- 
dies in part at institutions near at hand, and, in part, at schools in the 
cities just named. The provincial schools, each within a certain area, 
developed interest, inquiry, and study among members of the profes- 
sion, thus raising the standard of medical acquirement. They awakened 
an ambition to become teachers by affording opportunity for the display 
of talent in that direction. If it be said that in the establishment of 
these schools the founders were not altogether disinterested, but may 
have been actuated by motives relating to personal distinction and suc- 
cess ; this may be said with not less pertinency of metropolitan schools, 
and, moreover, such motives are not unworthy. If it be said that they 
have occasioned local jealousies and feuds; this is not less true of metro- 
politan schools. Thacher states with respect to the conferring of degrees 
upon the two first graduates of the Harvard Medical College, that, 
“ from a spirit of envy and jealousy towards the professors, great oppo- 
sition was made, and it was by the address and perseverance of John 
Warren that the object was finally accomplished.” The success of medi- 
cal schools in the city of Hew York was for several years retarded by 
local opposition; and the same difficulties were experienced in the early 
history of the schools in the “ city of brotherly love.” Hot a few of the 
professors in the larger schools of our country first tested their powers, 
and acquired experience as teachers in the smaller schools. The latter 
have had not an inconsiderable share in promoting the progress of Medi- 
cine. 
Within the first quarter of the present century, about twenty medical 6 
FLINT, 
journals were established. These contributed largely to the promotion 
and diffusion of medical knowledge. The subsequent multiplication of 
journals has not been proportionate to the increase and extension of 
our population, those now in existence not much exceeding twofold the 
number which had existed in 1825. Hitherto, as now, a considerable 
proportion have had a limited local circulation, having been issued gene- 
rally in places where medical schools were established, and being in a 
certain sense the organs of the latter. These facts are not stated by way 
of disparagement. Of the great service rendered to medical progress b}T 
the larger and widely distributed journals, it is not necessary to speak ; 
but, in justice to those comparatively small, and circulating within 
restricted limits, it should be said that they have in no small measure 
been serviceable. They have aided in diffusing medical intelligence. 
They have incited to reading, thought, and profitable discussion. They 
have increased the number of contributors to medical 
would be easy to cite numerous instances of valuable contributions 
which have appeared in journals relatively obscure. 
The bibliography of the first quarter of the present century shows a 
fair list of original works, foremost in number and influence being the 
writings of Hush. Some of the works of this voluminous author, and 
other contributions to medical literature during this period, were repub- 
lished abroad and translated into different languages. The profession of 
this country were by no means wholly dependent on foreign works. It 
would, however, have betokened a lack of the spirit of progress had an 
acquaintance with foreign authors been restricted by prejudice or indif- 
ference. It was far otherwise. English works were the authorities in 
Medicine, and many of those who could afford, the time and expense, 
crossed the Atlantic (the voyages requiring at least two months) in order 
to finish their studies in Edinburgh or London, the schools in these cities 
at that time taking precedence of those on the continent of Europe. The 
reminiscences of the Revolutionary struggle, and a renewal of war with 
the mother country during this period, had no repressing influence on 
the attachment to the medical literature and the distinguished teachers 
of Great Britain. Is it unpatriotic to say this with gratification and 
pride? May we not claim in behalf of Medicine that it tends to raise 
its followers above political contentions'. May I not refer to our late 
domestic strife as affording illustrations of a brotherhood which the 
legitimate objects of Medicine render impregnable! 
"As a source of influence affecting the progress of Medicine, the forma- 
tion of medical societies in the early, and still more in the latter, part of 
the present century is to be mentioned. Without going into historical 
details, suffice it to say, that thereby the advancement and diffusion of 
knowledge have been greatly promoted. Moreover, to voluntary asso- 
ciations Is due, in a great measure, the character of the profession as 
regards medical ethics and its position in relation to illegitimate systems 
of practice. I must be content with simply referring, in this connection, 
to one of the most important of the agencies concerned in medical pro- 
gress. 
In pathology and therapeutics during the early part of the present 
century, the influence of surviving his death, was still great. 
Rush, however, a pupil and a fervent admirer of Cullen, was too bold 
and independent a thinker to be satisfied with being an expounder of his 
teacher’s doctrines. In those days an object of medical philosophy was ADDRESS ON MEDICINE. 
7 
to reach a theory which should reduce to a simple system the practice of 
medicine—an object which, were it attainable, would obviate many of 
the difficulties in the way of diagnosis, embarrassing the practitioner of 
the present day. Rush was the author of a theory, the unity of disease. 
According to this theory all morbid phenomena are the varied manifes- 
tations of a single entit}7. This is not the time nor place to enter into any 
discussion of the merits of medical theories, or to consider their practical 
effects. Whatever may be thought of the “ theory and practice of physic” 
as taught by Rush, he influenced largely pathological views and thera- 
peutics during his lifetime, and the influence of Ins writings continued 
after his death. The system of Brown, the opponent of Cullen, had its 
advocates in this country—a system leading to rules of practice directly 
in conflict with those inculcated by Cullen and Rush. Even the extrava- 
gances of Darwin’s Zoonomia, which was republished in Yew York and 
Philadelphia in the latter part of the eighteenth century, with an intro- 
ductory address and an appendix by Charles Caldwell, were not without 
influence. Toward the close of the first quarter of the present century 
(1823) the “Study of Medicine,” by John Mason Good, was republished in 
Boston, a work inaugurating the “ physiological system” in nosology and 
practice. It is evidence of a true spirit of progress that, of the different 
systems, none had exclusive sway, and that, although there were enthu- 
siastic partisans of each, many, if not the majority of, thinking minds 
were guided by a rational eclecticism, selecting from any whatever com- 
mended itself to reason and experience. With regard to this point I 
quote from the worthy historian of “Medicine in America,” Thacher, 
the following, written in 1828; “We recognize in our institutions no 
uniform theoretical system as the rule of practice. Medical history 
affords abundant evidence of the instability of human systems. Every 
age has teemed with theories or visionary hypotheses fleeting as the wind, 
scarcely surviving their authors, but yielding to others as transient and 
unsubstantial as themselves. The medical authorities most respected are 
Cullen, Rush, and Good. These, modified and improved according to 
the judgment and views of the respective professors, are adopted and 
taught in the various American universities.” 
The introduction of vaccination in the beginning of this century was 
a striking instance of the prompt recognition and adoption of a great 
discovery. Jenner’s “ Inquiry into the Causes and Effects of the Yariolse 
Yaccinse” was published in London in 1799. In the following year 
Benjamin Waterhouse vaccinated four of his children with virus received 
from Jenner, and tested their insusceptibility to smallpox by exposing 
them to infection in a hospital for the treatment of patients with the 
disease. In 1801, Yalentine Seaman commenced vaccination in Yew 
York. Its speedy employment throughout the United States was 
unattended by the violent opposition which characterized its early 
history in the country honored by this greatest of all discoveries, as 
measured by its influence on the physical welfare of mankind. 
In 1817, an important event denoting progress was the project for the 
formation of a Rational Pharmacopoeia. This project originated with 
Lyman Spalding, and the initiatory steps were taken by the Yew York 
County Medical Society. In 1820, a convention of delegates from the 
different medical colleges and societies throughout the Union assembled 
at Washington and adopted an American Pharmacopoeia, which, with 
decennial revisions, has been continued up to this date. 8 
FLINT, 
The second quarter of the present century is an eventful period in the 
history of Medicine. The great American discovery of the annihilation 
of pain by anaesthetic inhalations was made in this period. It is signifi- 
cant of a cosmopolitan spirit pervading the medical profession throughout 
the civilized world, that this discovery was at once recognized and 
adopted in other countries. The first application to capital operations 
in surgery was in Boston, in September, 1846 ; and in the following 
January the brilliant success of this application was demonstrated in 
the hospitals of London and Paris. Directly following the application 
to surgery, anaesthetic inhalations entered into the treatment of diseases 
both here and abroad. 
Surveying the more memorable of the events relating to the medical 
knowledge of this period, it began with the advancement of morbid 
anatomy to the rank of a distinct department of medical study. This 
was the result of the labor of Bichat, which gave birth to General 
Anatomy. That great work, the “Anatomic Generate” of Bichat, trans- 
lated by George Hayward, was published in Boston in 1822. Bayle and 
Hollard’s Manual of General Anatomy was translated by Gross in 1828, 
and Bedard’s Elements of General Anatomy, which appeared in 1823, 
was translated by Joseph Togno, and published in Philadelphia in 1830. 
The Profession of this country were prepared by these works, together 
with the older works of Baillie, Meckel, Portal, Laennec, and others, for 
the grand development of this study by Cruveilhier, Andral, Lobstein, 
in France ; by Mueller, Gluge, Otto, Henle, Vogel, Hasse, Rokitansky, 
in Germany ; and by Carswell, Craigie, Hodgkin, and Hope, in Great 
Britain. With the writings of these distinguished authors the Profession 
of this country became immediately conversant. Some of the French 
and German works were translated, and all were brought to the notice 
of medical readers by means of analytical reviews. The spirit of pro- 
gress was shown by the efforts to keep pace with the advancement in 
other countries. To compete with these in the bibliography of this 
study was not to have been expected; yet in 1829 appeared “A Treatise 
on Pathological Anatomy,” by Horner, in two volumes; and in 1839 an 
elaborate work by the honored President of this International Congress, 
then a professor in the State which gave to the profession McDowell. 
Horner and Gross were thus pioneer authors in this branch of American 
medical literature. It is noteworthy that, for several years prior to the 
publication of the work by Gross, he had held a chair of pathological 
anatomy in the Cincinnati Medical College. I am fully warranted in 
saying that this field of observation was diligently cultivated by not a 
few, and that there was a general appreciation of its importance in 
relation to the knowledge of diseases. To the study of Pathological 
Anatomy during nearly all the period to which our attention is now 
directed, and up to the present moment, have been devoted the labors of 
one who, had he not been, unfortunately (I would almost say, with the 
utmost respect, blamably), satisfied with the gratification pertaining to 
his attainments, together with his usefulness as a professor, and his 
invaluable services as curator of one of the richest of the museums in 
this country, if not in the world, his name would have become so 
identified with the study in the medical literature of every country that 
it would have been superfluous to refer in this manner to J. B. S. 
Jackson. 
The discovery of auscultation can hardly be said to have had much 
efficient influence on the progress of Medicine prior to the second quarter ADDRESS ON MEDICINE. 
9 
of the present century. It is true, Laennec’s great work was published 
in 1819, and the translation by Forbes appeared in London in 1821; but 
the discovery met with distrust, and was disparaged by some authorita- 
tive authors. Forbes’s translation was republished in this country in 
1830, and from this date the great value of auscultation began to be 
recognized. Soon after this date James Jackson, Jr., opened up the 
study of the abnormal modifications of expiratory sounds, which Laen- 
nec had, in a great measure, overlooked. In 1835 Gerhard published a 
treatise on the diagnosis of thoracic diseases to “supply the wants of his 
classes and of others who felt an interest in the subject.” In 1836 the 
Massachusetts Medical Society published dissertations, b}r Oliver Wendell 
Holmes, Robert W. Haxall, and Luther Y. Bell, submitted in competi- 
tion for a Boylston prize, which was adjudged to Holmes. As early as 
in 1832 James Jackson, in his visits at the Massachusetts General Hos- 
pital, always carried a stethoscope, the counterpart of that which Laen- 
nec was accustomed to make with his own hands ; and the daily record 
dictated at the bedside of each patient embraced signs obtained by per- 
cussion and auscultation. It was not long before physical exploration 
by th,ese methods entered more or less into clinical and didactic teaching 
in most of our medical colleges, and thence speedily found its way into 
private as well as public practice. The Profession of this country were 
not tardy in accepting the fruits of Laennec’s discovery, and this branch 
of practical medicine has ever since had with us not a few zealous vota- 
ries. Our medical literature, during the past forty years, contains a good 
proportion of contributions relating to it. 
The physical diagnosis of diseases of the heart, which at the present 
time has reached such perfection, may be said to have had its point of 
departure in the works of Bouillaud and Hope. Hope’s treatise, issued in 
London in 1832, was republished, with notes by the late Dr. C. W. Pen- 
nock, in Philadelphia in 1812. In the interim Dr. Pennock and Prof. 
E. M. Moore, of Rochester, FT. Y. (1839), had devised and carried out a 
series of accurate experiments to elucidate the mechanism of the heart 
sounds. At the end of the second quarter of the present century, the 
progress in this province of medicine had been made familiar to American 
medical readers by the republished works of Andry, Raciborski, Barth 
and Roger, Aran, Stokes, Latham, Walshe, Blakiston, Watson, and by 
the writings of Gerhard, Bowditch, and Swett in our own country. 
A memorable event in the medical history of this period was the 
publication, in 1827, by Richard Bright, of his “ Reports of Medical 
Cases.” A full analysis of this work appeared in the February number 
of the first volume of the “American Journal of the Medical Sciences,” 
in 1828. The editor concluded the article with these words; “As Dr. 
Bright’s volume is so costly as to preclude its circulation in this country, 
and as its contents are highly interesting, we have been induced to ex- 
tend our notice beyond the usual limits, and have placed in our periscope 
some of the most interesting cases.” I make this reference to show how 
quickly important contributions to our knowledge abroad were brought 
to the notice of medical readers on this side of the Atlantic. The 
name Morbus JBrightii had not as yet been applied to affections, the ana- 
tomical characters of which Bright was the first to describe. Naturally, 
the morbid anatomy of these affections for some time engrossed atten- 
tion ; the fruits of their clinical study could not be gathered at once. 
It was not until the publication of Christison’s work, in 1889, that the 
profession in Great Britain and this country began to grasp the scope of 10 
FLINT, 
their pathological relations. Bright himself could hardly have dreamed 
of the extent of the new field in pathology which his researches opened 
up. Our present knowledge of uraemic conditions in etiology and symp- 
tomatology, acquired chiefly during the last quarter of the present cen- 
tury, he could not have anticipated. I think it not too much to say 
that the progressive developments in this field of pathology have been 
as fully appreciated and their influence on the practice of medicine has 
been as marked in this as in any country. 
The quotation just made from the “ American Journal of the Medical 
Sciences” leads me, in this connection, to refer to analytical reviews and 
bibliographical notices as affecting medical progress. This journal, suc- 
ceeding the “ Philadelphia Journal of the Medical and Physical Sci- 
ences,” in fact a continuation of the latter, dates from the year 1827. 
In the advertisement accompanying the first volume it was said ; u Ar- 
rangements have been made to import regularly from London and Paris 
every new medical work, and to obtain in exchange almost every medical 
journal published in Europe. These will be placed in competent hands 
for analysis or review, and whatever is valuable in their contents shall 
be laid before our readers as early as possible.” Writing, as I do, after 
having examined the volumes issued during the second quarter of the 
present century, I am impressed with the fidelity with which this 
promise was fulfilled. They contain reviews or notices of the important 
publications in England, France, Germany, and other countries during 
that period. This journal, continued up to the present time, under the 
same title, issued by the several successors of the first publishers, Lea & 
Carey, for more than forty years under the editorship of Isaac Hays 
(who, although a veteran in journalism, is not yet entitled to be called 
venerable), has had a powerful influence on the progress of Medicine in 
this country. This influence has been exerted not less by its original 
communications than by its reviews, notices, and general intelligence. 
Without any disparagement of the numerous able and useful periodicals 
during the last half century, may we not, with a feeling of pride, refer 
especially to a journal which, with such a history, is now the oldest rep- 
resentative of medical periodical literature, and which has probably a 
circulation larger than that of any other in Europe or America 
The physiological discoveries of Magendie, Charles Bell, and Marshall 
Hall, relating to the nervous system, forerunners of a further unfolding 
of the functions of this system within late years by Bernard, Brown- 
Sequard, and others, had a considerable influence on pathology and prac- 
tice; an influence which, by means of republications, reviews, and con- 
troversial articles, was perhaps felt as speedily here as abroad. But a 
memorable event in physiology, having direct practical bearings, was of 
American origin, namely, the observations and experiments of Beaumont 
in the case of Alexis St. Martin, published in 1833. Beaumont’s pro- 
longed, patient, careful, conscientious researches, demonstrating more 
completely than had yet been done the agency in digestion of the gastric 
juice, furnished important facts in relation to its quantity, its compo- 
sition, the circumstances affecting its secretion, together with the relative 
digestibility of different articles of food, and the influence upon digestion 
of local and general morbid conditions. These facts have, in the main, 
been corroborated by experimental physiologists who have since studied 
1 The American Journal of the Medical Sciences is the oldest of living journals, consider- 
ing it as a continuation of the Journal of the Medical and Physical Sciences. ADDRESS ON MEDICINE. 
11 
the functions of the stomach by means of artificial gastric fistulse in infe- 
rior animals. Looking at the fruits of his labors as affecting the pro- 
gress of medicine, may we not claim for them sufficient value to entitle 
the name of Beaumont to he mentioned in connection with the names 
of Magendie, Bell, and Hall ? 
The writings of Broussais are to be reckoned among the memorable 
events of the period under survey. The “History of Chronic Phlegma- 
sise” was translated by Isaac Hays and E. Eglesfeld Griffith in 188 i ; in 
the same year his “ Treatise on Physiology applied to Pathology” was 
translated by John Bell and La Eoche, and in 1832 his work entitled 
“Propositions Embodying Principles of Physiological Medicine” was 
translated by Hays and Griffith. By these publications the profession in 
this country were made acquainted with the so-called new physiological 
doctrine more commonly known as Broussaism. For a time it had not 
a few ardent supporters, prominent among whom was the late Professor 
Samuel Jackson, whose work, entitled “ Principles of Medicine,” was 
based upon it. The circulation of this work was arrested by the author, 
as was understood, because it became inconsistent with his more matured 
views, an act which reflected honor upon his character as an honest 
inquirer after truth. Like the systems of Eush, Brown, and Cullen, 
Broussaism had its day ; hut, unlike the preceding systems, this has had 
no successor. With the fall of Broussaism the race of isms became ex- 
tinct ; theoretical dogmas as the basis of different schools or sects have 
been relinquished to the illegitimate pathys. 
Broussais, however, was not the sole last survivor of the race. Coeval 
with this doctrine was one of American birth, namely, the doctrine of 
Cooke. John Esten Cooke, a man of much ability and of sterling moral 
worth, at that time Professor of the Theory and Practice of Medicine in 
the worthily distinguished Transylvania University, in 1831 published 
at Lexington “ A Treatise on Pathology and Therapeutics.” After com- 
menting on the extreme proneness of medical philosophers to frame hypo- 
theses instead of following the true spirit of inductive logic, he enunciated 
the doctrine that hepatic congestion is the fons et origo of most of the 
phenomena of disease. This doctrine was not entirely new, but it was 
carried by Cooke to the extreme point of culmination. Its practical 
effect on therapeutics was an excessive use of purgatives, and especially 
calomel in large doses. In those days of hypercatharsis, patients were 
purged by the followers of this system as patients had never been 
purged before. Cooke was afterward Professor of Practice in the Medical 
School at Louisville, and for a long time a dose of calomel which he had 
prescribed was preserved as a curious specimen in the museum of that 
school. With the audacious extravagance which characterizes American 
humor, it is related of a Kentucky yeoman that, finding in one of his 
fields crude mercury in considerable quantity, visions of wealth from a 
mine of quicksilver loomed up in his imagination; but they were dis- 
pelled when it was ascertained that the spot had been a burial ground 
for the remains of patients treated in accordance with this doctrine! 
An influence which contributed to prevent the formation of new sys- 
tems of medicine, and to promote in not a small degree, true medical 
progress, belongs to the works of Louis. Louis’s “ Eesearches on Phthisis,” 
translated by Cowen, revised and altered by Bowditch, his “ Eesearches 
on the Typhoid Affection,” translated by Bowditch, and his “Eesearches 
on the Effect of Bloodletting in some Inflammatory Diseases,” translated 
by Putnam, with a preface and appendix by James Jackson, were 12 
FLINT, 
published in this country in 1886. His “Researches on Yellow Fever,” 
translated from the manuscript by Shattuck, appeared in 1889. I need 
not enter into an exposition of the method of study which Louis exem- 
plified in these works. It would be out of place, even if time permitted, 
to discuss here the merits of this method. Of its influence, suffice it to 
say that it has led to a large proportion of the actual knowledge of the 
clinical history of diseases, of their anatomical characteristics, of the 
diagnostic value of symptomatic phenomena and of therapeutical agen- 
cies, which has been acquired within the past forty years. Of the per- 
manency of acquisitions in knowledge to which it has already led, let 
this statement suffice; the works of Louis, within the limits of the 
means of observation available in bis time, are as valuable to-day as at 
the date of their appearance. The method of study inaugurated by him 
was a new departure of the Philosophy of Medicine, offering now, and in 
all time, rich returns for honest work. 
The study of medicine in the direction given to it by the labors of 
Louis, led to an appreciation of the importance of knowing the natural 
history of diseases. Jacob Bigelow struck a key-note in his discourse 
on “ Self-limited Diseases” in 1885. From that time our teachers and 
writers have been alive to the truth that knowledge of the intrinsic 
tendencies of diseases must underlie actual progress in therapeutics. 
The true spirit of medical philosophy, after its emancipation from the 
thraldom of theoretical systems, speedily found expression in the works 
of Stille, Bartlett, Ware, Holmes, and others. The influence was soon 
felt in medical practice. Progressively, in this country, practitioners 
became more reserved in the use of heroic measures of treatment, and 
polypharmacy fell into disrepute; they became less ambitious to be the 
masters,and more content to remain the servants of nature; efforts were 
made to bring experience to the test of the numerical method of inves- 
tigation, and “ expectation,” using this terra in its true sense, took its 
proper place in clinical medicine. Is it presumptuous to affirm that these 
criteria of veritable progress have been not less, and perhaps, in some 
regards even more marked in the medical practice of American physi- 
cians than of those in the older countries, by whose writings and oral 
teachings we have largely profited? 
Warned by the length already of this discourse, I must not linger 
with other topics relating to the history of the second quarter of the 
present century. There are two events of importance, belonging to this 
period, to be added to those already noticed, namely, the publication of 
the United States Dispensatory and the organization of the American 
Medical Association. The first edition of the Dispensatory by Wood and 
Bache was published in 1833. With the additions and improvements 
called for in the successive thirteen editions, this work has met fully 
the wants of the practitioner, holding its place still, without a competitor, 
and, to say the least, comparing favorably with similar publications in 
other countries. The American Medical Association was instituted in 
1847, by the Profession, “for the protection of their interests, for the 
maintenance of their honor and respectability, for the advancement of 
their knowledge and the extension of their usefulness.”1 Since its 
organization annual meetings have been held, excepting a portion of the 
period during which intercourse of the Profession of the North and the 
1 Quoted from the resolution adopted by the Convention which preceded the first meeting 
of the Association. ADDRESS ON MEDICINE. 
13 
South was suspended by civil war. At these meetings representative 
members of the profession in all parts of the country have been brought 
together under circumstances conducive to fraternal union and good 
fellowship; and the twenty-six volumes of “ Transactions” contain much 
that is valuable, more especially in relation to climatology, and the dis- 
eases prevalent in different parts of the United States. The Association 
has encouraged original papers by prizes, and has kept the Profession in- 
formed of important contributions to knowledge by reports on Medical 
Science and Literature, and on the Progress of Medicine, Surgery, and 
Midwifery. In these different ways its influence has been not incon- 
siderable. 
The literature of any province of knowledge gives the truest expression 
of progress, while it does most toward promoting it. In this period, the 
increase of publications was proportionate to the growth of our nation in 
population and material interests. I shall enumerate some of the valuable 
contributions to practical medicine, without attempting to give a full 
list of them. My distinguished friend who will address the Congress on 
the subject of American Medical Literature will supply deficiencies here 
and elsewhere. 
The “ Practical Esssay on Typhous Fever” by Nathan Smith, although 
printed in 1824, may be reckoned as entering into the literature of this 
period. One of our most accomplished writers (Bartlett) in his work on 
the Fevers of the United States, published in 1842, says of this “ modest 
unpretending essay.” “To an American practitioner it is worth in- 
finitely more than all the modern English treatises put together.” The 
attainments and skill of that great man, united with perfect integrity 
and simplicity of character, excite our admiration ; nor can we less 
admire the energy and pluck which led him to establish the medical 
school of Dartmouth College, himself the sole professor for ten years, a 
faculty of one, but that one Nathan Smith, prominent among the medical 
heroes of the early age of our republic. 
The progress of knowledge of the essential fevers, within this period, 
was in no small measure affected by contributions to American medical 
literature. Gerhard, Pennock, in 1836, and Shattuck, in 1839, were the 
first to contribute ample clinical observations, showing the essential 
points of distinction between typhus and typhoid fever. To these 
observers belongs the credit of the doctrine of the non-identity of these 
fevers, a doctrine which, after twenty years of hesitation and discussion, 
was generally recognized as sufficiently established. James Jackson’s 
Report, in 1838, and Enoch Hale’s paper, in 1839, embodied the results 
of the application of the method of study inaugurated by Louis to the 
common continued (typhoid) fever of New England. The treatise on 
the Fevers of the United States by Elisha Bartlett, published in 1842, 
the fourth edition revised after the author’s death by Alonzo Clark, has 
been, almost up to the present time, a standard work, and is too well 
known to need any commendation. Meredith Clymer, in an article on 
typhoid fever, published in 1846, was the first to describe in this country 
the disease now known as relapsing fever. It may, perhaps, be assumed 
that the communicability of typhoid fever was first demonstratively 
shown by the circumstances attending an outbreak of the disease in a 
small hamlet in Western New York, in 1843.1 
1 Account of an epidemic fever which occurred at North Boston, Erie Co., N. Y., in 
October and November, 1843; American Journal of the Med. Sciences, July, 1845. 14 
FLINT, 
Important contributions relating to the differential characters of 
remittent fever and its clinical history were made by Stewardson, in 
1841 and 1842; by Swett, in 1845 ; by Anderson, Frick, Stilld, and 
Boling, in 1846. Our present knowledge of this disease rests mainly on 
the facts contained in these contributions. 
The doctrine of the combination of different fevers, or the “ blending 
of types,” was taught by Dickson and Drake, in contradiction of the 
theory of Hunter, which denied that the special causes of two or more 
diseases can act conjointly in the organism. The doctrine is now suffi- 
ciently established by clinical proof. Drake, in 1832, contributed a 
series of papers in advocacy of the animalcular hypothesis of the origin 
and diffusion of* epidemic cholera, and subsequently, in his great work, 
he argued at length, and cogently, for this hypothesis as applied to 
the etiology of other diseases. And in this connection the remarkable 
work of Mitchell on the “ Cryptogamous Origin of Malarious and Epi- 
demic Fevers” may be referred to. This work was published in 1849. 
If, as is perhaps more than probable, the truth of the “germ theory,” 
as it is now termed, be hereafter confirmed by direct observation, the 
writings of Mitchell and Drake on this subject will be cited as evidence 
of an "insight into the mysteries of etiology beyond that of their con- 
temporaries ; and at the psesent moment, when this theory is the subject 
of so much interest, these writings claim careful study. 
In referring to Drake, I cannot forbear a passing tribute of admiration 
of the talents and labors of that truly great man. As an eloquent 
expounder of medicine he was without a superior; and when we look 
at the work which he performed, as a writer, a medical teacher, and in 
travelling over large sections of our country, gathering from personal 
inquiries and observations materials for his treatise on the “Principal 
Diseases of the Interior Valley of Forth America,” which he did not 
live to complete, we must consider his name as worthy to be enrolled in 
the list of our medical heroes. 
The treatment of the periodical fevers with large doses of quinia, 
together with the discontinuance of the so-called preparatory treatment; 
the extent to which this drug may be given without risk of harm; the 
entire safety of its use in the state of pyrexia; and the advantage of 
arresting the paroxysms as speedily as practicable—points at that time 
in opposition to the prevalent practice—wTere set forth in this country as 
early as 1841.1 It may be added that the views which have since pre- 
vailed in reference to these points were adopted earlier, and diffused 
more quickly with us than in other countries. 
The literature of this period embraces many contributions relating to 
yellow 7 fever. Prominent among the contributors are the names of Bar- 
ton, Barrington, Cartwright, Dickson, Fott, Simons, C. H. Stone, Ashbell 
Smith, and "Fenner. Our medical literature from the earliest period of 
our history has abounded in writings on this subject, to which justice 
has been done in that marvel of laborious erudition, the Treatise on 
Yellow 7 Fever, by La Roche, published in 1855. The contributions by 
the authors just named, and others, led to the present prevailing belief 
in the non-communicability of the disease, but the portability of its 
special cause, and in the injudiciousness of perturbatory measures of treat- 
ment. 
Of contributions other than those relating to the essential fevers, and 
1 Vide article in the American Journal of Medical Sciences, No. for October, 1841. ADDRESS OX MEDICINE. 
15 
in addition to those referred to in other connections, I shall mention 
several, by no means undertaking to enumerate all, or even the greater 
part, of those which promoted progress by extending, more or less, the 
boundaries of knowledge. 
John Ware, in an analysis of his recorded experience published in 1831, 
brought to bear the numerical method upon the use of opium in the 
treatment of delirium tremens. The results of the analysis have ever 
since been a basis of practice in that disease. The same writer in a series 
of articles on croup, published in the latter part of this period, delineated 
clearly the different affections then embraced under that name. The 
distinctions derived from his recorded experience and founded in nature, 
are as valid to-day as at the date of their publication. 
John B. Beck’s treatise on infant therapeutics in 1849, had much 
influence in restraining the over-use of potential measures in the treat- 
ment of diseases in infantile life. The article by Cammann and Clark 
on auscultatory percussion, published in 1840, introduced a new method 
in physical exploration, and gave the results of its employment in obtain- 
ing accurate measurements of internal organs. The treatise by Amariah 
Brigham on “The Influence of Mental Cultivation on Health,” published 
in 1832, and the “Inquiry concerning the Diseases and Functions of the 
Brain, Spinal Cord, and Herves,” published in 1840, contained original 
views important in their practical applications. Horace Green’s treatise 
on “ Diseases of the Air Passages,” published in 1846, originated the prac- 
tice of making topical applications within the larynx, the feasibility of 
which was accepted after considerable distrust and acrimonious discussion. 
In 1841 Alonzo Clark began to treat acute peritonitis with large doses 
of opium, excluding calomel and venesection. He carried the use of 
opium further than had previously been done, and ascertained that the 
disease in some cases causes a marvellous tolerance of this remedy. The 
treatment exclusively or chiefly by opium has been generally adopted in 
this country, and may properly be called the American method. More- 
over, the success of the use of opium freely in peritonitis, has led to the 
useful employment of this remedy in other affections. Bowditch’s first 
employment of suction for the withdrawal of liquid from the pleural 
cavity, through a small canula, was a few weeks after the end of this 
period; but he then carried into effect a procedure which he had pre- 
viously maturely considered and resolved upon. I may, therefore, in this 
connection, refer to an improvement in the practice of medicine, the 
merits of which it were needless at this day to discuss. The use of the 
term aspiration, in place of the homely word suction, and the invention 
of more complicated instruments, have recently given to the procedure 
a new and more attractive aspect. The successful practical application 
of the method, however, belongs to the history of American medicine; 
and, taking into view the wide range of the application, it is certainly 
worthy of being reckoned among the important events affecting medical 
progress within the past century. 
These contributions, cited from personal recollection, without searching 
medical annals in order to extend the list, suffice to show that during 
this eventful period, the field of practical medicine in this country was 
not without efficient workers, and not wholly unproductive. Directing 
attention to another aspect of medical literature, the evidence and the 
means of progress are shown by the number of works relating to the 
Principles and Practice of Medicine. Original works in this department 
of literature began to appear prior to the second quarter of the present 16 
FLINT, 
century; but the number within this period was considerable, namely, 
the works of Dewees, Eberle, Dunglison, Cooke, Fort, Gallup, Hosack, 
Chapman, Paine, Dickson, Stille, and Wood. A considerable number of 
republished works, generally with notes or additions by American edi- 
tors, were added to those of native production. In this list are the works 
of Marshall Hall, revised and much enlarged by Jacob Bigelow and 
Oliver Wendell Holmes, Craigie, Billings, Elliotson, with notes by Stew- 
ardson ; Gregory, with notes by Peixotto, Alison, Williams,and Latham; 
Graves’s System of Clinical Medicine, with additional lectures by Gerhard, 
and Stokes’s lectures with an equal number added by Bell; Andral’s 
Clinique Medicale, translated by Spillan ; Chomel’s Pathologic Genflrale, 
translated by Oliver and Morland, and the lectures by AVatson. In addi- 
tion to works of this character were several on a larger scale designed 
for reference in regard especially to the practice of medicine, namely, the 
London Cyclopaedia of Practical Medicine, edited with large additions 
by Dunglison ; Copland’s Medical Dictionary, with copious notes by Lee; 
the Library of Practical Medicine by Tweedie, with American notes and 
additions by Gerhard. To this class of works belongs the American 
Cyclopaedia, edited by Hays. AVLen to these productions, native and 
foreign, we add the original treatises by Dewees, Eberle, Condie, and 
Stewart on the diseases of children ; not a few works, original and im- 
ported, treating of particular classes of diseases; the works on materia 
medica by Barton, Bigelow, Coxe, Chapman, Eberle, Dunglison, Griffith, 
Carson, Paine, Ellis, Beck, Bell, Harrison (all. native productions), and 
the medical dictionary, by Dunglison, have we not, in this point of view, 
evidence of an activity in the means of progress creditable to a nation 
under the age of fourscore years? Was not the growth of medical 
literature, in this aspect, proportionate, to say the least, to the increase 
of population, the extent of territory populated, and the advancement in 
other provinces of practical knowledge? 
Survey for an instant this period from one other standpoint, namely, 
the number and character of prominent members of the medical profes- 
sion. We must recognize in the personal influence exerted by individuals 
in their respective spheres as teachers, practitioners, and members of 
society, one of the most potent of the agencies concerned in progress. 
Some of those who, regarded from this standpoint, have a record most 
honorable to themselves, are still with us—may they live long to receive 
the honor which is their due 1 On the list of those who have departed 
for another life are such names as James Jackson, Samuel Jackson, 
Samuel Jackson of Northumberland, Chapman, Mitchell, Hosack, Ware, 
Gerhard, the two Becks, McNaughton, Pennock, Revere, Drake, Joseph 
M. Smith, Francis, Parrish, the elder Shattuck, Dunglison, Dickson, Fen- 
ner, Stearns, Bartlett, Moreton Stille, Caldwell, Laßoche, Lee, Swett, 
Twitched, Tally, Mussey ; and to these, and such as these, might be 
added the names of a host of practitioners who, without engaging in 
the labors of literature, or in medical schools, exerted within greater or 
lesser spheres, an influence promoting the diffusion of knowledge and 
ennobling the character of the physician. 
Having reached in our survey the third quarter of the present century, 
I hasten to say that the concluding part of ray address will be brief. I 
shall not enter into historical details for reasons which are obvious, in 
addition to the desire not to presume too much upon your patience. The 
professional lives of a considerable proportion of those whom I address ADDRESS ON MEDICINE. 
17 
embrace the last twenty-five years, and everything of importance per- 
taining to the history of this period is familiar to them. Moreover, to 
particularize events, to notice contributions to medical literature, and to 
refer to individual members of the profession, would involve questions 
of delicacy which I prefer to avoid. I shall therefore limit myself to a 
few remarks on topics suggested by the inquiry, what are some of the 
characteristics of medical progress in the United States within the last 
quarter of a century and at the present time? 
The predominant and most distinctive characteristics of progress in 
the medical science of this period, are derived from the developments in 
histology. Pathological histology followed the acquisition of a new 
territory in anatomy by Schwann in 1839, as the morbid anatomy of the 
tissues had followed the Anatomic Generate of Bichat; and the devel- 
opments by means of the microscope in the study of disease are to be 
dated chiefly after the middle of the present century. Prior to this, 
however, microscopy had enlisted the interest of medical teachers and 
students in this country, as well as in Europe; and as early as 1851, a 
prize was awarded to Burnett (whose untimely death was a loss to 
science), by the American Medical Association, for an essay on “ The 
Cell; its Physiology, Pathology, and Philosophy,” embracing deductions 
from elaborate original investigations. Histology entered at once into 
the formal instruction of many, if not most, of our medical schools. 
Our pilgrim sons who previously had paid homage at Paris, Edinburgh, 
Dublin, and London, for the past quarter of a century have gathered in 
larger numbers at Vienna and Berlin, Histological researches having 
been prosecuted with most zeal by our Austrian and Prussian brethren, 
German medical literature has thereby acquired a prominence and an 
influence which might be cited as a characteristic of Medicine at the 
present time. I need hardly say that it would not be fitting on this 
occasion to inquire into the actual increase of our knowledge to be 
ascribed to the progress of histology. That a vast and fruitful domain 
in physiology and pathology has been brought under cultivation, and 
that it has already jdeldect rich harvests, cannot be doubted. Herein 
will the history of Medicine in our day be ever memorable. And the 
future is full of promise when obstructions from doctrines connected 
with bioplasm, cyto-blastema, autogenesis, and the so-called cellular 
pathology shall have disappeared. With improved methods and increased 
power of microscopical investigation, it may not be long before the 
germs (using this word in either a literal or a figurative sense) of infec- 
tious and contagious diseases will be brought within the scope of ocular 
demonstration. When this is accomplished, it requires no prophetic 
sagacity to foresee that the influence on the progress of pathology, thera- 
peutics and prophylaxis must be immense. Perhaps in the developments 
of the future, the labors of our zealous workers will bear an honorable 
part. I will venture to add that we are not to expect from histology a 
royal road through pathological mysteries; but, profiting by past experi- 
ence, and avoiding doctrines based largely on hypotheses, our researches 
in this direction should go hand in hand with the tedious, but, if properly 
conducted, safe studies in clinical medicine. 
I have alluded to pilgrimages to other countries. The desire to profit 
by the distinguished schools abroad has always been an American charac- 
teristic. In the first half century of our national existence, the schools 
in Great Britain were chiefly resorted to; in the third quarter of the 
century, those of France had the preference, and in the last quarter the 
2 18 
FLINT, 
German schools. Some members of the Profession look with disfavor on 
this yearning for foreign instruction. It is thought to be antagonistic to 
a proper sense of a national independence, implying a sort of vassalage 
unfavorable to original developments. I do not share in these views. 
For us, in our adolescent age, to regard with a certain degree of defer- 
ence the institutions of older countries, is not a confession of dependence, 
but a becoming modesty. It is true that opinions which have travelled 
across the Atlantic acquire in the estimation of many an exaggerated 
importance; the weight of far distant authority is apt to be over-estimated. 
This is, in a measure, counteracted by judgments formed after personal 
inspection. A discriminating mind judges fairly from intercourse with 
distinguished teachers and writers of their claims as authorities. In this 
point of view our sojourners abroad benefit, not only themselves, but their 
brethren at home. In some instances, it must be admitted, personal ad- 
miration or attachment leads to a discipleship which is exceedingly un- 
favorable to the progress of the disciples; yet these render service by 
diffusing the opinions of their masters among those who, uninfluenced by 
partisan zeal, consider and judge without prejudice. That our independ- 
ence in thought and judgment is not compromised, is shown by what I 
believe may be stated as a fact, namely, no one who has returned from 
abroad and remained a mere satellite of a foreign luminary, has ever 
attained to any great distinction in the minds of his countrymen. 
A characteristic of the past quarter of a century, and of the present 
time, relates to the increase of American medical literature. FTative 
productions have been and are steadily increasing in number, and this 
not to the exclusion of, if, indeed, there have been any decrease in, the 
republication of foreign works. In order to appreciate the significance 
of this increase, as showing the progress of native literature, we must 
consider that American productions are in immediate competition with 
English works, the merits of which have been established, and for the 
republication of which the authors can claim no royalty. Much has been 
said of the injustice done to American authors by the want of an interna- 
tional copyright law. Without entering into any discussion of this topic, 
I will simply say that such a law is called for, not so much for the encour- 
agement of our own literature, as in behalf of the just claims of foreign 
authors. The medical profession of this country have given ample evi- 
dence of a disposition to receive with discriminating favor native produc- 
tions. I presume lam not in error in saying that our medical publishers 
are always ready to print any work which, from its intrinsic merits, may 
offer a fair promise of success. This is evidence of a demand for native 
works, inasmuch as it would imply a marvellous disinterestedness to sup- 
pose that publishers are actuated solely by a desire to promote a national 
literature. It is noteworthy that not long after French authors were 
held in special favor, the proportion of medical readers who were able to 
study the works of these authors in the language in which they were 
written, became so large as to render translations unprofitable to pub- 
lishers ; and it is probable that ere long this will be found to be the case 
in regard to publications in the German language. There will then be no 
occasion for a remark which I have heard imputed to a medical teacher 
in this country, that to know the German tongue is as essential for the 
student of medicine as a knowledge of anatomy ! 
I cannot forego a few words respecting the disposition of our English- 
speaking foreign brethren toward American medical literature. Many 
years ago an English reviewer and humorist, in a moment of irritation ADDRESS ON MEDICINE. 
19 
from circumstances of a personal nature which rendered it perfectly 
natural, exclaimed, “Who reads an American hook?” This has been 
over and over again quoted as a fair expression of the estimate in 
England of our bibliography. It should never be quoted except to add 
that its author was more unjust to his own countrymen than to us. All 
who are familiar with the medical periodical literature of Great Britain 
must have been impressed with the great candor and consideration 
generally shown in reviews and notices of American works. Hot unfre- 
quently these have received far more approbation abroad than at home. 
This is certainly a fitting occasion to declare that there is no ground to 
impute a prejudice,either in Great Britain or any other country, against 
our national literature. 
That our works and periodical literature have in general a practical 
character is readily accounted for by our youth as a nation, and the 
rapid extension of population over a vast continent. With increase of 
years, and the altered circumstances incident thereto, our future in 
medical literature, it may safely he predicted, will show a wider scope. 
Thus far in our progress, the pressing claim upon our writers has been 
the wants of our widely separated brethren as regards qualification for 
the active duties of the practitioner. 
The statement just made suggests the leading characteristic of our 
medical schools, namely, practical instruction. I shall not encroach 
upon the ground of the distinguished physician who is to address us on 
the subject of American medical education. He may, perhaps, point 
out defects in our educational institutions. That there are defects, is 
not to be denied. But, that we may not do injustice to our predecessors 
and our contemporaries, let it be considered how peculiar is the situation 
of the profession of this country in this regard. The whole responsibility 
for medical education, inclusive of the means for its promotion, rests, for 
the most part, with the Profession. Medical schools are without the 
jurisdiction of the general government, and our numerous States can 
only control, of course, those within their respective borders. Hence, 
uniformity throughout the country in legislating in behalf of medical 
education is impracticable. Legislative provisions for the increase and 
diffusion of medical knowledge are apt to be regarded in the light of 
appropriations for the benefit of a particular class of citizens. A diploma 
or a license to practise medicine from some legally authorized body is 
easily obtained, and the law practical!} 7 places no obstacle in the way of 
practising without either. How, in view of these facts, which are, of 
course, familiar to all of us, how are we to explain the annual gatherings 
of medical students and practitioners in large numbers in Philadelphia, 
Hew York, and other cities, many coming from distant parts of the 
Union, incurring expenses which often involve much exertion and self- 
denial? What other explanation is there than, first, that certain of our 
medical schools afford large opportunities in the way of practical in- 
struction ; and, second, that there is a wide-spread yearning for these 
opportunities simply on account of their intrinsic worth? Have we not 
here the evidence of a spirit of progress in both teachers and pupils, 
which is creditable to the past and present, as, also, an earnest for the 
future? Let us strive to remove defects, to correct abuses, and to 
improve, as fast as practicable, our system of instruction; but let us not 
be led into a disparagement of what has been done, and is now being 
done, in behalf of medical education. 20 
FLINT, ADDRESS ON MEDICINE. 
A few words in conclusion, concerning characteristics which relate to 
medical ethics. At the Convention held in 1847, resulting in the orga- 
nization of the American Medical Association, a code of ethics was 
adopted, and it has since been formally recognized as having binding 
force upon members of state and local societies throughout the Union. 
This code embodies rules which were in accordance with the usages of 
worthy members of the profession in this country, and with established 
ethical principles in other countries. It defines simply and clearly the 
line of conduct to be followed in the relations of medical men to each 
other and the profession at large, to their patients, to the public, and to 
those who, adopting a practice based on an exclusive dogma, or from 
unworthy acts, are not to be considered as professional brethren. This 
code has remained unaltered and with undiminished force for more than 
a quarter of a century. I state this fact as a characteristic which reflects 
honor on the representatives of American Medicine. I claim, in behalf 
of the Medical Profession of the United States, that the great majority of 
its members have been loyal to the code of ethics. With no penalty for 
violations of ethical rules beyond the loss of professional fellowship, a 
penalty which may be made subservient to selfish advantage, loyalty is 
secured by motives of self-respect, and regard for the power of the Pro- 
fession. It may perhaps be claimed that in no other country is the line 
dividing legitimate and illegitimate medicine more distinctly defined 
than with us; and nowhere are instances of affiliation with irregular 
practitioners more infrequent. The same may perhaps be said of the 
number of those who, having once been in respectable professional 
standing, have yielded to the temptation of originating secret nostrums 
and patenting remedies or inventions. These characteristics are consistent 
with the fact that in no other country does the Profession of Medicine 
hold a higher social position or exert a greater public influence than in 
these United States of America. 
Gentlemen, Members of the International Medical Congress: At this our 
Centennial Anniversary it has seemed to me appropriate to survey 
“ Medicine and Medical Progress in the United States” from the points 
of view which excite feelings of gratification, hope, and faith. We 
should by no means shut our eyes to errors, defects, and short-comings ; 
but there are other occasions more suitable for regarding these. The 
history of American Medicine for the past century contains much that 
we may rightly be proud of; we have no reason to be ashamed of its 
present condition, and need we doubt that the spirit of progress which 
has thus far guided it, will lead onward to the fulfilment of a glorious 
destiny! 21 
ADDRESS ON HYGIENE AND PREVENTIVE MEDICINE 
BY 
HENRY I. BOWDITCH, M.D., 
PRESIDENT OF THE STATE BOARD OF HEALTH OF MASSACHUSETTS. 
Gentlemen of the International Medical Congress : 
I have been requested to speak to you on Public Hygiene and its great 
resultant, State Preventive Medicine, as it appears to an observer looking 
back upon the Centennial Period now just closing. 
As a measure of vital importance to the well-being of any community, 
and, as such, worthy to be cheerfully and amply sustained by great cities 
and States, Public Hygiene, as we now understand that term, has, till 
within a very short time, been wofully neglected, save when, under the 
stimulus of some great and terrible epidemic, frantic but temporary ef- 
forts have been made to stay the plague by Hygienic or by other means. 
Of late, however, a new and better era seems opening to our view, and 
State Preventive Medicine affords us higher hopes for all coming time. 
To this last, this noblest phase of Public Hygiene, its very gradual evo- 
lution out of the dogmatism and skepticism of the past, its present 
status, our duties relative thereto, and our golden hopes for its futuie, I 
crave your candid consideration during the brief hour I shall have the 
honor of addressing you. If, at the termination of my remarks, our 
foreign associates feel that I have given them but little information, and 
my countrymen find that I have said but little in praise of my country, 
one and all of you, I trust, will generously allow me the credit of having 
endeavored at least to speak the exact truth about the various States, 
and the United States as a Ration, in their relation to these matteis. May 
I dare to hope that the plain unvarnished story of our present condition 
and short-comings, in regard to practical public hygiene, may do some- 
thing to stimulate each State and the United States governments, to do 
more thoroughly the plain duties that lie open before them? 
Before laying down the propositions I intend to defend, let me say we 
cannot, in the consideration of them, confine our view simply to this 
country, but must frequently refer to the men and ideas of other countries, 
as well as to those of our own. 
And let me add that in citing the names of men who have been promi- 
nent here or elsewhere, I shall do so without intending either praise or 
blame, but simply as those of illustrious representatives of great systems 
of medicine or of wide currents of thought, upon which the greater part 
of mankind has been borne almost unconsciously along. 
NATURAL DIAHSIORS OP THE CERTERRIAL PERIOD. 
In its Medical and Social ideas, the past centenary easily divides itself 
into three unequal epochs, viz.: I. From 1776 to 1832, the era of theory 
and of dogmatism ; 11. From 1832 to 1869, or that of strict observation, 22 
BOWDITCH, 
and of bold, often reckless, skepticism; 111. From 1869 to 1876, which 
is destined to continue and progress while the nation itself lives, the 
noblest and most beneficent of all, viz., that in which the profession, 
joining heartily with the laity and aided by the material and intellec- 
tual resources of great States, will study to unravel the primal causes of 
ail disease with the object of preventing it. It is the epoch of State 
Preventive Medicine. 
First Epoch, or that of Medical System-making, filled with an Over- 
weening Confidence in our Art, with little or no Faith in the Vis 
Medicatrix Naturae. 
(From 1776 to 1832, or thereabouts.) 
The influences which governed this period and the previous centuries, 
may be briefly sketched as follows : The illustrious Boerhaave began to 
enunciate his doctrines of disease at Leyden in 1701. His doctrines held 
sway in America until about 1765, or ten years before the opening of 
our centennial period. Following closely after him came Hoffmann, 
Cullen, Brown, and Darwin, and each with his own peculiar sj^stem. 
Our ingenious and renowned countryman, Benjamin Rush, in 1790, 
proclaimed his own idea, viz., that a convulsive motion of the arte- 
ries is the proximate cause of all fevers, however different the causes 
may be.1 Benjamin Rush was one of the most noteAvorthy men this 
centenary has produced, and as he had more influence than any other 
one person upon medical opinion during the fiTst epoch; as he is called 
by one of his admirers “the American Sydenham,” it seems to me not 
improper that I should on this occasion mention some facts of his life. 
He was born Dec. 24,1745, on his father’s plantation, fourteen miles 
from Philadelphia; consequently he was just entering the prime of man- 
hood in 1776. Seven years before that, at the early age of twenty-four, 
he had been appointed Professor of Chemistry in the University of Penn- 
sylvania. 
During the Revolutionary Avar he resigned this professorship, and Avas 
made Medical Director of the Middle Department of the Continental 
Army. In 1789 he resumed his professorship of chemistry, and in 
October of that year became Professor of the Theory and Practice of 
Medicine, which office he held until his death in 1813. During all these 
years he energetically and ably defended his system, as he had previously 
upheld Cullen’s. He has left accounts of various epidemics of yellow 
fever and other observations and essays, which are valuable as records 
of the period and as evidences of his intellectual and moral Avorth. 
He Avas essentially a medical system-maker like his predecessors. He 
believed fully in heroic remedies, and rather scoffed at Nature’s influence 
in disease. His pupils spread themselves over some of the Eastern but 
more over the Middle, Western, and Southern States, carrying Avith them 
not only the Avisdorn but the errors of their great master. He thus had 
vast influence on the medical ideas of the country. This becomes still 
more evident when we remember that he held the chief professorship in 
the foremost medical school in the Union, and that, toAvards the end of 
his career, the number of students that listened to his eloquent and per- 
1 Rush’s Med. Inquiries and Observations, Philadelphia, vol. iii. p. 11. ADDRESS ON HYGIENE. 
23 
suasive tongue, amounted to about four hundred, annually drawn to 
Philadelphia from every part of the country. 
The reputation of our profession among the more intelligent of the 
laity, when Dr. Push was in his full glory, is brought out in the follow- 
ing extract from a letter from Thomas Jefferson to his friend Dr. Wistar 
in 1807. He writes, “I have myself lived long enough to see the fashions 
of Hoffmann, Boerhaave, Stahl, and Brown succeed one another like the 
shifting figures of a magic lantern, and their fancies like the dresses of 
the doll-babies from Paris; becoming from their novelty the vogue of 
the day, and yielding to the next novelty their ephemeral favor.”1 We 
may well fear that Mr. Jefferson’s opinion of our profession was not 
much improved when Dr. Rush dogmatically proclaimed, during a 
heated discussion with some physicians of Philadelphia, that the time 
must and will come when the general use of calomel, jalap, and of the 
lancet without a physician’s advice, will he considered “among the most 
essential articles of the knowledge and the rights of man”! 
But Dr. Rush’s theory and dogmatism were destined to fall under the 
influence of the fascinating theories of Broussais. Broussais was born 
in 1772, when Rush had already given evidence of his great powers as a 
teacher. This great Frenchman died in 1838, after his authority, which 
had been world-wide, had begun to decline. Broussaism spread widely 
in America, but less in Hew England, which had been trained more to 
close observation under the great masters in medicine, Dr. E. A. Holyoke, 
Dr. James Jackson, and others, than it did in the Middle, Western, and 
Southern States. In or about 1832, the system began to fall in America, 
as it had been previously falling in Europe. With its fall our first 
epoch terminates. The whole tenor of medical opinion during the 
period, as you readily perceive, with its theories and systems concocted 
in great minds, was not in the smallest degree suited to the growth of 
State Preventive Medicine. 
Second Epoch ; or that of Observation, and accurate recording and 
SUBSEQUENT ANALYSIS OF PACTS ; WITH AN EXTREME CONFIDENCE IN 
HATURE’S POWER IN DISEASE; A CORRESPONDING SKEPTICISM IN REGARD 
TO THE USE OF DRUGS ; AND, FINALLY, DIM PRESAGES OF PREVENTIVE 
Medicine. 
(From 1832 to 1869.) 
The second epoch presents characteristics precisely the reverse of the 
first. Louis and his numerical method stand prominent in it. 
Louis may be called the lineal scientific descendant of such men as 
William and John Hunter, Morgagni, etc. His nature rebelled against 
the dogmatism of the past, unsupported as it was by well-ascertained and 
recorded facts. You all know the great and wide-spread influence of his 
works in Europe; Broussaism fell before them. The epoch in America 
commenced when Dr. Gerhard, of Philadelphia, and Dr. James Jack- 
son, Jr., of Boston, and other pupils of the observation school, returned to 
America. Drs. Gerhard and Jackson had high mental powers finely 
cultivated. Both came back devoted friends, and admirers of Louis as 
a man and as a medical reformer. They were full of the new ideas, and 
enthusiastic defenders and expounders of them. The influence of these 
' Works of Thomas Jefferson, Washington, 1854, vol. ix. p. 107. 24 
BOWDITCH, 
ideas on the currents of medical thought in America was immense. It 
extended gradually over the whole country. 
It must be admitted that at times there was something unwarrantably 
supercilious in the terms in which some of Louis’s disciples, rather than 
Louis himself, spoke of the past. It seemed as if they would, if they 
could, wholly ignore the past in their desire to build up the medicine 
of the present and of the future upon the firm basis of strictly recorded 
fact. By this exclusive spirit of man}7 of the “Numerical School,” 
while infinite good has been done, a great apparent evil to practical 
medicine has arisen. I allude to the more or less complete skepticism on 
the part of many of the profession, and of the laity, in regard to every 
species of medical treatment, except perhaps that of good nursing. The 
pendulum of human thought, as always happens in such cases, has swung 
far beyond the line of exact truth, so that from a blind faith in the 
supreme power of our art, noticeable in our first epoch, many have passed 
into an equally blind and fanatical skepticism in reference to it. Never- 
theless I presume all will admit that Louis’s school was needed to sweep 
away all false systems unsupported by well-recorded and sufficiently 
numerous facts. 
Louis’s doctrines, though vehemently opposed by some who had 
grown old under the previous epochs, were received by most young men 
with joy, and philosophical minds among the elders were charmed with 
the accuracy observable in Louis’s Numerical Method, as shown in his 
writings. Under the direct or indirect influence of his writings and 
Numerical Method, which Dr. Guy1 considers the guiding power of the 
present time, a very large number of independent observers and workers 
have been educated in this country and in Europe. The mottoes selected 
by Louis as his own guides are identical with those of modern science. 
In addition to the specific disciples of Louis, there were three others, 
all men of great intellectual ability, who by their writings and teachings 
powerfully influenced this epoch. I allude to Jacob Bigelow and Elisha 
Bartlett, of America, and John Forbes, of England. Two of this trio 
are now dead. Dr. Bigelow entered his 90th year last February. His 
life nearly spans the century, and as it closely unites the first and second 
epochs, I hope you will permit me to allude to him somewhat as I did 
to Dr. Rush. He was born February 27, 1787 ; that is, two years before 
Dr. Rush resumed his professor’s chair in the University of Pennsylvania, 
at the close of the Revolutionary war. After a most honorable and 
successful life as a physician, and as professor of the Harvard Medical 
School, Dr. Bigelow has been, for years, totally blind, and hopelessly 
unable to move from his bed for more than eighteen months. To a 
casual visitor he seems as bright and as witty as ever, while his beautiful 
and uncomplaining submission to what most persons would deem a sad 
fate, raises him in the eyes of all beholders even higher than he was at 
the period of his greatest energy and fame. A visit to his bedside 
affords a delightful sense of repose from the bustle of daily toil. It was 
my happiness to have a long conversation with him a few months ago. 
I found he retained a vivid reminiscence of the days of his youth. He 
was one of Dr, Rush’s class, and bears full testimony to the eloquence 
and earnestness with which Dr. Rush advocated his medical theories 
more than half a century since, and only a few years before he died. 
1 Public Health; Win. A. Guy, M.8., F.R.S., London, 1874. ADDRESS ON HYGIENE. 
25 
Dr. Bigelow full}7 sustains me in my position relative to Dr. Rush’s views 
of Nature and of our Art. 
Dr. Bigelow’s influence upon this second epoch was diametrically 
opposed to Dr. Rush’s, during the first. Dr. Bigelow earnestly supported 
the principles and methods advocated by Louis and the Numerical 
School. By his writings and teachings he had great power over New 
England directly, and indirectly over the medical opinions of the whole 
country, by means of his pupils, who migrated to our most distant States. 
The skepticism of Louis’s School was augmented thereby. 
Whilst Dr. Bigelow was thus sapping our faith in drugs, or rather in 
the polypharmacy which had come down to us from the past, there was 
sent forth from the chief medical journal of that day, viz., The British 
and Foreign Medical Review,1 and apparently under the sign manual 
of its able editor, John Forbes, one of the boldest avowals of the same 
creed. I allude to Dr. Forbes’s article entitled “ Homoeopathy, Allopathy, 
and Young Physic.” Admired by the few, ignored or violently opposed 
by the many, it has nevertheless stood the test of time, as one of the 
strongest of protests against the drugging of the day, and an eloquent 
defence of the power of Nature in the treatment and cure of disease. 
Notwitstanding ray high estimate of this manifesto by Dr. Forbes, I 
think that very few young men would be led by it to the study of our 
most noble profession. It is too destructive of all earnest faith in our 
art. It was, however, exactly what was needed at the time. The poly- 
pharmacy of a past age then and there received its most deadly blow. 
Nature and her powers were glorified. And no one who reads carefully 
the record of the preceding time can doubt that such a blow was needed 
previously to our entering upon a new phase of development of medical 
science, expressed by the term State Preventive Medicine. Dr. Forbes, 
indeed, frequently and in glowing terms, hints at the “ reformation” that 
is impending. He is no prophet, although he sees dimly, what is to be 
“ the result of mature reflection, and of the labor of many years and 
many hands” (p. 262); “we must,” he says, “ direct redoubled attention 
to hygiene, public and private, with the view of preventing disease on a 
large scale.” “ Here the surest and most glorious triumphs of medical 
science are achieving and to be achieved” (p. 263). 
The third individual, who by his writings and as a teacher, seems one 
of the noblest types of men of this epoch, is Dr. Elisha Bartlett. He 
was undoubtedly one of the most philosophical medical men America 
has produced during the Centenary. And his heart was devoted to 
medical reform. He was born at Smithfield, R. 1., in 1805, and died 
July, 1855.2 He practised the profession for some years in Lowell, Massa- 
chusetts, and was respected as an able and most accomplished physician. 
He felt, however, as he said to me, “ called to teach.” He was soon sum- 
moned to the chair of Theory and Practice at Pittsfield. Subsequently 
he held a professorship at Dartmouth College, New Hampshire; at the 
schools at Lexington, and at Louisville; subsequently at Baltimore, and 
finally at New York, in the University and with the College of Physi- 
cians and Surgeons. 
From these various chairs he was able to influence North, East, South, 
and West of our country. He was an admirable and attractive teacher, 
winning belief by his earnestness, his fairness of statement, and fasci- 
1 British and Foreign Med. Rev., vol. xxi. p. 502. 
2 Appleton’s Cyclopaedia. 26 
BOWDITCH, 
nating address. Though not educated under Louis, he thoroughly ap- 
preciated his methods and his writings, and proclaimed them as the dawn 
of a new and great era in the history of medicine. In Dr. Bartlett’s 
Philosophy of Medical Science, published in Philadelphia in 1844, he 
says “ that to find out the best methods of preventing, of modifying,” as 
well as “curing” disease (page 287), “is the great mission which lies 
directly before us, and this is to constitute the great work of the next 
and of succeeding generations.” He, in these words, appears as one of 
the prophets of the present epoch, now in its infancy, which delights and 
encourages us rather by its anticipations than by its actual accomplish- 
ments. 
Thus with beautiful prophecies for the future, I close the list of men 
whom I deem most prominent in carrying forward the ideas underlying 
this second epoch. But no one of them saw what we now see. Their 
mission was chiefly destructive, or constructive only in some degree of 
the natural history of disease. The general tendency of their writings, 
so far as they bore upon medical practice, was to utter skepticism not only 
in regard to the manifest absurdities of our fathers, but likewise in refer- 
ence to the good things suggested by them. Although they sometimes, 
as we have seen, hinted at prevention of disease, they did not dream of 
the noble idea of State Preventive Medicine in its widest scope which 
has already commenced in various States of this country, and among the 
nations of Europe. Their skepticism, like all skepticism, was chiefly 
iconoclastic. We need faith in an idea before we can build it up in ac- 
tual life. Such a faith we shall see breaking out in our third and last 
epoch, and to this I now call your attention. 
But before proceeding to speak of it, let me make two remarks, which 
I regret to feel compelled to submit, but for their truth I can vouch from 
my own professional experience of nearly half a century:— 
First. The medical profession as a body has heretofore taken very little 
interest in the ideas underlying preventive medicine, and hygiene, private 
or public. This must be patent to every one of us. We all know how 
few sanitarians there have been among us until very recently, and how 
little they have been to our taste. I confess myself to have been a most 
decided sinner in this matter. It is proved likewise by the almost total 
neglect hitherto of physical culture in our schools and great seminaries 
of learning. I know of but one medical college in which there is a full 
professorship devoted to hygiene. The Harvard Medical School, which 
has made great advances in medical instruction within the past ten years, 
has only a lecturer, and as I learn from students now at the school, and 
who for some few years past have been there, the subject is scarcely known, 
as compared with other branches of medical learning. 
Second. We owe to the laity, rather than to the profession, the first and 
strongest efforts in behalf of State Preventive Medicine. 
Third Epoch ; or, that in which the Medical Profession is aided by 
the Laity, and the idea of State Preventive Medicine fairly in- 
augurated, AS MARKED BY THE LEGAL ESTABLISHMENT OF THE FIRST STATE 
Board of Health. 
(From 1869, and which will reach into the far-off future.) 
The ruling idea of this epoch is still in its infancy, but it shows by 
what it has already accomplished, trivial though that performance may ADDRESS ON HYGIENE. 
27 
seem, at first glance, to be, its inherent, great, and nascent power. Its 
objects are vastly wider than those of any preceding epoch. Its destiny 
is as fixed as that of the steam-engine, the telegraph wire, the locomotive, 
or the use of anaesthetics. I cannot foresee a time when the ideas under- 
lying it will not be held in esteem and acted upon for the welfare of 
mankind. 
Among the men who stand prominent in their relations to this epoch, 
and in connection with the English speaking race, are two laymen. One 
of them I fear may be but little known to most of my hearers, or even 
to the people of his native State: I allude to Lemuel Shattuck, of Boston. 
The other is Edwin Chadwick, a Barrister of London, for many years 
known and honored by every civilized nation as one of the ablest and 
most earnest of sanitarians. 
Mr. Shattuck, in 1850, presented to the legislature of Massachusetts, 
a most exhaustive State Paper entitled, “ Report of the Sanitary Com- 
mission of Massachusetts.” In that document are laid down all the 
principal ideas and modes of action which underlie the present sanitary 
movements in Massachusetts, and I think I may also add in America. 
By this document were laid deep in the second epoch the fundamental 
ideas of the third. It was seed well sown, but destined to lie dormant 
for nearly a quarter of a century. 
The report fell flat from the printer’s hands. It remained almost un- 
noticed by the community or by the profession for many years, and its 
recommendations were ignored. Finally, in 1869, a State Board of Health 
of laymen and physicians, exactly as Mr. Shattuck recommended, was 
established by Massachusetts. Dr. Derby, its first secretary, looked to 
this admirable document as his inspiration and support. In giving this 
high honor to Mr. Shattuck, I do not wish to forget or to undervalue the 
many and persistent efforts made by a few physicians, among whom stands 
pre-eminent Dr. Edward Jarvis, and occasionally by the Massachusetts 
Medical Society, in urging the State authorities to inaugurate and to 
sustain the ideas avowed by Mr. Shattuck. But there is no doubt that 
he, as a layman, quietly working, did more towards bringing Massachu- 
setts to correct views on this subject than all other agencies whatso- 
ever. Of the second layman, Mr. Edwin Chadwick, I need say nothing. 
You all know him. Fortunately for himself, he has lived to see rich fruits 
from his labors. That was not granted to Mr. Shattuck. 
But other influences have been at work tending to the same end. Europe 
has influenced us more than at any preceding time. France long since 
entered on a career of study and of publication on public health. The 
Annales $ Hygiene Publique are proof of this. The labors of Parent-Du- 
chatelet are recognized by all. The zeal of Quetelet, of Belgium, has 
been like a household word everywhere among the laity and profession in 
every civilized State. Pettenkofer, of Munich, more recently has labored 
successfully in the same field ; and, still nearer to the present, comes up 
that extraordinary genius, Yirchow, of Berlin, great in every depart- 
ment of science or of State upon which he enters. But by far the 
greatest influence has been exerted upon us in America by England, 
who, by her unbounded pecuniary sacrifices and steady improvement in 
her legislation, and her able writers, has far outstripped any country in 
the world in the direction of State Preventive Medicine. I think I 
may, with perfect truth, say that the consummate skill in the discovery, 
removal, and prevention of whatever may be prejudicial to the public 
health, shown under the admirable direction of Mr. Simon, late Medical 28 
BOWDITCH, 
Officer of England’s Privy Council, by his corps of trained inspectors, is 
wholly unequalled at the present day, and unprecedented, I suspect, in 
all past time in any country on the globe. 
In this country the papers published more recently by several of the 
State Boards of Health, have tended to interest the whole community 
on the subject of public hygiene. The number of single laborers in the 
same held is daily augmenting. The United States Government, by its 
Army and Navy publications, previous to, during, and since the late 
Civil War, has done a vast sanitary work. The library and museum in 
the Surgeon General’s Department at Washington, commenced during 
the horrors of that contest, are also invaluable in the same direction. If 
they be hereafter thoroughly sustained by the government, as in the past, 
we cannot estimate the great advantage that will arise in all depart- 
ments of medicine, and in none more than in that of public hygiene. 
As the Crimean war taught the world very much in reference to this 
subject, so our war, dreadful as it was to both parties, was the means of 
bringing into life several most beneficent institutions which were never 
before thought of, or at least never carried out on so grand a scale. I 
allude to the Sanitary and Christian and Western Sanitary Commissions 
of the North ; to the Wayside Hospitals, Christian Relief Associations, 
and State Hospitals at Richmond, etc., of the South. Through these, 
money and food were distributed without stint to the sick and wounded, 
often to foes as well as friends, wherever found, either on the battle-field 
or in hospital. We can never know how many human lives were saved, 
or how much torture prevented, by the agents of these noble institutions 
on both sides of the line of battle. But we can estimate how much the 
desire to save life, prevent disease, and promote health, and to provide 
some of the means for so doing, were, under their blessed influence, in- 
stilled into the minds and hearts of our people from Maine to Texas. 
Great strides in Public Hygiene were also made during the war, by 
the fact that the people outside the military lines, and the officers and 
soldiers within them, very soon began to learn, by dire experience, or by 
the urgent appeals of experts in Sanitary matters, the all-important 
advantages of cleanliness, sobriety, and strict methods of action, as op- 
posed to'the distress consequent on filth,intemperance, and chaotic rule; 
and we cannot doubt that every surgeon, whether National or Confederate, 
•who served during the war, became more practically versed in the advan- 
tages of prevention of disease than he was before. All that knowledge 
is now brought back to civil life. 
The National Quarantine Conventions, so called, had also important 
influence. Four were held before the breaking out of the war, viz.: in 
Philadelphia, 1857 ; in Baltimore, 1858; in New York, 1859; and in 
Boston, 1860. The war closed their labours. From the eminent persons 
engaged in them, and attendants at the meetings, and the characters of 
the papers published, there can be no doubt that they contributed very 
much to lead the public mind to the ideas prevalent at the present time. 
In April 18, 1872, was held the primary meeting whence has sprung 
the successor of the National Quarantine Conventions, above alluded to. 
I refer to the American Public Health Association, which has held meet- 
ings in New York, Philadelphia, and Cincinnati; and will this autumn 
hold its session at Boston. Able papers have been published by it on 
various Sanitary matters, on the transmission and prevention of disease, 
on quarantine, longevity, hospital hygiene, etc. ADDRESS ON HYGIENE. 
29 
The American Social Science Association has, of late years, done most 
valuable work in the same direction. 
Among the more strictly professional institutions that have helped 
forward the cause of Public Hygiene and Preventive Medicine, may be 
named the American Medical Association. In 1847, this Association was 
instituted, and almost from its inception, it has annually published 
papers relating to our subject, and still more recently very earnest efforts 
have been made by some of its members to obtain a definite National 
Health Organization from the United States Government. The frequent 
intermingling of men, brought about by this Association, from all parts 
of the Union, has contributed to the same end. It must be confessed, 
however, that, judging from the small number of members attending the 
Section on Hygiene, that subject seems to afford less interest than any 
other. 
Finally I may assert that, during the past three or four years there 
has sprung up in many parts of the country, a wide-spread thoughtful- 
ness about the necessity and value of hygienic measures. Almost all 
persons in their various spheres, have become more accessible to the pro- 
tests of the sanitarian. Still further, it may be asserted that during this 
last epoch, short as it is, more practical work has been done among the 
people, tending to prevent and crush out disease, and more valuable 
papers written, illustrative of Public Hygiene, the world over, than since 
the Christian era began. In every State there are active and earnest 
laborers in this field, and their number is daily increasing. It would be 
impossible on this occasion, to name even a tithe of them. Some States 
in their corporate capacity, have sustained these workers for the public 
good. But I regret to say a large majority of the States and Territories 
of this Union are not yet sufficiently enlightened to appreciate the duty 
devolving on them to be careful of the health of their people. 
With these general historical remarks on the gradual evolution of 
State Preventive Medicine and Public Hygiene, during the past centen- 
nial period, I now pass to the consideration of the actual condition of 
the Country at the present time with regard to these all-important topics. 
THE PRESENT CONDITION OF STATE PREVENTIVE MEDI- 
CINE IN THE VARIOUS STATES, TERRITORIES, AND THE 
NATION. 
Several months ago I issued a circular containing several questions 
bearing on this subject, and tending to elucidate it as far as I thought I 
could do so with the means at my command. Doubtless, to critical eyes, 
objections may be made to the small number and to the relevancy and 
character of the proposed questions. It appeared to me, however, that 
a lew interrogations, all or most of them, answered, even monosyllabi- 
cally, from all quarters of the Country would enable the inquirer to get 
a glance at the present condition of Public Hygiene and of State Preven- 
tive Medicine better than he could from any large number, very many 
of which would not be answered at all from some of the States. The 
paper was sent to two hundred and sixty-seven (267) medical men living 
in the thirty-eight States, nine Territories, and the District of Columbia, 30 
BOWDITCH, 
making in all forty-eight governments. These embrace an area covering 
(25°) twenty-live degrees of latitude and (47°) forty-seven degrees of lon- 
gitude, between the Atlantic and Pacific Oceans, In the South they lie 
almost in the tropics; at the North they reach close to the coldest inha- 
bitable portion of the Globe; in all embracing an area of 3,608,884 
square miles. 
Of the character and ability of my correspondents, I would say that I 
tried to select the ablest men, and, as far as possible, those known or 
supposed to be interested in Public Hygiene ; representative men, in 
fact, resident in the various regions. I may have failed to apply to all 
who perhaps would have willingly answered my questions. If, however, 
I have selected with any accuracy, I think you will admit that their 
various reports will together constitute as full and as accurate a state- 
ment of the whole matter, so far as my questions cover it, as it is possi- 
ble for me, without governmental aid, to obtain. Replies have come 
from one hundred and sixty-seven (167) physicians, residents in every 
State and territory except the Indian Territory, which last is a reserva- 
tion held still in an unorganized state as the residence of Indians, in 
various conditions from barbarism up to a low civilization, and where 
ideas of Public Hygiene are little thought of. 
Analysis of Correspondents’ Replies. 
First Question.—Does your State by its legislation shoio a due appreciation 
of the duty devolving upon a State to he careful of the health of its people ? 
I considered this a fundamental question. The answers from the forty- 
eight States and Territories were as follows: 
Thirty-four, (34) No.1 
Eight, (8) Yes.1 
Four, (4) Indefinite.2 
Two, (2) No Reply, 
In other words, of the forty-eight governments in this Union, thirty- 
four (nearly three-quarters), by their legislative acts, have, according to 
correspondents resident therein, shown, but little care for the health of 
their people. Among those thus failing in duty, appear the great States 
of New York and Pennsylvania; I cite these two, not in invidious dis- 
tinction, but simply because they have been the chief States of our Union 
since Colonial times, and because they hold that proud position now. 
Moreover, it will be admitted by those States which have replied affirma- 
tively (1) that it is only within six or eight years that they have shown 
any marked interest on the question of State Preventive Medicine, and 
(2) that the number of deaths from preventable diseases, in every State, 
is still frightfully great, which ought not to be the fact if these States 
had really shown, for any length of time, this due appreciation claimed 
for them by my correspondents. Let not us, however, who have traced 
the very gradual evolution of the idea of State Preventive Medicine 
during the past centenary, wonder at this apparent neglect of Public 
Hygiene, shown by the various States; let us rather rejoice at even this 
small awakening of the public interest upon these matters, wheresoever 
a European civilization has any foothold. 
1 Yes or No means that a unanimous opinion was returned by all correspondents in the 
State or Territory. 
2 This term is used when the opinions of correspondents were not unanimous on any ques- 
tion. ADDKESS ON HYGIENE. 
Second Question.—Is the State willing to expend money (a) to support 
State or Local Boards of Health? (b) to carry out Scientific Investigations as 
to the causes of Disease ? (c) to repress noxious or offensive trades ? (d) to 
■prevent adulteration of food? (e) to prevent the Cattle Disease? or (f) to carry 
on any other investigations tending to promote Public Health, or to prevent ill 
Health ? 
The touchstone which tests the earnestness of an individual or of a 
Nation in reference to any subject, is a willingness to spend money in 
furtherance of it. Tested by this talisman, how stands our Country in 
reference to Public Hygiene and State Preventive Medicine? Let us look 
at the answers to the above questions. 
. Is the State willing to spend money (a) to support State or Local Boards of 
Health? The following answers were received from correspondents. 
Thirty-six, (36) ' Ho. 
Ten, (10) Yes. 
Two, (2) Ho Reply. 
The fact here brought out is that three-quarters of all the governments 
of this country are unwilling to spend money to support a State Board 
of Health. How I contend that the legal establishment of such a Board 
is the first step towards any definite sanitary organization in a State, and 
the fact that so many States have done nothing towards the formation of 
such Boards, or when legally established, have refused to pay money for 
their ample support, plainly shows the very small advance yet made by 
this country on these vital questions. Still, further, if we look at the 
States from which an affirmative reply has been received, we shall find 
that only very recently, since 1869, have any such Boards been estab- 
lished, and generally that the amount of money appropriated for their 
support is small, compared with what is spent in other departments of 
government vastly less important to human welfare. 
Is the State willing to spend money (b) to carry out Scientific Investigations 
as to the Causes of Disease? The following are the replies;— 
Thirty, (80) Ho. 
Twelve, (12) Yes. 
Five, (5) Indefinite Reply. 
One, ( 1) ‘Ho Reply. 
Thus thirty governments out of the forty-eight are reported as being 
unwilling to spend money for the scientific study of the causes of disease. 
Twelve reply affirmatively. But from several of these we find some 
qualifications of answer, e.g., “ rather unwillingly,” or “not much,” or 
“when importuned,” or “to a limited extent.” Some of the foremost 
decline to make grants for special investigation. One of the most known 
and respected Sanitarians in the Union declares that his State “grants as 
much as is asked for,” which fact, coupled with a second one, viz., that 
his State has not yet established a State Board of Health, seems to sup- 
port the idea that he and his medical associates are at fault: Hoes the 
State even now need an efficient layman to stir it up to efficient 
action? Only during the past year, has Massachusetts done anything in 
this precise direction, viz., when it appropriated ten thousand dollars 
($10,000) for the investigation of the question of the Pollution of Streams. 
As I had nothing to do with the making of that report, and as the 
majority of the committee having it in charge, was selected as the ablest 
men who could be found, though residents of other States, I feel at 
liberty to express the opinion that the sum expended was infinitely 
small in comparison with the very valuable and exhaustive report made; 32 
BOWDITCH, 
a report which will be of importance to every other State undertaking 
the same or similar trains ot investigations. 
Is the State willing to spend money (c) to repress noxious or offensive 
trades? The following answers were made:— 
Twenty-six, (26) No. 
Fourteen, (14) Yes. 
Seven, (7) Indefinite Reply. 
One, (1) No Reply. . 
A. priori, one would consider this a most legitimate and imperative duty 
of a State to so govern noxious and offensive trades that they should not 
bring ill health to the people, yet it appears that more than half of the 
States do nothing. Fourteen only seem attempting to do something. 
In this connection I cannot help referring to some results in Massachu- 
setts. , . . 
The town of Brighton is beautifully situated in an undulating country, 
within easy access of Boston, and as such admirably fitted for residences 
of the business men of the city. This beautiful suburban district vyas, 
only a few years ago, a disgusting place, in consequence ot about fifty 
vile smelling and filthy looking slaughter houses, which were dotted all 
over the township. No one could drive or go by rail through it without 
offence, and at times almost nausea. New slaughter houses were daily 
springing up. Under the influence of a law, empowering the State 
Board of Health to attend to the matter, and giving it very wide power, 
every private slaughter house has been swept away within the past eight 
years. A very large, cleanly conducted abattoir, which burns up iiy a 
great measure, if not wholly, its own noxious odors, and which is built 
a little distance from the village, now includes the whole of the indi- 
vidual slaughter houses above named. One can now drive in any direc- 
tion without offence to eye or sense of smell. Meanwhile, the price of 
land has more than doubled in value. Before this was brought about, 
however, many hearings and personal examinations were made by the 
Board. Eminent lawyers appeared and protested against its proceeding 
under the extraordinary powers which the legislature had given it, and 
which those advocates said were unconstitutional, because, as they con- 
tended, contrary to the “Bill of Rights” of Massachusetts. 
The Court, however, when appealed to, always sustained the decisions 
of the Board, and once it threatened a contumacious butcher, who refused 
to obey, with imprisonment for contempt. For these reasons and for 
others that might be named, I heartily commend the law, as it stands in 
Massachusetts, as worthy of consideration by those who wish to control 
noxious trades in other States. 
Is the State willing to spend money (d) to prevent the adulteration of food? 
Twenty-three, (28) No. 
Sixteen, (16) Yes. 
Seven, ( ( ) Indefinite Reply. 
Two, (2) No Reply. . 
Certainly an extraordinary result, but one which possibly might have 
been anticipated, when we remember the widespread system of sophistica- 
tion and adulteration known to exist among us. Rapidity and quantity 
of work rather than excellence are sought for. When Public Hygiene 
is duly thought of, and State Preventive Medicine has full sway, the 
adulteration of the food of the people will be deemed one of the most 
heinous of crimes. Practically, now it is allowed to flourish unrestricted 
in the majority of the States, even in those which have laws intended ADDRESS ON HYGIENE. 
33 
to prevent it. Europe is undoubtedly far in advance of America on this 
subject. 
Is the State willing to spend money (e) to prevent the cattle disease? The 
following answers were received: 
Twenty-one, (21) No. 
Ten, (10) Yes. 
Sixteen, (16) Indefinite Reply. 
One, (1) No Reply. 
(For remarks on this subject see Question Sixth.) 
Is the State willing to spend money (f) to carry on any investigations tend- 
ing to promote public health or to prevent ill-health ? The answers were 
these:— 
Twenty-eight, (28) No. 
Ten, (10) Yes. 
Nine, (9) Indefinite Reply. 
One, (1) No Reply. 
That is, one-half the governments seem unwilling, and less than a 
quarter claim to be willing to spend money for this purpose. This seems 
a most natural consequence to all preceding answers. 
Third Question.—Has your State established, a State Board of Health ? 
If so, (a) when was it established ? (b) What amount of annual appropria- 
tion is made for its support ? (c) Are any occasional grants made for specific 
investigations? (d) Has the Board any organized body of correspondents 
throughout the State? (e) What executive powers have been given to the Board 
in reference■ to local nuisances or noxious trades? 
Some of these questions have been fully or partially answered already. 
I shall in this place summarily include them in one answer as follows: 
Twelve only of these States have State Boards of Health. The first one 
wras legally established in Massachusetts in 1869. It operates equally 
over every portion of the State. The amount of money paid, as I have 
already stated, is small considering the wealth and population of the State. 
For special purposes, Louisiana and the District of Columbia have at times 
spent large sums. Not a single State has as yet a perfect list of corre- 
spondents or inspectors. Massachusetts has done much in this direction, 
and is annually improving her position by selecting the ablest men, phy- 
sicians or laymen, who can be found in the various towns. 
The position of correspondent of this Board is frequently considered 
an honor, though there is no pay attached to the office, and often it is 
no sinecure. In reference to executive powers given to the Board, it 
cannot be said that any State Board has plenary powers, as town Boards 
have, in some States. It is, perhaps, well that their duties should gene- 
rally be advisory merely, on certain occasions only having plenary 
powers conferred upon them, and with the right to appeal to the Courts 
to sustain their decrees, whereby the moral force of the Boards is mate- 
rially augmented. 
Fourth Question.—Have County Boards of Health been established by 
law f 
The answers are— 
Twenty-three, (28) No. 
Four, (4) Yes. 
Seven, (7) Indefinite Reply. 
Four, (4 j No Reply. 34 
BOWDITCH, 
That is, only four of the States report affirmatively. Evidently the 
necessity of such Boards is not admitted. Yet I cannot but think that 
eventually, when Public Hygiene shall have its thorough organization, 
these County Boards will form an integral part of it; certainly in the 
Southern, Western, and sparsely settled States. 
Fifth Question.—Have any Town Boards of Health been established, by 
law ? 
The answers are— 
Eight, (8) ISTo. 
Fourteen, (14) Yes. 
Twenty-two, (22) Have them by local or municipal 
rather than state law. 
One, (1) Indefinite Reply. 
Three, (8) Ho Reply. 
Which replies, as I understand them, intimate that in one-half of the 
governments many towns have established, by their inherent right of 
self-defence, local Boards of Health without first appealing to State 
Authority. 
Sixth Question.—Has the State passed, any law leading to a thorough and 
definite improvement of the Public Health ? (a) by a Sanitary Survey of the 
State ? (b) by cl law for the registration of Births, Heaths, and Marriages? 
(c) If so, how long has it been in operation? (d) Has the Registrar been able 
to draw from such records any law governing the Public Health? (e) Has any 
law been passed relating to drainage of land? (f) to irrigation? (g) to 
checking the influence of rivers by levees ? (h) to the introduction of water into 
cities? (i) to the prevention of contagious diseases? (a) Smallpox? f) 
Cholera? (y) Yellow Fever? if) Cattle Plague? etc. etc. 
It is impossible on this occasion to consider all of these questions. I 
shall make selections from the answers which will best illustrate my main 
subject. 
(a) By aSa nitary Survey of the State? The returns are as follows : 
Forty, (40) Yo. 
Yone, (0) Yes. 
One, (1) Indefinite Reply. 
Seven, (7) Yo Reply. 
One would suppose that this would be one of the first questions asked 
by the settlers of a new country, and yet, judging from our returns, not 
one of the States in this Union has ever made such a survey, save per- 
haps indirectly in connection with some matter of trade or a geological 
or other examination for the purposes of gain. Doubtless very grave 
mistakes have been made in consequence of this neglect. Considerations 
of trade and personal safety from external danger have too often decided 
the question of the site of a town. It is to be feared, moreover, that with 
the keenest examination of a locality, the emigrant, upon a new and 
virgin soil, would be unable to decide the question. For often, not until 
months after the plough has passed through it, and the colony has become 
firmly established, does the deadly malaria show itself. But when a 
State has arrived at sufficient strength and power to be able so to do, it 
would seem that a thorough Sanitary Survey should be considered the 
first of duties. And yet I doubt if any State Legislature of this Union, 
at the present time, would for a moment consider the question. It would 
be deemed a useless expense! The people will demand it ere long. ADDRESS ON HYGIENE. 
35 
(h) By a law for the registration of Births, Deaths, and Marriages? 
Sixteen, (16) No. 
Twenty, (20) Yes. 
Eight, (8) Indefinite Reply. 
Four, (4) No Reply. 
That is, one-third definitely declare that this fundamental law, upon 
which all vital statistics are founded, has never been passed. Twenty, 
less than half, have such a law. But eighteen out of the twenty use 
various qualifying phrases in regard to the character or enforcement of 
the law, e.g., “imperfect,” “ not carried out,” “defective,” “ no regular 
registration,” “ carried out only for certain great cities.” In one it is “a 
dead letter,” and in another “ not enforced ;” others have it “ a farce,” or 
that “it was enforced before the late war.” Some have “ only marriages,” 
some “ only deaths.” 
The sum total of the matter is that only two States have made affirma- 
tive replies without special qualifications. Knowing what Ido of one 
of these, viz., Massachusetts, I cannot claim that to be perfect in many 
respects. If, turning from the States, we look at the United States cen- 
suses, we find the same short-comings. For further remarks on this topic 
I refer to Question Eighteenth; remarks by Messrs. Walker and Elliott. 
No one can regret more than I do the necessity of stating these facts. 
May the sting of their severe truth, stimulate us and our children to 
better work in the coming centuries! 
(c) If so (that is, if a registration law has been enacted), how long has it been 
in operation f After the facts stated in regard to the last query, the further 
question of time seems unimportant. It is evident, however, that for the 
last ten or twenty years only, have State Registrations been carried on 
in a very few States, although some of the larger cities have had imper- 
fect returns for a much longer period. The United States Government 
has had decennial censuses since 1790. To judge of their value in certain 
respects, we have simply to look at the remarks made upon them by the- 
superintendent of the last. (Vide Question Eighteenth.) 
(d) Mas the Registrar been able to draw from such records any law govern- 
ing the Public Health? I shall make my remarks in connection with this 
subject, under the last question of the entire series. 
(e) Bias any law been passed relating to the drainage of lands? 
Twenty-four, (24) No. 
Seven, (7) Yes. 
Six, (6) Indefinite Reply. 
Eleven, (11) No Reply. 
That is, one-half report that nothing has been done by the State. Only 
one-seventh report affirmatively. But Ido not understand that in any 
case such a drainage was made for a sanitary object, but rather to im- 
prove the land for agricultural purposes. How much the Sanitaryr 
Physical, Moral, or Intellectual wealth of a people is wrapped up in simple 
drainage of the land, we may judge from the glowing account given by 
my correspondent, Hr. Breed, at Princeton, Illinois. By that it appears- 
that no less than 86,000 acres of land lying in one mass, and compre- 
hending at least half of three counties in Illinois, were drained by the 
State, with the most gratifying results upon the health and character of 
the settlers thereupon. Moreover, a great sum accrued to the Common 
School Fund of the State, from the enhanced value of the land for all 
purposes. One cannot but recommend the example of Illinois to the 
consideration of the Legislatures of many of her sister States. 36 
BOWDITCH, 
(f) Has any law been passed relating to irrigation of land? The answers 
are;— 
Thirty-one, (31) USTo. 
Five, (5) Yes. 
Five, (5 ) Indefinite Reply. 
Seven, • (7) Yo Reply. 
All the affirmative replies except one, viz., Utah, report that it was 
done for “Agricultural Purposes.” Apparently no one thought of Health 
in connection with it. Even Utah probably was induced to irrigate more 
by its actual wants than by any thought of Sanitary improvement. Year 
Salt Lake, which itself is utterly impotable, pure water was of prime 
necessity for two imperative reasons, viz., for culinary purposes, and for 
agriculture. What the Moors did for Granada, the Mormons have, to a 
certain extent, done for our American Desert, by their “thousands of 
miles of ditch under a general law,” as my correspondent graphically, if 
not scientifically, describes the immense work done by this people. 
(g) Has any law been passed relative to checking of rivers by Levees, etc? 
The answers are:— 
Twenty-eight, (28) Yo. 
Four, (4) Yes. 
■ Five, (5) Indefinite Reply. 
Eleven, (11) Yo Reply. 
In proposing the question, I had my mind chiefly on the great cities 
•situated upon our mighty Mississippi, and its various tributaries. 
Eventually, it would apply to other rivers, like the Yellowstone and 
others. In various parts of the land, I regret that my correspondents 
enable me to state but little in reference to sanitary measures connected 
with the question. It is evident that Yew Orleans, e.g., depends for its 
very existence upon them. Correspondents from Arkansas state that 
some levees have been made for agricultural purposes, and one adds sig- 
nificantly, “but it has improved the land and the health of the people 
living near the place.”1 
(h) Has any law been passed for introducing water into cities ? The an- 
swers are as follows; 
Twenty-three, (23) Yo. 
Fourteen, (14) Yes. 
Four, (4) Indefinite Reply. 
Seven, (7) Yo Reply. 
Indiana and Pennsylvania have general laws upon the subject. Pro- 
bably all the States have permitted, either by general or special statutes, 
this introduction of water, because of its prime necessity. More particu- 
larly within the last ten years have towns and cities waked up to the 
propriety of introducing fresh water from distant sources, in order to 
avoid the evil results of the possible contamination of wells from privies, 
etc., in the immediate neighborhood. 
But it is a singular fact that while thus bringing in new water, cities 
1 In the very able and interesting report of the United States Bureau of Topographical 
Engineers (Philadelphia, 1861), prepared by Capt. A. A. Humphreys and Lieut. H. S. 
Abbott, U. S. A., on the Physics and Hydraulics of the Mississippi River, etc., it is 
suggested that, eventually, there should be a uniform and scientifically constructed system 
of levees for that river, from the Ohio to below New Orleans (p. 417, etc.). Surely such a 
plan would be worthy of the nation, and, under the idea of its value to commerce between 
the several States and foreign nations, would it not be legitimate national work under our 
Constitution ? ADDRESS ON HYGIENE. 
have not often scrutinized its exact purity, nor have they sufficiently pro- 
vided against its future impurities. Boston, Albany, and I fear Chicago 
and Philadelphia, and I doubt not many other cities in this Union, might 
he cited in proof of the truth of this proposition. Some of these cities 
have wholly ignored the warnings of sanitarians in this respect, listening 
to selfishness and political partisanship, rather than to the dictates of 
Hygienic Law. As they have sown the wind, so, at some future time, 
they will doubtless reap the whirlwind, if an epidemic like Cholera 
should sweep over the land. 
(i) Has any law been passed relative to the prevention of contagious dis- 
eases ? (a) Smallpox. The answers are : 
Sixteen, (16) Ho. 
Twenty-one, (21) Yes. 
Seven, ( 7 ) Indefinite Reply. 
Four, (4) No Reply. 
There must be some error here, for I cannot think that sixteen of the 
States have, as yet, passed no law relative to smallpox. And yet from 
the way in which the laws on this subject are neglected, or limited of 
operation even in those States which claim that they have proper laws ; 
and from the fact that we have smallpox epidemics all over the country 
constantly prevailing, which could easily be prevented by vaccination; 
from all these facts, I feel sure that great ignorance and carelessness on 
the subject are to be found everywhere in this country. The recent 
events in Montreal, relative to vaccination, in which a mob of infuriated 
and ignorant men attacked and over-awed the Common Council of the 
city, show what might happen in these States. 
A late city physician of Boston, used to declare that he could keep 
Boston free from smallpox if he could prevent the citizens from meeting 
immigrants from Maine, who flocked, most of them unvaccinated adults, 
into the city limits. This assertion, though not perhaps strictly true, 
I have no doubt is partially so, and it illustrates an important fact, viz.: 
that it is indeed impossible for one State to free itself from this scourge, 
until the United States shall, by a general law, require that every child 
born shall be vaccinated at a very early period, and afterwards occasion- 
ally revaccinated. Yet more, we shall never be free from it until every 
foreign nation shall adopt the same method, and an international code 
of health in this respect shall have been established. Though such a code 
may be in the far future, it must eventually come, not only in reference to 
smallpox, but in regard to every other pestilential scourge of our race. 
(3) Has any law been made relative to the prevention of Cholera? The 
answers are:— 
Twenty-one, (21) No. 
Sixteen, (16) Yes. 
Four, (4) Indefinite Reply. 
Seven, (7) No Reply. 
Entirely similar reports came in regard to this disease as in regard 
to smallpox; all indicate a “ laissez oiler” method in regard to it, so that 
if the cholera were to strike any State at the present time, there is pro- 
bably not a town in the land which would not be liable to fatally suffer 
from its ravages in consequence of “ filth”1 within the town limits. 
1 Used in its broadest signification. Simon on “Filth Diseases and their Prevention.” 
Vide Report of Medical Officer of the Privy Council and Local Government Board (Eng.), 
New Series, No. 2. Reprinted in Boston, Campbell, 1876, under the direction of the Mass- 
achusetts State Board of Health. 38 
BOWDITCH, 
But the United States Government, through the War Department, has 
recently published an invaluable bistory of cholera in this country. By 
this volume alone we can judge of the immense importance to the whole 
country, a central [tower, such as I have suggested above, would speedily 
become. It would grasp the whole country in one mass, rather than as 
separate States, and immensely broader, almost cosmic views of disease 
would be thereby given instead of those derived from detached local ob- 
servations. In order to gain this desirable end we need a National Health 
Council composed of representatives from each State, and a Secretary of 
Health, the peer of other Secretaries in the National Cabinet. 
For further elucidation of my views on this subject, I beg leave to 
refer to my address delivered before the American Medical Association 
at its session in Louisville, in 1875, 
(y) Has any law been passed relative to the prevention of Yellow Fever f 
The answers are:—• 
Twenty, (20) Yo. 
Twelve, (12) Yes. 
Ten, (10) Indefinite Reply. 
Six, ( 6 ) Yo Reply. 
I suspect the above data and other replies of my correspondents repre- 
sent in a general way the present uncertainty in the country about the 
prevalence and characteristics of this disease. There seem, however, to 
be some facts that are quite patent. Yellow fever is said (1) by some to 
exist as a permanent endemic disease in some of our southern cities (New 
Orleans, e.g., according to Chailß); “ with waves of increase and decrease 
down almost to no prevalence at all.” Some equally eminent (Herrick), 
declare that it cannot he called endemic in New Orleans, and that it 
might be extirpated but for importation. From both of these parties 
we may infer that it virtually has a permanent habitation there. But 
for an accurate and minute knowledge of the essential cause of the dis- 
ease and means for its prevention we must look to the coming century. 
It seems (2) equally plain that during the last centennial period, yellow 
fever has virtually wholly disappeared from Boston, New York, and 
Philadelphia, in which latter city it prevailed to a terrible degree in the 
latter part of the last and in the earlier part of this century. 
May we not hope that as in the past, so in the future, there may be a 
gradual pushing back of this frightful disease until it shall be fairly ex- 
cluded from our borders! 
(8) Has any laic been passed relative to the prevention of the Cattle Disease? 
The answers are:— 
Twenty, (20) Yo. 
Eleven, (11) Yes. 
Eive, (5) Indefinite Reply. 
Twelve, (12) Yo Reply. 
As at one time pleuropneumonia among cattle threatened very seriously 
to interfere with the food of the people, I deemed this a proper question. 
It is evident from my correspondence that it has influenced very dif- 
ferently the different States. In those States where it occurred, as c. g. 
in Massachusetts and in some of the Western States, much money was 
expended, large meetings were held, and many cattle were slaughtered 
in order to check it. I may refer on this subject to my correspondent of 
Illinois (Dr. Breed) for an interesting notice of what was done at a Con- 
vention of Cattle Dealers of the Northern States and Canada ; to the 
Report of the Metropolitan Board of Health in New York, and also to ADDRESS ON HYGIENE. 
39 
the action of the Massachusetts Legislature. By strict quarantine and 
care in sanitary matters connected with the cattle, and absolute destruc- 
tion of those earliest seized with the disease, and above all by a national 
co-operative action rather than by that of any single State, I believe we 
may keep that and all such pests at bay. But eternal vigilance will be 
needed on all the great ways for cattle traffic, so that the disease shall 
not get a foothold in the country, otherwise disaster may follow. In 
connection with this subject I would refer to the report made by the 
United States Commissioner of Agriculture on the Diseases of Cattle, 
containing investigations by Prof. Gamgee, and by Drs. Billings and 
Woodward of the United States Army. 
(j) Has any law been passed regulating Tenement Houses for the poor ? 
The answers are:— 
Thirty-three, (33) Yo. 
Four, (4) Yes. 
Three, (8) Indefinite Reply. 
Eight, (8) Yo Reply. 
That is, on this most important measure, on which so much depend 
the health and morality, and intellectual progress of a people, only four, 
(f's) one-sixteenth of the various governments, have, according to my 
correspondents, done anything, while fifteen-sixteenths either reply 
negatively or indefinitely, or not at all. 
In the light of what is doing in England by public law, and in Yew 
York and Philadelphia by less comprehensive, but most opportune private 
work, on the basis of pecuniary gain, combined it may be with philan- 
thropy, this report seems meagre. In this connection, I beg leave to refer 
to interesting correspondence with Drs. Harris and Thayer of Yew York, 
and Dr. Ford and Mr. Blodget of Pennsylvania. 
(k) Has any law been passed relative to incorporating Building Companies 
for the improvement of the dwellings of the poorf The answers are;— 
Twenty-nine, (29) Yo. 
Six, (6) Yes. 
Four, (4) Indefinite Reply. 
Ten, (10) Yo Reply. 
This question, allied to but more comprehensive than the preceding, 
has, as we see, received as little attention. Yet, strictly speaking, I know 
of no two questions more important at the present hour than this and the 
previous one. The fact is patent to every one that there are in every city 
and township in this land, and in every other country, dwelling places 
in which the poor are obliged to live, which are a disgrace to modern 
civilization. Such abodes are moral pests in the community, and sources 
of unmitigated evil to the Body Politic. They are, in fact, places in 
which it is impossible for the majority of human beings to grow up, ex- 
cept to filth, crime, and disease. These I fear will always exist, unless 
the public authority takes charge of these tenements and either builds 
others under State laws, or authorizes associations, partly for pecuniary 
and partly for philanthropic and sanitary reasons, to erect them. Having 
erected them it will be necessary to faithfully supervise them at all times 
and seasons, otherwise filth, and consequently disease, will come as here- 
tofore. 
We have one house in Boston yclept in derision the “ Crystal Palace,” 
which is occupied, when full, by about three hundred people, and which 
has been for years the abode of drunkenness and crime. It was well 
known to the officers of the State’s Prison as its chief primary school of 
Crime. I know it well. It is impossible to tell at this time the rich 40 
BOWDITCH, 
though painful experience gained from it by the Boston Co-operative 
Building Company. This, as its name partially indicates, was incor- 
porated by the State in order to enable philanthropy and capital to unite 
on an equitable basis, viz., in newly building or in renovating the houses 
of the poor, with the hope of receiving an adequate return for the capi- 
tal expended. This corporation has been a success in building many 
houses, united in a block, and giving a perfect home to every family, only 
one, or at the most two, families being on one floor. But desirous of 
trying the plans followed so successfully, by Mrs. Octavia Hill, of London, 
in her renovation of some of the most wretched houses in that Metropo- 
lis, the Boston Association took possession of this “Crystal Palace.” 
We forthwith drove tenants from the filth}' cellars and opened windows 
into every bed-room, the large majority of them having previously had 
none. We shut two of the dark 'passages leading as common corridors to all 
the tenements in the building, but we could not shut up a third. At first 
our success seemed very certain, but the commercial panic came in 1873, 
and that drove away many, and paralyzed the labors of others of the 
tenantry. Finally the lease was given up for this reason chiefly, that we 
were losing money. But even if it had been a pecuniary success, it be- 
came the decided opinion of most of the Committee, who had charge of 
it, that morally it must, from the inherent vices of its construction, 
remain vile. 
Whilst so many are congregated in one house, with long dark com- 
mon corridors actually inviting vice and crime of the lowest kinds, it is 
impossible to check the tendency thereto. The committee saw young 
girls and boys grow up into vice (without a possibility of saving them), 
owing, as it appeared in a great measure, to the very structure of the tene- 
ment, and of its out-buildings. 
Whilst taking this opposition to the idea of large buildings, with dark, 
easily accessible, common corridors, instead of rows of moderate-sized 
buildings, containing but few families, it was gratifying to the committee 
to find that the death-rate in the building was much lessened by the alter- 
ations made in it, and by constant vigilance in regard to sanitary rules, 
as far as it was possible to have any rules, in a place provided with a 
few common privies and slop receptacles, which were constantly, day and 
night, resorted to by people having small ideas even of the comfort of 
cleanliness, and totally ignorant of its immense value in a hygienic point 
of view. 
I have cited this case simply because of my four and half years of 
personal experience upon it. But the same facts of wretchedly con- 
structed abodes for the poor exist everywhere, and human nature is the 
same. Our experiment, I think, proves very conclusively the folly of 
expecting people to be temperate, or honest, or healthy in badly con- 
structed houses. I commend this topic of providing suitable homes, 
not houses only, for the people, as one of the most important that can 
command the attention of Philanthropy and Capital during the coming 
Century. 
Seventh Question.—(a) Are there well-attested facts proving that any 
disease formerly prevalent in your State has ceased to appear? 
The answers are:— 
Twenty-five, (25) No. . 
Nine, (9) Yes. 
Eight, (8) Indefinite Reply. 
Six, (6j No Reply. ADDRESS ON HYGIENE. 
41 
Of the nine affirmative replies not one can present positive proof of 
the statement, but some suggest a lessening of some diseases. This 
seems to be undoubtedly the fact in regard to malarial fevers, yellow 
fever, etc. 
That intermittents have disappeared from some localities, which have 
been drained, seems to be true. Smallpox is wonderfully lessened and 
quite shorn of its terrors. A few special diseases, as, for example, the 
“ milk sickness,” and the “black tongue,” are mentioned as having pre- 
vailed formerly, but not of late. These statements, though less reliable 
than accurate statistic proofs, give us hopes for the future when State 
Preventive Medicine shall have obtained its due influence. 
(b) Are there any well-attested facts proving that any disease formerly 
prevalent in the State has been crushed by State or Individual action? The 
answers are:— 
Thirty-seven, (37) No. 
None, (0) Yes. 
. Four, (4) Indefinite Reply. 
Seven, ( 7 ) No Reply. 
The returns give a most decided negative, and not a correspondent 
takes the affirmative of the question. 
Eighth Question.—Are there any similar facts proving that any special 
disease has arisen or been generated, or has been introduced into the State 
during the past century, which did not exist in Colonial Times, and which 
now remains endemic ? 
The answers are:— 
Twenty-seven, (27) No. 
Six, (6) Yes. 
Two, (2) Indefinite Reply. 
Thirteen, (18) No Reply. 
The same indefiniteness of statement prevails on this question as on 
the preceding. In one of the six affirmative replies. Dr. Denison, of 
Denver, claims that perhaps phthisis has been introduced into Colorado. 
Of course it has been, as a great many go there now as a place most 
fitted for the cure for the disease. And future statistical mortuary data, 
unless care be taken, will lead to great errors of judgment in regard to 
the value of that climate, and its influence on phthisis. In some of the 
Northern States some physicians claim that cerebro-spinal meningitis, 
diphtheria, and even croup, have been introduced during the centenary. 
There are grave doubts about the truth of all such statements. Others 
claim that yellow fever and cholera are such diseases; “yellow chills” 
are named by one, “ trichiniasis” by another. I feel that there is no 
proof that any new disease has been introduced, and become endemic 
here. 
Ninth Question.—lf there he any such new disease, has it been investi- 
gated by the State or by individuals ? 
The answers are:— 
Twenty-seven, (27) No. 
Six, (6) Yes. 
Two, (2) Indefinite Reply. 
Thirteen, (13) No Reply. 
My correspondents cite investigations by a commission of the city of 
New Orleans in 1853, relative to typhoid fever; by Dr. Kedzie, of 42 
BOWDITCH, 
Michigan, on cerebro-spinal meningitis; on diphtheria, by the Y. Y. 
Metropolitan Board of Health ; on “yellow chills” by various persons in 
Alabama. 
Of course this meagre statement falls far short of the truth in regard 
to the number of investigations undertaken by individuals, corporations, 
and commissioners, on the various diseases of the country, some of which 
have no more right to be classified as new diseases, than typhoid fever 
and diphtheria; and none of them can be certainly said to be diseases 
never seen before the past century. 
Tenth Question.—Has the town or city in which you reside taken any 
measures for the improvement of the Public Health? 
(a) By health laws ? 
The answers are;— 
Nine, (9) Yo. 
Twenty-five, (25) Yes. 
Nine, (9) Indefinite Reply. 
Rive, (5) Yo Reply. 
From the above, it seems that the majority of the towms have done 
what mere self-defence would inculcate. But of the twenty-five affirma- 
tive replies very many report either inefficient enforcement or complete 
abeyance of such laws. Many towns have special laws for drainage, and 
other objects seem partially or wholly ignored. For my own State of 
Massachusetts, I think I can say that in not a single town has there ever 
been a complete system of health laws enacted and thoroughly enforced. 
But, notwithstanding this unsatisfactory statement, I also believe that I 
may with equal truth assert that so recently has the idea of State Pre- 
ventive Medicine begun to take hold of our people, that our advance has 
been quite as much as could be expected. Very many more years will be 
needed before this country or Europe will even approximate to that point 
which, at present, only an ideal sanitary legislation would require, but 
which the coming century will bring forth into actual operation. 
(b) By special action in specific cases ? 
Three, (8) Yo. 
Twenty-five, (25) Yes. 
Eleven, (11) Indefinite Reply. 
Yine, (9) Yo Reply. 
The remarks made on the previous question apply to this. 
Eleventh Question.—Does your town use well-water for culinary uses? 
Twelfth Question.—Is care taken to prevent pollution ? 
Thirteenth Question.—Do you have a water supply from distant lake 
or river ? 
Fourteenth Question.—Is care taken to prevent pollution ? 
Including all these questions under one category; of 143 towns 82 use 
wells, 61 use rivers or lakes. In regard to the care taken to keep either 
class of waters pure, I find as follows : 
49 or 34.26 per cent, try to keep it pure ; 
69 or 48.25 per cent, make no attempt to do so ; 
25 or 17.48 per cent, make no, or an indefinite reply. 
In other words, taking my returns as furnishing at least an approxima- 
tion to the general state of the country in this respect, 34.26 per cent, 
only of the towns make any claims, even the most trivial, to be careful 
of the purity of their water; while 65.78 per cent., or nearly twice as ADDRESS OX HYGIENE. 
43 
many, are totally neglectful. That is to say, nearly two-thirds of the 
people of this Union are living in a senseless disregard as to whether they 
are drinking pure water or water which, though “sparkling and tasting 
pleasant,” may be loaded with every species of filth! 
Fifteenth Question.—Have you sewers to carry off such water supply ? 
The answers are : 
Eleven, (11) Yo. 
Thirteen, (13) Yes. 
Twenty, (20) Indefinite Reply. 
Four, (4) Yo Reply. 
These replies coincide with all the preceding, and intimate very fully 
the primitive ideas held by the people of this country in regard to the 
necessity of carrying off water once made impure. What happens in 
Boston I fear happens elsewhere, viz.; that abundant supplies of water 
have been introduced into certain parts of the city without any imme- 
diate provision being made for its removal by sewers. The consequence 
has been that the cesspools have been overflowed, and that the land has 
been soaked with water, perchance containing the elements of disease, 
and certainly tending to develop phthisis, from the soil moisture induced 
by such overflow. Of course, evil must result. 
I might refer to other particular cities and places, now the common 
summer resorts for the most wealthy people, where a most scandalous 
condition exists in this respect, making it at times more dangerous to 
visit the “ health resort,” so called, in country and sea-side, than it would 
be to remain at home, even in a poorly-sewered, offensive-smelling city. 
But we have no need to visit health resorts to find great imperfections 
of sewerage. That of Boston, which I have already quoted in reference 
to its suburbs, has been, even within its city limits, notoriously bad, not- 
withstanding it has been claimed to be nearly as perfect as could be. 
Some of the main sewers of that city are even now nearly filled with 
refuse, more or less solid. One of the main conduits is occupied to a 
great depth by so-called “ mud,” composed of dirt from the often street 
gutters and of human excreta. Others are more or less partially ob- 
structed. The whole congeries of them form one vast network of cess- 
pools, belching out at times filthy odors from “ manholes” along the 
streets. The mouths of the sewers, which open all around the city 
limits, and in the closest proximity to it, pour forth volumes of similar 
foul exhalations while the tide is low, and the quantity of refuse 
issuing from them has been declared, under oath, to interfere very 
much in certain places with trade, by preventing vessels which were 
formerly able to approach certain wharves, from so doing at the pre- 
sent time.1 I summon thus significantly my own city to the bar of 
public sanitary rebuke, not because I think her really a worse sinner in 
these respects than many other and some greater cities, but for two 
reasons: (1) that I know whereof I speak, and can vouch for the truth 
of the assertions, extraordinary as they may seem to some of you, and 
(2) that I rejoice to say that, in this centennial year, Boston is seemingly 
repentant, and is prepared to amend her system at a large expense. 
Thank God ! Her citizens are beginning to feel that the worst prodi- 
gality is the waste of human life, and that mere money is as nothing before 
the idea of perfect human health! 
1 Vide Tyler et al. v. Squire et al., before the State Board of Health of Massachusetts, 
1873. 44 
BO WDITCH, 
Sixteenth Question.—How far are the sewer outlets from the source of 
water supply ? 
Upon this question it may be generally stated that these distances in 
different cities of the Union vary from what may be practically called 
zero to 20 or even 80 miles. It would seem that, where it is convenient 
so to do, a distance more or less great is always chosen ; but strange as 
it may seem, some of our great cities have been wholly thoughtless. If 
my correspondent be correct, even in this great city of Philadelphia in 
which we meet, although the majority of the sewerage is carried far 
below the water supply, we cannot claim the same for all of it. And not 
a few cities which take water from rivers and lakes are practically re- 
gardless of the quantity of impurities that enter the stream or lake at 
some distance, it may be, but nevertheless above the part whence the city 
gets its own water supply. I might cite Albany as a great and most 
glaring example of this latter statement. 
Seventeenth Question.— What is your method of disposing of sewerage ? 
House offal? Slops or filth liable to accumulate about homesteads? 
I have received answers from eighty-four towns, and the summary of 
them is, that only in about one-fifth (sixteen) are there any proper and 
efficient means for the removal of these various sources of contamination. 
A great many have still most primitive ways of disposing of them ; 
“they are thrown away carelessly.” Many have “surface drainage.” In 
some they are “ thrown into open lots,” or “ to the hogs ;” and in some 
“each inhabitant does as his own will dictates.” Nothing can be more 
chaotic than the present method pursued in this country, considered as 
one great whole. 
Eighteenth Question.—Have any State, County, or City reports of Health 
or Deaths been published ? 
The answers are:— 
Thirty, (30) No. 
Nine, (9) Yes. 
Two, (2) Indefinite Reply. 
Seven, ( 7 ) No Reply. 
That is, 62.50 per cent., or more than half of the correspondents, say 
there is no registration in their States; 18,75 per cent, have had some 
registration, most of them only for a few years past; and 18.75 per cent, 
make indefinite or negative replies. Adding together the first and last 
items as being essentially the same, we have, as the final probable result, 
that 81.25 per cent., or more than three-fourths of these States, have vir- 
tually ignored vital statistics during the whole centennial period. Add 
to this that among those which claim to have had registration, it is like- 
wise stated by my correspondents that in not a few the registration is 
very imperfect. 
The United States commenced its national censuses in 1790, and has 
continued them decennially ever since, but never with the accuracy 
which is desirable. I judge this from the opinion of experts whose 
opinion I have asked of even the latest, that of 1870. The following 
remarks by General Walker and Mr. Elliot seem also to indicate that 
my inference is true. 
General Walker says: “The gross incompleteness of the returns of 
deaths in the census of the United States is shown by Mr. Elliott’s Ap- 
proximate Life Table. What, it may be asked, is the value of statistics ADDRESS ON HYGIENE. 
45 
confessedly so imperfect?”1 He elsewhere admits that the number of 
deaths falls short 40 per cent, of what must actually be the fact. 
Mr. Elliot, who calculates life tables from these returns, admits that he 
is obliged to “ resort to the somewhat arbitrary assumption of 40 per 
cent, limited, however, by an investigation of the rates of mortality rela- 
tive to population which obtain in other communities, so far as accessi- 
ble, and in portions of our own country.”2 
Nineteenth Question —How many years, approximately or definitely, 
have these registration reports been published f 
I regret that, owing to imperfect returns, I cannot give any but gene- 
ral statements. 
But when I think of the comparatively brief period of time since the 
registration has been commenced in the different States where any is 
made, and knowing as I do, the imperfections of those which may be sup- 
posed to be the best, I feel sure I am within the limits of truth, when 
declaring that not a State in this Union has a registration which has 
been in progress a sufficient number of years, or which has been con- 
ducted with sufficient accuracy, to be fairly comparable with that regis- 
tration which will be eventually demanded by an enlightened State 
Preventive Medicine, after that idea has been firmly grasped and acted 
upon for some years by the intellect and conscience of our people. 
In confirmation of this assertion, I state the following fact. I was 
desirous of learning definitely, not from theorizing on the influence of 
civilization, not from the records of foreign countries, but from accessible 
statistics collected and printed in this country, whether man lives longer 
now than at the commencement of the centennial period. I consulted 
several eminent American experts in statistical data. I asked them to 
point out to me any such data. Not one of them could do so. One who 
stands pre-eminent, and whose word is listened to by Europe, advised me 
as follows: “You may consult hills of mortality; grave-yard records; 
family Bibles; traditions of the former and later times, and they will 
show whether we have gained or lost in longevity.” I have no doubt 
that, provided we could find those records, we should perhaps partially 
gain the end proposed. My question was whether he could point out to 
me any printed document, derived from accurate records made in the 
United States, answering my question. He could not do so. 
Twentieth Question.—Has any law of development, or of partial develop- 
ment, of any disease been discovered, by individual or State action, by attention 
t°, which in coming centuries we may hope to greatly lessen or destroy such 
disease ? 
I proposed this question of fact as the test question, so to speak, of the 
Centennial Period, It was the culmination of all these questions hitherto 
proposed. 
The answers are : 
Thirty-nine, (39) No. 
Six, (6) Yes. 
None, (0) Indefinite Reply. 
Three,_ _ (8) No Reply. 
The returns indicate that my correspondents have a more decided 
opinion upon this question than upon any other of the series. There are 
1 Statistical Atlas of the United States. By P. A. Walker. 
2 Ibid. Approximate Life Table for the United States. By E. B. Elliott. 46 
BOWDITCH, 
only three who fail to make any answer, and not a single State has replied 
indefinitely. Again, thirty-nine out of forty-eight States, or 81.25 per 
cent., reply in the negative ; six of the forty-eight, or 12.50 per cent., 
reply affirmatively. 
But let us look carefully at the affirmative replies, and interpret more 
closely their exact meaning. The replies I think may be justly arranged 
in two categories:— 
First. Those in which it appears that by close attention to sanitary 
arrangements, and their rigid enforcement, certain diseases are checked. 
One correspondent remarks, “all the acquired knowledge concerning all 
and each of the typho-contagia, and the factors of their propagation is 
equivalent to discovery.” (Dr. Harris, of Hew York.) From other States 
we are informed that “ the laws of development of typhoid fever are 
known better.” (Drs. Plummer, of Oregon, and Butler, of Vermont.) Drs. 
Stuart and Toner, of Washington, D. C., say they are “ able to control 
and prevent zyraotics by sanitary enforcement.” Dr. Baker, of Lansing, 
the self-sacrificing, efficient Secretary of the State Board of Health of 
Michigan, writes as follows : “ It seems proper to modify very much the 
‘ Yes,’ which I have placed opposite the question ; if we substitute for 
‘ law of development,’ or ‘partial development of,’ the words ‘general truth 
respecting,’ I think the answer will he truthfully ‘Yes.’” He then 
cites scarlet fever “which will he lessened in the near future, because of 
the accumulated evidence of the great mortality caused by it.” He also 
thinks “croup and pneumonia will be eventually greatly lessened from 
the fact that a cold and dry atmosphere causes the greatest mortality 
from both. And by securing such favorable conditions in our houses, 
and particularly in our sleeping rooms, it is reasonable he thinks, to 
hope that many deaths from pneumonia and croup may in the future be 
prevented.” These may be considered as one category. 
Second. Let us grant that all this is true, nevertheless I do not see that 
any “ law” of development of disease, similar in degree at least, if in 
character, to that of “soil moisture” as a very prominent cause of 
phthisis, has been presented by any of the above respected correspond- 
ents. Massachusetts, through the agency of the Massachusetts Medical 
Society,1 proved many years ago by data received from her three hundred 
and twenty-five towns, and where consumption had been previously con- 
sidered everywhere equally endemic, that there were dry spots where it 
was very rare, and wet where it was very rife. B}7 accurate statistical 
data, laboriously gathered, it was further proved that of two families 
growing up, one on a wet soil and the other on a dry soil, the one resident 
on the wet by that fact became twice, if not three times, as liable to 
phthisis as the other, resident on a dry spot. That law was first dis- 
covered and announced in New England, and subsequently by ample 
statistical data proved to exist in Old England. I think it may now be 
said to be a Cosmic Law, and as such it seems to me I am justified in 
placing it alone in the second category under this final question. 
In order to meet the numerous similar questions which will inevitably 
arise in the future, we need, as Mr. Elliot suggests, a National System 
for the registration of all the Births, Marriages, and Deaths taking place 
in the country. Moreover, the Registrar should, for the whole country, 
learn the exact character of the localities in which the deaths take place, 
if we would know exactly and broadly the endemic influences of any place. 
I Topographical Distribution of Consumption. Annual Address before Mass. Med. 
Society, 1867. ADDRESS ON HYGIENE. 
47 
SUMMARY. 
Gentlemen: My work is done. I have endeavored to place before 
you the exact truth in these matters so far as I could obtain it. No one 
can feel more keenly than I do that it has at times been most unpalata- 
ble, and that it seems to be but little creditable to the country. Never- 
theless, looking at the very recent growth of a regard for Public Hygiene, 
and at the certain though small advances made in various parts of the 
country in State Preventive Medicine, I have the strongest hopes for the 
future of our Country and the world in this regard. We could not, with 
the influences hitherto pressing upon us, have advanced further. System 
making, the outgrowth of many previous centuries, prevented all pro- 
gress in this direction during our first epoch. The overthrow of these 
theories and theory makers, and the bringing of medical inquiries into line 
with the methods pursued by modern science, was the great fact gained 
during the second. Although this has been followed by a sweeping and 
widespread skepticism in our own art, we must remember that this same 
skepticism is found everywhere within the domains of modern thought. 
Good will ultimately result from it. But these facts have not allowed 
of the growth of Preventive Medicine until within a very recent period 
of time. 
We stand now at the very dawn of the grandest epoch yet seen in the 
history of medicine. While philosophically, accurately, and with the 
most minute skill, studying by means of physiology, pathological anatomy, 
chemistry, the microscope, and, above all, by careful clinical observation, 
the natural history of disease and the effects of remedies, our art, at the 
present time, looks still higher, viz.: to the 'prevention of as well as to the 
cure of disease. And this is to be done by sanitary organizations 
throughout each State and the Nation, the laity and the profession 
heartily joining hands in this most noble cause. 
Our Present Duty. 
Our present duty is organization, National, State, Municipal, and 
Village. From the highest place in the National Council down to the 
smallest village Board of Health, we need organization. With these 
organizations we can study and often prevent disease. 
This great and beneficent object of the prevention of disease appeals 
to all. The aged may give counsel. To the young of this and of future 
generations belongs the solid work which is to bless the coming centu- 
ries. I appeal therefore with all the earnestness at my command to the 
young men of the present hour. Can there be anything more inspiring 
to a generous hearted, intelligent youth than the thought that, by labo- 
rious research into the causes of disease, by the discovery of means for 
its prevention, and by the teaching of these various causes and means to 
the people, he may help to save even a few of the more than two hun- 
dred thousand human beings now annually slaughtered in this country 
by preventable disease ? 48 
BOWDITCH, ADDRESS OX HYGIENE. 
Our Hopes for the Future. 
I trust that this discussion will have given rise in your minds to some 
of the bright hopes for the future which have arisen in my own. Al- 
though Public Hygiene has made but few advances hitherto, it is never- 
theless founded upon Natural law. It has been legitimately and health- 
fully growing during a portion of the past quarter of a century. Modern 
Science greets it and brings it within its domain as one of its most pre- 
cious objects for thorough investigation. I hope therefore that, standing 
as we now are near to the close of this fair Centennial Birth-year of our 
Nation, up to whose festival all nations of the earth have been invited, 
1 may be allowed to appeal to all, whether young or old, American or 
collaborating friends from other lands, to join with me in a Cordial All 
Hail to Coming Centuries, not only in America but in every civilized spot 
of God’s earth ; because everywhere, and to all coming time, human life 
will be lengthened, made more healthy, and consequently more truly 
happy, by the potent influence of 
State Preventive Medicine. 49 
ADDRESS ON MEDICAL CHEMISTRY AND TOXICOLOGY. 
BY 
THEO. G-. WORMLEY, M.D., PhD., LL.D., 
professor of chemistky and toxicology in starling MEDICAL COLLEGE, COLUMBUS, OHIO. 
When it is remembered that nearly all human thought and labor are 
devoted to the promotion of the welfare of the human body, and that 
agriculture, manufactures, and commerce have this as their chief end, it 
will not be deemed strange that a science so comprehensive and withal 
so flexible in its applications as Chemistry, should be laid under contri- 
bution to preserve that body in health, or to restore that health when 
unpaired. Before chemistry had become a true science, its aid was in- 
voked by the old alchemists in their search for the “ Elixir of Life.” A 
universal remedy was the dream of many a toiler in secret places, whose 
occult science had for him a strange fascination. There were among the 
Arabians many who, in their rude way, applied such chemical knowledge 
they possessed to the discovery of new medicines. The same was 
rue of the earlier physicians of Europe. There was everywhere an effort 
o make nature reveal some secret which might be turned to account in 
16 healing art. This, more than any other, was deemed the true func- 
tion of Chemistry. 
It was not until Bacon announced the true method of scientific inves- 
ofA?°1J’ 
-leaven, was to be entered as a child, rather than with the spirit of a 
mtator, that the mists of earlier times were gradually swept away, and 
m path prepared for the appearance of Science with exact methods and 
Wl|h exact results. 
Th iS.now onty about a century since Chemistry took shape as a Science, 
th a:>ors °1 hflaok, Priestley, Scheele, Lavoisier, and others showed 
hav f 
anfl6 een exploring this field, and have taken possession of many a spot, 
fes ?ecured permanent title-deeds for posterity; but, it must be con- 
anflL 1 a centuiT lar t°° short for the survey of the whole domain, 
fou ?Ur descendants will have ample scope and incentive for the pro- 
p>rit/( labor and research. Only two years since, the chemists of Great 
hirt^11*-. America celebrated the centennial of Chemistry, dating the 
Rrie\l J0 Bcaence Horn the discovery of Oxygen by the distinguished 
plac ey\AugUSt 1774 The 
commemoration in this country took 
The -^orthumberland, Pa., the American home of Dr. 
notegeneAa - Progress of the century was there ably set forth by men of 
address fp 8e^ra! departments of investigation. The very valuable 
tribunal* Vu I>>en.iamin Silliman, on this occasion, on American Con- 
iuclebte B 1 lem'ißiry, (a complete compendium to which we are greatly 
this C shows that in this country we have not been idle in advancing 
Afterartment °f Bcience- 
the discovery of oxygen, nitrous oxide, and'other gases, by 50 
WO EM LEY, 
Priestley and others, Sir Humphry Davy, then a young man with ma- 
jority unreached, was employed at Bristol, through the generosity of 
Messrs. Watt and Wedgwood, to undertake a careful series of experi- 
ments with gases as remedial agents. So important and intimate is the 
connection between chemistry and medicine, that we should naturally 
look to those who feel the imperative need of this science in its sanitary 
applications, for the best labors in the science. There could be no other 
incentive more potent. The air and vapors we breathe, the food we eat, 
the fluids we drink, the medicines we take, and the poisons we seek to 
avoid, all come within the range of the analyst, and his words of counsel 
and caution are to he heeded. In this held of labor many eminent 
chemists have labored with exclusive devotion, while others, as Davy, 
Scheele, and Liebig, commenced their distinguished careers as pharma- 
cists, and may be said to have emerged from the apothecary’s shop. 
Indeed, we may not overlook the close connection between chemistry 
and pharmacy. As we trace the history of medical chemistry in the 
United States, it will be seen that the contributions of the pharmacists 
have been so many and various, that the historian must give them a 
high and honorable place in the annals of American progress. 
One hundred years ago we find that the only medical college in the 
land, with an occupied chair of chemistry, was the Philadelphia Medical 
College, soon after (1791) merged into the University of Pennsylvania, 
the institution in whose halls we are now assembled, an institution not 
only venerable in years, but renowned for the great and noble work it 
has accomplished. The occupant of this chair, elected August 1, 1769, 
was none other than Dr. Benjamin Rush, distinguished alike for his 
professional labors, which brought honor upon medical science, and for 
his devoted patriotism in the dark daj-s when our national independence 
was won. He graduated at Princeton, and afterwards studied medicine 
in Philadelphia, Edinburgh, London, and Paris. While in Edinburgh 
he studied chemistry with the eminent Dr. Joseph Black. He was one 
of the signers of the Declaration of Independence, which this centennial 
year commemorates. In 1777 he was made surgeon-general of the army 
in the middle department. Ever a distinguished physician and medical 
professor, ever active in all public and philanthropic movements, his long 
life was one of singular usefulness and honor, and no name in our annals 
should be mentioned with more reverence and resjiect than that of Ben- 
jamin Rush, the earliest American professor of chemistry. The only 
other chair of chemistry in the colonial days was that established in 
William and Mary College, Virginia, in 1774, and filled by the Rev. 
James Madison. 
In 1779 a professorship of chemistry and natural philosophy was 
established in the literary department of the University of Pennsylvania. 
Thus two of the first three chemical professorships in America were 
established in Philadelphia. In the medical department of Harvard 
University, Aaron Dexter was elected Professor of Chemistry and Ma- 
teria Medica in 1783; and in 1792 Dr. Samuel Latham Mitchell was 
elected Professor of Chemistry in Columbia College, Hew York. Dr. 
Mitchell graduated in medicine in Edinburgh in 1786. Two years after 
entering upon his professorship of Chemistry, he published an essay on 
the Nomenclature of the New Chemistry. In 1797 he, with others, estab- 
lished the Medical Repository, the first scientific periodical ever published 
ill the United States. He is now widely known as an early student of ADDRESS ON MEDICAL CHEMISTRY. 
51 
natural history, and bis publications on zoological subjects are yet 
prized. 
In 1795 Professor John McLean, a young chemist of Scotland, was 
elected Professor of Chemistry in Nassau Hall, Princeton. In 1803 Pro- 
fessor Benjamin Silliman, the first professor of chemistry in Yale College, 
entered upon his duties. lie became widely known as an able and elo- 
quent expounder of chemical science. In 1818 he established The Ame- 
rican Journal of Science and Arts, which became, more than any Ameri- 
can journal, the means of disseminating discoveries in chemistry and in 
cognate sciences. His name will ever remain an honored one in the his- 
tory of American science. 
The work done in chemistry in the medical schools has not always 
been marked by scientific thoroughness; indeed, in too many cases, verv 
little practical benefit has resulted from the lectures, often only heard to 
be forgotten. But a change is now being effected in this respect, and 
we note with satisfaction that a two years’ course of systematic labora- 
tory practice is made part of the regular curriculum of study in the 
Medical Department of Harvard University. 
The earlier professors of chemistry in the Medical Schools did not con- 
tribute largely to the advancement of the science in the way of original 
research. The science was in its infancy, and the circumstances^sur- 
rounding them were not generally such as to awaken that measure of 
enthusiasm which is necessary to scientific discoveries, A marked ex- 
ception, however, is found in the case of Dr. Robert Hare, who became 
I rofessor of Chemistry in the University of Pennsylvania in 1818. In 
bis youth he was a member of the Chemical Society of Philadelphia, to 
belonged Priestley, Seybert, and others. At the early age of 
twenty, he announced the discovery of the oxy-hydrogen blowpipe, which 
A once gave him distinction in both hemispheres. This became a valu- 
able instrument in certain departments of chemical investigations, and 
111 the arts. Dr. Hare had great mechanical skill, and with his ingenious 
apparatus was enabled to perform experiments with great brilliancy and 
8 In addition to many valuable contributions, he published, in 
-o, a Compendium of Chemistry, a valuable and useful work at the time.. 
n this connection it should be mentioned that in 1819 Dr. John Gor- 
'Qln.b 1 rofessor of Chemistry in the Medical Department of Harvard. 
diversity, published the first original systematic treatise on chemistry 
Woe‘^0d in this country, entitled the Elements of Chemical Science, a 
sh Ihi Ui tw° v°hmies, which reflected great credit upon its author. It 
rerfVr he stated, however, that there had been, before this, American. 
Publications of foreign chemical works. 
Re i 6 now come? in the order of history, to the name of Prof. John 
I'ati,nan oxe’ who deserves mention for the part he played in inaugu- 
ln nSa movement, which, as we shall see, has contributed, perhaps,, 
gtaf.e lan ailJ other to the progress of Medical Chemistry in the United 
°f EP* hart mechcal education was obtained in the University 
He ‘iff Urgh’ hut he graduated in the University of Pennsylvania in 1794.. 
In lC«noTards sf)ont considerable time in London, Edinburgh,and Paris, 
Was t’ y3 was elccted by bis Alma Mater Professor of Chemistry, and 
latter1 tUR ■ I'rfd to tdle chair of Materia Medica in 1818. While in this 
special aU' 16'Ua1s He “leading spirit” in a movement to provide a 
drua-o7«+Cl°Ui;Sei0f io(rhlres iu Pharmacy for the young druggists and 
rue iff.!* fa hS ot 1 hiladelphia. This was early in 1821. this move- 
sted the attention of the leading druggists of the city, and led; 52 
WORMLEY, 
them at once to establish a new and independent institution—first called 
the College of Apothecaries, but changed the next year to the Philadel- 
phia College of Pharmacy—to secure the same results, but upon a more 
liberal plan. 
The founders of this college were wise men, and secured for their new 
institution professors of high scientific character. The first course of 
lectures was given in 1821-2. Dr. Samuel Jackson, a medical graduate 
of the University of Pennsylvania, was the first Professor of Materia 
Medica. In 1827 he was elected to a professorship in his Alma Mater. 
His career as a lecturer, as an author, and as a practitioner, was in all 
respects distinguished. Dr. Gerard Troost, afterwards eminent in other 
departments of science, was the first Professor of Chemistry, but was 
succeeded within a year by Dr. George B. Wood, happily still living to 
enjoy the rewards of a life well spent in the service of science and of 
humanity. His published works, at once so complete and scholarly, 
have honored the profession of which he has so long been a distinguished 
member. 
In 1831, Dr. Wood was transferred to the department of Materia 
Medica. His successor in the chair of Chemistry was. Dr. Franklin 
Bache, a worthy descendant of the eminent statesman and philosopher 
whose name he bore. In 1833, Professors Wood and Bache published 
the first edition of the United States Dispensatory, a work which has 
passed through thirteen (13) editions, and is still the indispensable hand- 
book of the physician and pharmacist. These eminent professors im- 
pressed upon the College of Pharmacy a character for thorough science 
which it has never lost. Our brief sketch would be imperfect should we 
here fail to mention the name of the late Prof. William Procter, Jr., 
who became the Professor of Pharmacy in this college in 1846, and who 
by his scientific labors, prosecuted through many years, contributed 
more to the special department of Medical and Pharmaceutical Chemistry 
than, perhaps, any other American. It should here be mentioned that, 
four years after the establishment of the Philadelphia College of Phar- 
macy, its friends founded the American Journal of Pharmacy, a journal 
still issued, and which has contributed very greatly to the dissemination 
of a knowledge of chemistry in its relations to medicine. 
The second College of Pharmacy in this country was established in 
Hew York in 1829, through the instrumentality of George D. Coggeshall, 
<i graduate of the Philadelphia College. The first Professor of Chemistry 
was the late Dr. John Torrey, whose labors in science, and especially in 
American botany, have given him a name which will ever be honored. 
MEDICAL CHEMISTRY. 
Having thus glanced at the history of the introduction of chemistry 
into our schools, in passing on to discuss the theme assigned us, Medical 
Chemistry, we find ourselves entering upon a broad domain of investi- 
gation. We might enlarge upon the many and wide bearings of chemistry 
upon medical practice, and show how indispensable it is to the best suc- 
cess of the practitioner; point out its grand achievements in the depart- 
ments of physiology and pathology, and show how inseparable is its 
•connection with the progress of medical science in all its departments ; ADDRESS OX MEDICAL CHEMISTRY. 
53 
but, perhaps, as more consonant with the occasion and with the limita- 
tions of the hour, we may restrict ourselves to a brief consideration of 
the more prominent of the American Chemical Contributions to the Medical 
Progress of the Century. In this review, we find that these contributions 
relate largely to the examination of the chemical and therapeutic pro- 
perties of our indigenous plants. 
One of the first of these plants examined was Sanguinaria Canadensis, 
or Blood-root. Attention was first called to this plant in 1803, by Dr. 
Wm. Downey, of Maryland, as a powerful emetic; and in 1819, Dr. 
Wm. Tully, of Hew Haven, investigated with care its therapeutic pro- 
perties. In 1828, Dr. J. F. Dana, of Dartmouth, first chemically exam- 
ined the plant, and succeeded in isolating a basic or alkaloidal principle 
which he called Sanguinarine (H. Y. Lyc. Hat. Hist., ii. 245, 1828). The 
identity in ultimate composition of this alkaloid with the alkaloid of 
Chelidonium majus, subsequently discovered by Probst and called chelery- 
thine, was fully established by Dr. Joseph Schiel, of St. Louis, in 1865 
(Anier. Journ. Sci. (2), xx. 220). A second principle was extracted from 
Sanguinaria Canadensis by Riegel, which he considered identical with 
Merck’s porphyroxine, from opium; but this identity was subsequently 
denied by Dr. G. D. Gibb. A third proximate principle derived from 
this plant was described by Prof. E. S. Wayne, of Cincinnati (Amer. 
Journ. Pharm., 1856, 521); and for it Dr. Gibb proposed the name 
puecine. Prof. Wayne has also recognized in blood-root the presence of 
ehelidonic acid, first found in the plant Chelidonium majus. 
In 1819, Dr. John Torrey, while investigating a curious underground 
fungus called Tuckahoe* or Indian-bread (Scleroticum gigantium), dis- 
covered a new principle which he termed Sclerotine, an account of which 
was read before the Lyceum of Hatural History, Hew York, Hov. 15, 
1819, and published in the H. Y. Med, Repository, Dec. 1820. In 1824 
Braconnot described pectic acid, a principle now obtained from many 
succulent plants. In 1827 Dr. Torrey republished his former paper with 
a-dditions, and showed the identity of the two substances (Amer. Journ. 
kci. (2), xxvii. 439). 
Another interesting native plant that early received attention is Lobelia 
Vnflata, known as Indian tobacco, and used as a medicine by the abori- 
gines. The attention of the medical profession was first called to this 
plant by Rev. Manasseh Cutler, of Ipswich, Mass., eminent as a botanist 
lli the latter part of the last century. Lobelia was first examined cherai- 
PjHy in 1833 by Dr. S. Colhoun, Professor of Materia Medica in Jefferson 
Medical College, Philadelphia, who announced the existence of a basic 
principle capable of forming salts with acids, but failed to isolate the 
principle (Amer. Journ. Pharm., v. 300, 1833). Wm. Procter, Jr., who 
)as already been referred to, in his Inaugural Thesis, in 1837, on Lobelia 
luaata, demonstrated that the active principle of the plant is a liquid 
alkaloid, which he succeeded in isolating. He named this principle 
, and he described the salt formed by it with the leading acids, 
is very elaborate thesis was published in the American Journal of 
(armacy for July, 1837. In Hovember, 1850, Wm. Bastick read a 
paper before the Pharmaceutical Society of Great Britain on Lobelia 
iflata, in which he described the same alkaloid, and his name is often 
in foreign publications as its first discoverer. A number of 
ascs of poisoning have occurred in this country from the use of this 
I ant, chiefly as administered by empirics. 
in next indigenous plant to be noticed is Veratrum viride, or Ameri- WOKMLEY, 
can hellebore. This plant was known to the Indians chiefly as a poison. 
According to Joselin, an early visitor to this country, it was used by them 
in the selection of their chiefs, the individual found least susceptible to 
its effects being regarded as the “ strongest of the party, and entitled to 
command the rest” (Amer. Journ. Pharrn., vii. 208). It was brought to 
the attention of the medical profession about the year 1830, by Drs. Tully 
and Ives, of Hew Haven. Its therapeutic properties were more fully 
investigated by Dr. Charles Osgood, of Providence, in 1835 (Amer. Journ. 
Med. Sci., xvi. 296). In 1851 Dr. W. C. Norwood, of South Carolina, 
again brought it before the profession in a series of papers highly extoll- 
ing its medicinal virtues. 
The chemical history of this plant presents some features of peculiar 
interest. Very contradictory conclusions have been reached by different 
investigators in regard to the exact chemical nature of its active princi- 
ple or principles. The first chemical examination of this plant was made 
in 1835 by Dr. Charles Osgood, but he failed to obtain satisfactory results 
(Amer. Journ. Pharrn., vii. 202). It was again examined by Dr. Thos. 
R. Mitchell in 1837, who also failed to determine the true nature of its 
active principle (Ibid., ix. 181). After a somewhat extended examination, 
Henry W. Worthington, in 1838, concluded that the plant contained 
an alkaloid identical with veroiria, previously obtained from veratrurn 
album, its European congener (Ibid., x. 89). In 1857, Dr. Jos. G. Rich- 
ardson, after a very elaborate investigation and an extended series of 
parallel chemical experiments, with the alkaloids of both these plants, 
came to the same conclusion (Ibid., 1857, 204). In 1862 Mr. G. J. Scat- 
tergood announced that in addition to the alkaloid veratria, the plant 
contained a resin, to which he ascribed the sedative action of the drug, 
and he also obtained some evidence of the probable existence of the 
alkaloid jervia in the plant (Proc. Amer. Pharrn. Assoc., 1862). Mr. 
Charles Bullock, of Philadelphia, in 1865, claimed that the alkaloid in 
question was not identical with veratria, and that the resin of Scatter- 
good owed its activity to the presence of another alkaloid. These prin- 
ciples were afterwards named respectively veratroida and viridia (Amer. 
Journ. Pharrn,, 1865, 321). In 1872 Dr. Eugene Peugnet, of New York, 
also assented to the want of identity between veratroida and veratria, 
and he announced the identity of the viridia of Bullock with the alka- 
loid jervia, first discovered in,veratrurn album by Simon (Med. Record, 
May, 1872). These views of Dr. Peugnet were endorsed by Mr. C. L. 
Mitchell, of Philadelphia, after an elaborate investigation in 1874 (Proc. 
Amer. Pharrn. Assoc., 1874, 436). Lastly, in this singular history, in a 
paper in the January number of the American Journal of Pharmacy for 
the current year, it is again claimed that the alkaloid, other than jervia, 
of this plant is identical with veratria, it fully responding to all the 
known tests for this alkaloid. The paper just cited, by Dr. T, G. Worrnley, 
also points out the behavior of jervia with reagents, and cites cases in 
which both alkaloids were recovered from the blood of animals poisoned 
with veratrurn viride. 
In 1875 Mr. Charles Bullock contributed a valuable paper on the 
methods of preparation and properties of jervia (Amer. Journ. Pharrn., 
1875, 449). In this connection we should not fail to mention the inter- 
esting and valuable series of experiments upon the physiological action 
of the alkaloids of this plant by Prof. Horatio C. Wood, Jr,, of Phila- 
delphia, published in the American Journal of the Medical Sciences, 
January, 1870, and the Philadelphia Medical Times, vols, ii. and iii. ADDRESS ON MEDICAL CHEMISTRY. 
55 
Leaving this protracted notice of the American hellebore, let ns turn 
to a plant of milder name and properties, the Wax Myrtle or Bayberry, 
the Myrica cerifera of the botanists. In 1819 the berries of this plant 
were examined chemically by Dr. J. F. Dana, then chemical assistant in 
Harvard University (Amer. Jonrn. Sci., i. 294). Air. G. E. Moore, in 
1862, made a complete analysis of the Wax of the Bayberry, and found 
it to consist of palmitin and palmitic acid, with a small quantity of lauric 
acid (Ibid. (2), xxxiii. 313). In 1863 the bark of the root of this plant 
was examined by Mr. Geo. M. Hambright, of Philadelphia, who found 
that it contained a new crystallizable principle, to which he gave the 
name myricinic acid (Amer. Journ. Pharm., 1863,193), The bark of this 
plant, as a remedial agent, was first brought to the attention of the pro- 
fession in 1822, by Dr. W. M. Fahnestock, of Harrisburg, Penn. 
According to Rev. F. Heckewelder, the Indians of this country em- 
ployed Podophyllum peltatum, or May apple, as a poison to destroy them- 
selves (Eberle’s Therapeutics, i. 205). This plant was long used as a 
popular cathartic, and was brought to the attention of physicians, by Dr. 
Bigelow, about 1818. 
The first chemical examination of this plant was made in 1831, by 
Wrn. Hodgson, who obtained a crystallizable bitter principle, which he 
believed to be the active principle of the plant, and which he named podo- 
Vhyllin (Amer. Journ. Pharm., iii. 273); but Prof. T. F. Mayer was led to 
believe that the principle obtained by Hodgson was the alkaloid berberina 
(Ibid., 1863, 98); and this fact was fully established by Prof. J. M. Maisch 
(Ibid., 303). After an elaborate examination of the plant by John R, 
Lewis, the results of which he presented as an Inaugural Essay, he con- 
-ohides that the active properties of the root are due to the presence of 
two peculiar resinous principles, the one soluble, the other insoluble, in 
ether (Ibid., 1847, 165). According to Prof. Mayer, the root contains, 
besides berberina, a colorless alkaloid, a neutral volatilizable principle, 
and saponine (Ibid., 1863, 98). 
A native plant that has received considerable attention at the hands of 
the physician and chemist is Hydrastis Canadensis, or Yellow puccoon. 
It was known both as a medicine and as a dye to the aborigines of this 
country, and employed by irregular practitioners before being used by 
tbe regular profession. The first chemical examination of this plant was 
pUde in 1851, by Alfred A. B. Durand, of Philadelphia (Am. Journ. 
I bar., 1851? 112). He obtained a colorless crystallizable base, which he 
Ruined hydrastia, but he failed to obtain it in a pure state. In 1862, Mr, 
L D. Per rins, of Worcester, England, obtained it pure and determined 
s°me of its properties. He read his paper before the London Pharma- 
ceutical Society, April 2, 1862, an abstract appearing in the Chemical 
ews (v. 204), and the paper in full in the London Pharmaceutical Journal 
Vr May, 1862. In 1863, F. Mahla, of Chicago, Illinois, in a very vain- 
he paper published in Silliman’s Journal (op. cit. (2), xxxvi. 57) very fully 
the properties of hydrastia and gives its ultimate composition. 
.. e bave given the history of this alkaloid somewhat in detail, since 
iere have been different claimants for the honor of its discovery. 
Mr. F. Mahla, in 1861, fully established the presence of berberina in 
hydrastis Canadensis (Sill. Journ. (2), xxxiii. 43). This was the first 
Ds ance in which this alkaloid—-now known to be so widely distributed 
tl' b ailts—was found in a plant belonging to the Ranunculaceae, and it 
1'!ls established the fact that the same alkaloid may occur in plants 
e onging to different families. The chemical history of the alkaloid 56 
WOEMLEY, 
berberina is somewhat remarkable. In 1826, Chevallier and Pelletan 
discovered it in the bark of Xanthoxylum clava Herculis, and named it 
xanthopicrite. In 1835, it was found as herberina, by Buchner, in Berheris 
vulgaris. These observers erroneously regarded it as a weak acid. Fleit- 
man established its basic character ; and Perrins, in 1862, showed the 
identity of xanthopicrite with berberina, and established its formula. 
The probable existence of a third alkaloid in bydrastis canadensis, “ more 
resembling berberina than hydrastia, but decidedly different from the 
former,” was announced in 1873, by A. K. Hall, of Ann Arbor, Mich. 
(Am. Journ. Phar., 1873, 247). This third principle was more fully 
examined in 1875, by John 0. Burt, of the University of Michigan (Ibid., 
1875, 481). 
Cimicifuga racemosa, or Black snakeroot, a native of the United States, 
was first introduced to the attention of the regular profession by Hr. 
Thos. J. Garden, of Charlotte, Ya., in 1823. This plant was examined 
chemically in 1834, by John H. Tilghman (Amer. Journ. Phar., vi. 14); 
in 1843, by J. S. Jones (Ibid., xv. 1); and in 1861, by Geo. H. Davis 
(Ibid., 1861, 391); but neither of these gentlemen succeeded in obtaining 
the active principle of the plant. At a meeting of the Y. Y. Academy 
of Medicine, April 3, 1871, Dr. S. R. Percy exhibited a sample of a new 
alkaloid obtained by him from the cimicifuga racemosa, which he 
named cimicifugia (Amer. Med. Times, IST. Y., April, 1861). 
The poisonous nature of the leaves of Prunus Virginiana, or Wild 
cherry, has long been known. As early as 1806, Dr. Coxe, of Philadelphia, 
conjectured that the poisonous properties of water distilled from the 
leaves of this plant were due to the presence of prussic acid (see Am. 
Journ. Pharm., 1859, 433). In 1834, Stephen Procter determined the 
proximate composition of the bark of the tree, and established the pre- 
sence of hydrocyanic acid and a volatile oil, as products of distillation 
with water (Amer. Journ. Pharm., vi. 8). In 1838, Prof. ¥m. Procter, 
Jr., established the existence of amygdaline and of a decomposing agent, 
identical with ernulsine, in the bark, leaves, and kernels of the wild 
cherry, and showed that these principles (as had before been shown by 
Liebig and Woehler in the case of bitter almonds) were the source of 
the volatile oil and hydrocyanic acid obtained by distillation (Ibid., x. 
197). 
In 1856, Prof. E. S. Wayne, of Cincinnati, obtained from the root of 
Leptandra Virginica, or Black root, a peculiar, bitter, crystallizable prin- 
ciple, which possessed the properties of the plant, and which has been 
named Leptandria (Amer. Journ. Pharm., 1856, 510). Prof. Wayne also 
found that the root contained mannite (Ibid., 1859, 557). In 1863, Prof. 
F. F. Mayer announced the presence in the plant, of a glucoside closely 
resembling senegin in its properties, but more readily decomposed by 
alkalies (ibid., 1863, 298). 
We may next notice Rhus toxicodendron, or Poison oak, a native plant 
well known from its peculiar action upon the skin of some individuals. 
It was used by the Indians, both as a poison and as a medicinal agent. 
The first chemical examination of this plant seems to have been made in 
1857, by Dr. Joseph Khittel, of Munich, who determined its principal 
proximate constituents, among which he claimed to have obtained a 
volatile alkaloid upon which the poisonous properties of the plant 
depended; but of this he failed to give any proof. In 1865, Prof. John 
M. Maisch, of Philadelphia, obtained from the fresh leaves of the plant, 
a new volatile, organic acid, which he named Toxicodendric acid, and fully ADDRESS ON MEDICAL CHEMISTRY. 
57 
established that it was to the presence of this principle the plant owed 
its peculiar poisonous effects. Prof. Maisli failed to obtain any evidence 
of the presence of a volatile alkaloid (Proc. Amer. Pharm. Assoc., 1865, 
166). Several cases of poisoning of children who have eaten the fruit of 
this plant, have been reported. 
The beautiful climbing plant G els emium semper virens, or Yellow jasmine, 
a native of the South, wasbrought to the notice of the profession by an 
accident, in which a decoction of the root was administered for that of 
another plant. Its claims as a therapeutic agent were strongly urged 
upon the profession by Prof. Wm. Procter, in 1852 (Amer. Journ. Pharm., 
1852, 307). This plant is now not only used quite generally by the pro- 
fession of this country, but has found favor with the profession of 
Europe, having been first employed there more especially as a remedy 
for neuralgia. Its physiological effects were very carefully studied by 
Prof. Bartholow, of Cincinnati, in 1870 (London Practitioner, Oct. 1870); 
and very recently by Drs. Ringer and Murrell, of University College, 
England (Lancet, March and April, 1876). The first attempt to deter- 
mine the chemical composition of the root of this plant was made in 
1854, by M. H. Kollock (Amer. Journ. Pharm., 1855,197). It was again 
examined in 1868, by C. L. Eberle (Ibid., 1869, 35). Both these gentle- 
men, however, failed to isolate the active principle. In 1869, Dr. T. G-. 
Wormley obtained from the plant a new alkaloid, gelseminia, and an 
organic acid, gelseminic acid, the properties of both of which he fully 
described in the American Journal of Pharmacy for January, 1870. 
This paper also contains a report of a case of poisoning by the fluid 
oxtract of the plant, in which the alkaloid was recovered some months 
Mter death. On physiological grounds, Drs. Ringer and Murrell are 
mdined to the view that the plant contains two active principles, one 
capable of paralyzing, the other of exciting, the spinal cord. 
An indigenous plant, used more especially as a domestic remedy, that 
early received chemical attention was the Prickly ash, Xanthoxylum 
fraxineum, which was examined in 1829, by Dr. Edward Staples, who 
found that it owed its active properties to the presence of a peculiar crys- 
follizable principle which he named xanthoxyline.(Amer. Journ. Pharm., 
l' 163). After the discovery of berberinaand its identity with xanthopi- 
Cl']te had been shown, it was generally believed that Dr, Staples's xantho- 
xyline was identical with berberina, especially when the wide distribu- 
10n of this alkaloid became known ; but Mr. Perrins, who first pointed 
cut the identity of the two former alkaloids, states that xanthoxyline is 
au entirely distinct principle (Amer. Journ. Pharm., 1863, 459, note). 
In connection with this early contribution of Dr. Staples may be men- 
tioned that of Dr. J. F. Dana, who in 1819 discovered the existence of 
\e animal alkaloid cantharidine in the Potato fl}7, Lytta vittata, the alka- 
md having been first obtained in 1812 by Robiquet from the Spanish 
-fo vesicatoria. Other American contributions to the chemistry of 
muharidine have been made by Prof. Procter, in 1852 ; by Wm. B. 
arner, of Maryland, in 1856 ; and by Prof. Maisch, in 1872. 
,_®fotely American tree, named from its large and beautiful flower, 
e luliptree or Liriodendron tulipifera, affords a bark which was recora- 
to the profession by Dr. Young, of Philadelphia, in 1792, as a 
r stltute for Peruvian bark in intermittent fevers, and in diseases 
a gentle stimulant and tonic. In 1831, Prof. Emmet, of the 
Uersity of V irginia, obtained from this bark a neutral, bitter principle 58 
WORMLEY, 
which he named Uriodendrin, and which he described as a white crystal- 
lizable solid (Ainer. Journ. Pharm., iii. 5). 
Apocynum cannabinum, or Indian hemp, loner known as a powerful 
emetic and cathartic, was examined chemically by Dr. Knopp, who found 
it to contain, among other proximate constituents, a peculiar, bitter, 
active principle to which he gave the name apocynin. This plant was 
subsequently examined by Dr. Griscom (Amer, Journ. Med. Sci., May, 
1836). This plant is different from Cannabis indica, also popularly known 
as Indian hemp, which was examined chemically in 1865, by Prof. Wm, 
Procter (Amer. Journ. Pharm., 1865, 23). 
The American water hemlock, Gicuta maculata, found abundantly 
throughout the United States, was examined in 1855, by Jos. E. Young, 
who found it to contain a peculiar acid (probably the coniic acid of Per- 
schier), and the volatile alkaloid conine, first obtained from coniurn macu- 
latum, by Geiger, in 1881. 
Wahoo, Euonymus atropurpureus, so well known throughout the 
Western States, and sometimes called “ burning bush,” from the brilliancy 
of its crimson fruit, was made the subject of a very elaborate chemical 
examination by Wm. F. Wenzell, in 1862, who found it to contain a 
peculiar basic principle, which he named Eaonymine, and a new organic 
acid, euonic ado.l (Amer. Journ. Pharm., xxxiv. 387). 
Many other American plants have contributed to the wants of the 
physician, and have been the subjects of chemical examination, but special 
reference to them is necessarily omitted. 
We now come to consider the history of the discovery of a compound 
which is not only interesting in itself, but is more especially so on account 
of its subsequent applications and the important position it now holds in 
the medical world. 
In 1831, Dr. Samuel Guthrie, of Sackett/s Harbor, Y. Y., a man of 
unusual chemical knowledge for his time, discovered a substance which 
he prepared by distilling a mixture of chloride of lime and alcohol, and 
an account of which he published in the American Journal of Sciences, 
Oct. 1831, under the title “ A new mode of preparing a spirituous solution 
of chloric ether.” In this paper Dr. Guthrie states that in order to ascer- 
tain the effect of this substance in full doses on the healthy subject, and 
thus discover its probable value as a medicine, he had, during the last 
six months, administered it to a great number of persons, not only very 
freely, but frequently to the point of intoxication, and that the effects 
were grateful both to the palate and the stomach, and he concluded that 
u it would seem to promise much as a remedy in cases requiring a safe, 
quick, energetic, and palatable stimulant.” His attention was, as he 
states, first directed to this subject by a statement in Prof. Silliman’s 
Elements of Chemistry (vol, ii. p. 20), then just published, to the effect 
that an alcoholic solution of chloric ether, when diluted, was a grateful 
diffusible stimulant and might probably be introduced in medicine. 
.Prof. Silliman distributed samples of this substance to Dr. Eli Ives, of 
the Medical Department of Yale College, and to others, to be used in 
their practice. Under date of January 2,1832, Dr. Ives reported that he 
had administered it in a number of cases with marked advantage, and 
had also used it by inhalation with good results (Amer. Journ. Sci., xxi. 
406). The product thus produced by Dr. Guthrie was regarded by him 
at the time as the substance then known as “chloric ether” or “Dutch 
liquid,” whereas it was an entirely new and distinct substance, that now ADDRESS ON MEDICAL CHEMISTRY. 
59 
known as chloroform. Chloroform was also discovered by Souheiran, of 
France, and an account of it published in February, 1881, under the name 
ot Ether bichlorique. So, also, Liebig, in 1882, made another independent 
discovery of the same substance, naming it Chloride of carbon. It was 
named chloroform by Dumas, who discovered its true chemical constitu- 
tion in 1834. A committee of the Medico-Chirurgical Society of Edin- 
burgh awarded Dr. Guthrie the credit of having first published an account 
of its therapeutical effects as a diffusible stimulant in 1832 (Amer. Journ. 
Sci. (2) vii. 143). 
As this substance afterwards became a prominent agent in producing 
anaesthesia, it leads us naturally, but very briefly, to notice the use of 
this and other substances inhaled for anaesthetic purposes, and the part 
which Americans have taken in a discovery which has proved an inesti- 
mable blessing to mankind. 
In this memorial year, we naturally follow the years back to the be- 
ginning of the century we commemorate, and find that in 1776, or just 
one hundred years ago, Dr, Priestley, who had previously made the bril- 
liant discovery of oxygen, discovered Nitrous Oxide, which hecalled Dephlo- 
gisticated Nitrous Air. In 1779, Sir Humphry Davy, then a very young 
man, entered upon a series of experiments in Bristol with this nitrous air, 
which he named nitrous oxide, and on the 11th of April of that year, 
made the \first inhalation of the gas, and recorded its effects upon himself. 
By his investigations he ascertained its exhilarating effect, and discovered 
lts power, when inhaled, to remove intense physical pain. His remark- 
able generalization from his experiments was expressed in the following 
°lt-quoted words: “As nitrous oxide in its extensive application appears 
capable of destroying physical pain, it may probably be used with advan- 
tage during surgical operations in which no great effusion of blood takes 
place.” (Researches, etc., concerning Nitrous Oxide and its Respiration, 
Bristol, June, 1800.) While this suggestion appears to have been for- 
gotten, yet nitrous oxide became widely known and used as a stimulant, 
<md its administration as “laughing gas” was a matter of popular exhi- 
bition. In like manner, ether, the date of the first inhalation of which 
18 m some obscurity, was used for the same purpose in the United States, 
as. mentioned by the earlier writers on chemistry. In the experiments 
imth both nitrous oxide and ether, there were cases in which these agents 
Pfoduced perfect insensibility, but the anaesthetic condition was not spe- 
cially observed. 
I'i the fall of 1844, Horace Wells, a dentist of Hartford, having wit- 
nessed an exhibition of the inhalation of nitrous oxide, and observed that 
a Pe’’son under the influence of the gas was injured without being con- 
of suffering, boldly inhaled the gas, and had a tooth removed 
yithout sense of pain, and gave it to others for the same purpose, with 
nnilar results. Thus the suggestion of Sir Humphry Davy in Bristol, 
ngland, published in 1800, was realized by Horace Wells at Hartford, 
U)nm, in 1844. 
yy 11 1846, Wm. T. G. Morton, a dentist of Boston, a former student of 
n. e8’ a,jd aware of his labors with nitrous oxide, commenced experi- 
epentß with ether for the same end. The administration, in the Massa- 
en!’SettS hospital, of ether by inhalation to a patient upon whom the 
c.a|lrlei.B B>r. John C. Warren performed a surgical operation, authenti- 
miclV as an anaesthetic agent to the surgical and medical profession, 
1-.., • dOlll that time the knowledge and practice of anaesthesia extended 
Japidly over the world. 60 
WORMLEY, 
As already shown, chloroform was employed by inhalation by Dr. Ives, 
of Hew Haven, in his practice in the winter of 1881-32 with marked 
benefit. In March, 1847, M. Flourens experimented with this agent 
upon lower animals, and in November of the same year the distinguished 
Prof. James Y. Simpson, of the University of Edinburgh, employed it as 
an anaesthetic agent with success, and introduced it into surgical and 
obstetrical practice. 
Thus, in summary, we find that anaesthesia, first suggested by Sir 
Humphry Davy, in 1800, was demonstrated with nitrous oxide as an 
agent, by Horace Wells, in 1844; with ether as an agent, by Wm. T. G. 
Morton, in 1846; and with chloroform, by Sir James Y. Simpson, in 1847. 
The next American chemical contribution to medicine that we may 
mention, is that on the “ Origin of Urea in the Body,” by Prof. John C. 
Draper, of the University of the City of Hewr York (Hew York Journal 
of Medicine, Feb. 1856). In this paper the author shows the error in the 
statement of Liebig that muscular action increases the amount of urea 
secreted. The process employed was the decomposition of urea by 
nitroso-nitric acid, and weighing the carbonic acid produced as carbonate 
of baryta. The results obtained by Prof. Draper have since been verified 
by Pick and Wislicenus, but the credit of the first disproval of the state- 
ment of Liebig belongs to Dr. Draper. 
Dr, Draper has also contributed papers, which may be mentioned in 
this connection, on “Products of Respiration,” Hew York Med. Times, 
July, 1856; “Insensible Perspiration,” Proceedings of the Hew York 
Academy of Medicine, May, 1864; “The Heat produced in the Body, 
and the Effects of Exposure to Cold,” American Journal Science and 
Arts, Dec. 1872. 
The last contribution we shall mention in this connection, is a valuable 
paper in the department of Physiological Chemistry, entitled “ Experi- 
mental Researches into a new Excretory Function of the Liver,” by Pro- 
fessor Austin Flint, Jr., widely known in the field of experimental phy- 
siology. This paper was published in the American Journal of the Medical 
Sciences for October, 1862; and afterwards presented to the French Aca- 
demy of Sciences, from which it received in 1869 honorable mention and 
an award of 1500 francs. The important discoveries put forth in this 
memoir were the production of cholesterine in the physiological wear of 
the brain and nervous tissue, and its elimination by the liver, and dis- 
charge from the body in the form of stercorine. Dr. Flint’s researches 
and interesting conclusions upon this subject have lately been confirmed 
in Germany, by experiments in which cholesterremia has been produced 
in animals by injection of cholesterine into the blood. 
TOXICOLOGY. 
We now enter upon the other and not less important branch of the 
subject assigned us, namely that of Toxicology. This science is one of the 
highest moment to the race. While health and life are assailed by various 
diseases, by the ill-adjustment of outward circumstances, such as climate, 
locality and the like, by the unsuitableness of food and drink, or by an 
excessive use of these*, and by a thousand other harmful conditions, these ADDRESS ON MEDICAL CHEMISTRY. 
61 
assaults are generally made by slow and noticeable approaches, and are 
within the ken of the physician. But there have always lurked in the 
mineral and organic kingdoms, foes which may be likened to assassins 
who spring upon the unwary and destroy life as by a secret blow. These 
assailants are the poisons, the very Thugs of nature. 
Before the present century little was known of poisons beyond their 
deadly effects and the attending physiological circumstances. Indeed, 
any true knowledge of poisons was unattainable until the advent of 
Chemistry as an exact science. Poisons are naturally grouped into two 
kinds—inorganic and organic. 
in noticing the inorganic or mineral poisons, that one which holds the 
highest position in historical toxicology, and the one which until recently 
has been used as a toxic agent very much more than any other, is Arsenic. 
Although known in its metallic state, and as arsenious acid, as early as 
the eighth century, to G-eber, the Arabian, and although it had been used 
as a poison for centuries, yet so little progress had been made in regard 
to its chemical detection under these circumstances, that Sir R. Christi- 
son, as late as 1824, declared that the tests for arsenic at that time in 
general use were so fallacious, when applied to complex mixtures, as to 
be unfit for medico-legal investigations. He then proposed a process for 
the detection of this metal which, as modified by Presenilis and Babo, 
continues in use to the present day. At the time of introducing this 
method, Prof. Christison remarked that by ft he was able to detect the 
one-sixteenth of a grain of the poison. This, at the time, was regarded 
as a great triumph of analytical skill. Hot long before this (1795) Dr. 
Black stated that one grain was the least he could detect; and at a 
somewhat earlier period, yet less than a century since (1786), Hahne- 
mann stated that ten grains was the least quantity he could recover. 
In 1836, Mr. Marsh, of Woolwich, England, proposed for the detection 
°f this metal, a method which has since been known by his name, and 
wf*soh has proved of the highest value in chemico-legal practice. As 
originally employed by Mr. Marsh, this test was restricted to obtaining 
deposits of the metal from the ignited jet of the arsenide of hydrogen; 
9nt in 1841 Berzelius proposed the reduction of the arsenical gas by heat 
aPplied to the exit tube of the apparatus, and it has been found that this 
a|othod is even more delicate than that proposed by Marsh. In 1841 Dr. 
iugo Reinsch proposed, for the detection of this metal, his copper test, 
w dch has proved a most admirable method for the recovery of the poison, 
specially from complex organic mixtures. In point of delicacy, as now 
employed, this test is not inferior to the process of Marsh, and it has in 
certain cases even the advantage over the latter in simplicity of appli- 
cation. The two tests now mentioned, both in regard to simplicity of 
application and delicacy of reaction, leave little or nothing more to be 
csired in regard to the recovery and identification of this poison, 
tine of the first American contributions relating to the detection of 
msenic was by Prof, James F. Dana, a graduate of Harvard University, 
qi 0 studied chemistry in London, and was afterwards Professor of 
ministry in Dartmouth College and in the College of Physicians and 
u rpfeons,’ Hew York. As early as 1816, he prepared a paper on the 
pri °StS r J^-1’serd<b” f°r which he received the award of the Boylston 
Pot26') 1818’Dr- Thomas Cooper announced the use of chromate of 
In tl aS a teSt *°r arseid° 5 but it did not prove to be a distinctive test. 
Pl-i 16 Bame year, he read a paper on the subject before the American 
°sophical Society (Amer. Journ. Sci., iv. 16). In 1830, Prof. John 62 
WORM LEY, 
P. Emmet, of the University of Virginia, proposed iodide of potassium 
as a test for this metal. In the next year (1831) Dr. Lewis Feuchtwanger 
published a paper entitled Remarks on Arsenic, with drawings of the 
color of its precipitates,” in which he gave a full account of the processes 
then known for the detection of this poison (Amer. Journ. Sci., xix. 339), 
An important and original contribution on this subject was made in 
1832, by Prof. J. K. Mitchell, of Philadelphia. In this paper, “On the 
Properties of Arsenic,” Dr. Mitchell determined the specific gravity of 
the different varieties of arsenious acid; its solubility under various 
conditions; and the vaporizing temperature of metallic arsenic and of 
arsenious acid (Amer. Journ. Med. Sci., x. 126). 
The next contribution to be mentioned is that “ On the Detection of 
Arsenic in Medico-Legal Investigations,” by Dr. Wm. P. Fisher, of the 
University of Maryland, in a paper read in 1836 before the Maryland 
Academy of Science and Literature, and published in their Transactions 
(vol. i. p. 117). In 1838, Dr. Robert B. Hall published a Summary of 
Experiments upon dogs, with hydrated peroxide of iron as an antidote 
in arsenical poisoning (Amer. Journ. Pharm., x. 263). And in 1840, Dr. 
Fisher, already mentioned, contributed a paper on the same subject 
(Ibid., xii. 1). In 1841, Prof. J. Lawrence Smith, of Louisville (to 
whom science is indebted for many original researches, and whose special 
investigations of meteoric bodies have given him a wide and lasting 
reputation), when a studertt in Paris, prepared a valuable paper On the 
Tests and Antidotes for Arsenic (Am. Journ. Sci., 40, 278). Two years 
later (1848), Dr. D. P. Gardner, Professor of Chemistry in Hampden- 
Sidney College, Va., contributed an elaborate paper On the Application 
of Reinsch’s test for detecting Arsenic in Medico-Legal Investigations 
(Amer. Journ. Sci., 44, 240). In 1862, Charles H. Porter, Professor of 
Chemistry and Medical Jurisprudence, Albany Medical College, pre- 
sented to the Medical Society of Yew York an excellent paper entitled 
Medico-Legal Contributions on Arsenic, which contains reports of a 
number of cases of arsenical poisoning, together with an account of the 
methods employed in their chemical examination. 
We next notice a very valuable contribution by Prof. John C. Draper, 
of the University of the City of Yew York, On the Quantitative Deter- 
mination of Arsenic, published in the American Chemist for June, 1872. 
Professor Draper suggests a modification of Marsh’s apparatus, and the 
use of a ribbon of magnesium for decomposing the arsenical solution ; 
and, also, the use of a fagot of platinum wire on which the arsenic 
forms a coating, the weight of which can be determined. By re-heating 
the fagot in dry oxygen, the arsenic is obtained in the form of oxide, 
which may be dissolved in water and submitted to the usual tests. In 
July of the same year, Dr. Draper published in the same journal a paper 
On the Distribution of Arsenic in the Body. Another contribution to 
this subject that deserves mention, is a record of The Chemical Testimony 
in the Sherman Poisoning Case, by Prof. George F. Barker, of the Uni- 
versity of Pennsylvania (Amer. Chemist, June, 1872). This paper con- 
tains a detailed account of the methods pursued and results obtained in 
the examination of the different tissues submitted for analysis. In this 
case, a quantity of arsenic, corresponding to about five grains for the 
entire organ, was obtained from a portion of the liver. The bodies of 
four (4) of the eleven (11) persons supposed to have been poisoned by 
Mrs. Sherman were examined by Prof. Barker, and arsenic found in 
each. ADDRESS ON MEDICAL CHEMISTRY. 
Having tlms noticed the principal American contributions relative to 
arsenic, it is proper in this connection to refer to some of the more im- 
portant American contributions relating to other poisons. 
In 1827, Prof. Robert Hare proposed a method for determining the 
presence of opium by the reaction of one of its constituents, meconicacid, 
in striking a red color with a persalt of iron. He asserted that this test 
would show the presence of laudanum when only ten (10) drops were 
contained in one-half gallon of water (Amer. Journ. Sci., xii. 290). With 
but little modification this test is the one employed at the present time 
for the detection of opium. 
In 1856, Hr. Lewis H. Steiner, of Baltimore, made a report to the 
American Medical Association, On Strychnia, in which, in addition to a 
discussion of the chemistry of the subject, he gives a detailed history of 
the noted case of Hr. Gardner, of Washington, who destroyed himself 
with that poison. In a paper On the Chemical Reactions of Strychnia, 
published by Hr. T. G, Wormley, in 1859, in the American Journal of 
Science, the relative delicacy of the various tests for this poison is 
pointed out. The fact that the color-reaction of strychnine is interfered 
with by the presence of morphine, having first been noticed by A. W. 
Brieger in 1850, this interference is fully considered in this paper, and 
the conclusion reached, that the interference increases both with the 
relative proportion and absolute quantity of morphine in the mixture 
submitted to the test. Another paper to be mentioned in this immediate 
connection, is that of Prof. John J. Reese, On the Hetection of Strychnia 
as a Poison, and the Influence of Morphia in Hisguising the usual Color- 
test, published in the American Journal of the Medical Sciences for 
October, 1861. So also in this connection may be mentioned a valuable 
contribution On the Behavior of the Color-test for Strychnine, with other 
Vegetable and Animal Proximate Principles, by Hr. Thomas E. Jenkins, 
ci Louisville, Ky. (Semi-monthly Med. Hews, April, 1859). The be- 
havior of this test with a number of proximate principles other than 
strychnine, was first examined in 1856, by M. Eboli, Professor of Chem- 
lBtry at the Academy of Medicine, Lima. Hr. Jenkins so extended this 
examination as to include about fifty of these principles; and Prof. Wm, 
A. Guy, of London, in 1861 investigated some sixteen additional sub- 
stances. 
. Another contribution to this subject is a Report of a Trial for Poison- 
luB' by Strychnia, by Prof. Geo. E. Barker, recorded in the American 
ournal ot the Medical Sciences for October, 1861. In this paper Prof, 
arker gives a very complete history of a case remarkable in that violent 
niptoms were present in about three minutes after the poison had been 
a<,eu by an adult, the effects thus manifesting themselves perhaps more 
apidly than in any other instance yet reported of poisoning by this 
substance. 
Ay'i e!a^orate paper entitled Experiments of Poisoning with Vegetable 
of haloids, by Hr. J. H. Salisbury, was published in the American Journal 
0f le.Medical Sciences for 1862. In regard to the limit of the reactions 
Wr PolBons and other principles, with chemical reagents, Hr. T. G. 
oinaley has contributed papers on the reactions of the following; 
iSfin?I?®’ Chemical Hews, London, June, 1860; Brucine, Ibid., July, 
Sem ’ q PrPbiue, Ibid., Sept. 1860 ; Harcotine and Meconic Acid, Ibid., 
Med' Corrosive Sublimate, Ibid., Sept. 1860; Veratrine, Ohio 
Vo]/ Surg. Journ.,.vol. xii., Ho. 6; Hicotine and Haturine, Ibid, 
xui., Ho. 1; Solanine, Ibid., vol. xiii., No. 2; Codeine, Meconine, 64 
WORMLEY, 
Narceine, and Aconitine, Ibid., vol. xiii., No. 4 ; Conine, Ibid., vol. xiv., 
No. I ; Oxalic Acid, Ibid., vol. xiv,, No. 5. 
Mention may next be made of a curious plant, Erythroxylon coca, the 
leaves of which have arrested considerable attention because of their use 
by the Indians of Peru for the purpose of producing excitement, and 
giving strength for prolonged physical exertion. Dr. Samuel R. Percy, 
of New York, presented a paper on this subject before the N. Y. Academy 
of Medicine, Dec. 2, 1857, and exhibited tine colorless crystals of the 
alkaloid of the plant, for which he proposed the name Erythroxyline 
(Amer. Med. Times, Nov. 1860). In 1860 Prof. Woehler and Dr. Nie- 
man, of Gottingen, obtained the same alkaloid, giving it the name 
cocaine. 
In 1866, Dr. Percy, of New York, presented a paper to the American 
Medical Association, On Digitaline, its Chemical, Physiological, and The- 
rapeutic Action, for which the Association awarded a prize; and, in 
1868, the same gentleman received a prize from the Alumni Association 
of the Medical Department of Columbia College for a paper On Atropia, 
its Chemical, Physiological, and Therapeutic Action, with Experiments 
instituted to ascertain its Toxicological Properties. In January, 1871, 
Prof. John J. Reese, of Philadelphia, published a communication On the 
Antagonism of Poisons, in the American Journal of the Medical Sciences, 
in which he examined the antagonism of morphia with hydrocyanic acid, 
atropia, strychnia, aconitia, and arsenic, and also of strychnia with 
tobacco, aconite, iodine, and Calabar bean. Eor the destruction of the 
organic tissues, in searching for poisons in medico-legal investigations, 
Prof. Henry Wurtz, in 1851, proposed the use of bromine as an agent 
possessing certain advantages over the ordinary agents used for this pur- 
pose (Silliman’s Journal (2), xi. 405). 
We now notice a very interesting and valuable paper on Experimental 
Researches relative to Corroval and Yao, two new varieties of Woorara, 
the South American Arrow Poison; by Drs. Wm. A. Hammond and 
S. Weir Mitchell, published in the American Journal of the Medical 
Sciences, July, 1859. This is an original and exhaustive examination 
of the physiological effects, and the chemical properties and physical 
characters, of these varieties of Woorara. The authors extracted from 
both varieties an alkaloid, for which they proposed the name corro- 
valia, obtaining it in larger quantity from the variety corroval. This 
substance was not obtained in a crystalline state, nor were any of its 
salts. One of the authors of the last-named paper, Dr. S. Weir Mitchell, 
published in the Smithsonian Contributions, vol. xii. (1860), a very elabo- 
rate and complete monograph, entitled, Researches upon the Yenom of 
the Rattlesnake. This contribution is marked by the same patient and 
thorough research which characterizes the other scientific labors of this 
original investigator. It considers the anatomy of the venom apparatus, 
the physiological mechanism of the bite, the toxicological action of the 
venom on warm-blooded animals, and the various antidotes for the poison. 
His chemical investigations show the toxicological element of the venom 
to be a peculiar albuminoid principle, which he names crotaline. 
Again, in 1868, Dr. Mitchell instituted a series of experiments on the 
Insusceptibility of Pigeons to the Toxic Action of Opium, in which he 
showed that this bird was almost wholly insusceptible to the action of 
that drug. The same immunity was observed whether the drug itself, 
or morphia, was emplojmd, and also whether it was administered inter- 
nally or employed hypodermically. In his final experiment, Dr. Mitchell ADDRESS ON MEDICAL CHEMISTRY. 
65 
administered to a large pigeon twenty-one grains of powdered opium, 
without producing any evidence of opium poisoning (Amer. Journ. of 
the Med. Sci., Jan. 1869). Dr. B. W. Richardson, of London, on repeat- 
ing Dr. Mitchell’s experiments, fully confirmed his results. As a com- 
parison of the relative susceptibility of the pigeon and the child, Dr. 
Richardson states that a pigeon can receive at once as much opium as 
would produce dangerous or even fatal symptoms, if divided equally and 
administered to twenty children under one year old, the weight of the 
bird being two hundred times less than the combined weight of the 
children (Brit, and For. Med. Chir. Rev., April, 1869). Continuing his 
researches, Dr. Mitchell extended his experiments to the physiological 
effects of the derivative alkaloids of opium, including morphia, narcotina, 
thebaia, raeconine, codeia, narceia, and cryptopia, employed both inter- 
nally and subcutaneously. In these experiments, Dr. Mitchell obtained 
some very interesting and novel results. Thus, he found that while 
opium, which is a poison to man, is with difficulty hurtful to the pigeon ; 
°n the other hand, narcotina, which is nearly inert in man, is fatal to 
birds (Amer. Journ. of the Med. Sci., Jan. 1870). 
We next notice some very original and interesting investigations of 
Br. James Blake, of San Francisco, who has been engaged for many 
years in examining the connection between Isomorphism, Molecular 
Weight, and Physiological Action (Amer. Journ. Sci. (2) viii. p. 193). 
LF. Blake has investigated the effects of compounds or salts of forty (40) 
pf the elements, including substances contained in all the more important 
]sornorphous groups, and in all of these, with the exception of the com- 
pounds of potassium and ammonia, finds that when introduced directly 
lnto the blood of living animals, the substances in the same isomorphous 
§r°up exert analogous effects; and also that amongst the more purely 
Metallic elements, the intensity of physiological action is in proportion 
t0 the atomic weight of the substance compared with other substances 
the same isomorphous group. From experiments made by others, 
Blake believes that the same law will apply to organic or carbon 
£°inpounds, and that living matter will be found to be a valuable reagent 
or elucidating their molecular relations. His latest researches on Lan- 
Janiurn and Didyrnium place the former evidently in the magnesium 
g> and the latter with aluminium. These researches, with those of 
18, Brum Brown and Fraser, and with those of Dr. Richardson, are in 
Dew field of inquiry, and promise very interesting and important 
results to science. 
laving thus glanced at the more important American contributions to 
Xicology, the way is prepared to take a broader view of this science, 
flc observe the progress of its development, especially in its chemical 
t ures. This progress will be seen to be greater in regard to the organic 
m --s, the marked advance in methods of chemical analysis having 
c e such progress possible, 
of Je oPening of the present century, the fact that the toxic effect 
prpCe vegetable poisons was due to the agency of a peculiar active 
s 0’ r.es^ent di the plant, had not been determined. The vegetable 
ol)se .anf wbich the existence of a principle of this kind was first 
,ecolVed Was opium, in which Serfurner and also perhaps Seguin in 1804 
ie Pres(rnce °f a new substance; but it was not until 1817 
lfe ortiirner obtained it in a pure state, and examined its properties, 
°und that the alcoholic solution of this new principle acted upon, 
o » 66 
WOEMLEY, 
vegetable colors like solutions of the mineral alkalies, and that the sub- 
stance combined directly with acids, forming neutral salts which were 
soluble in water, and that it was precipitated from solutions of its salts 
by the mineral alkalies. To this substance Sertiirner gave the name 
morphine, and from the properties just mentioned he regarded it as a 
kind of alkali; hence the name vegeto-alkali or alkaloid for principles 
of this kind. 
Very soon after the discovery of morphine it was found that nux 
vomica, white hellebore, cinchona bark, belladonna, tobacco, and certain 
other vegetable products which had been long known as capable of 
exerting marked physiological effects, owed their activity to the presence 
of similar alkaline principles. The number of such natural principles 
now known is quite considerable. Since 1848 a great number of organic 
alkalies have been obtained artificially, some of which rival potash and 
soda in* the degree of their alkalinity. The study of these artificial 
alkaloids has thrown much light upon the constitution of the natural 
alkaloids, which is, as yet, imperfectly understood. 
The discovery of the natural alkaloids has been of great service to the 
physician, giving him a more concentrated and manageable form of me- 
dicine; but to the toxicological chemist this discovery has been of the 
very highest value, enabling him in cases of poisoning by crude vegetable 
substances, in just so far as he can recover the alkaloid or active principle 
from complex mixtures (such as the contents of the stomach), and can 
separate and determine it by special chemical properties, to identify the 
toxic substance employed. There are, however, many vegetable and 
animal poisons, the exact nature of the active principle of which has not 
yet been determined. 
Formerly, about the only method of detecting vegetable poisons was 
by means of the physical and botanical characters of the subtance taken, 
such as the leaves, seeds, etc., and this method is yet of service in furnish- 
ing corroborative evidence in cases even in which the nature of the pecu- 
liar principle is known. It is obvious that in poisoning by crude vege- 
table and animal substances, we can determine the presence of the poison 
by chemical methods only, first, when we know that the substance con- 
tains an alkaloid or other principle peculiar to itself; second, when we 
are able to recover this principle from complex mixtures; and third, 
when we are acquainted with one or more chemical reactions character- 
istic of this principle. Thus, in poisoning by opium, we cannot prove 
the existence of opium as a whole, but only inferentially, by proving the 
presence of a principle peculiar to this drug. Our success in the dis- 
covery of organic poisons, where the existence of a peculiar principle is 
already known, depends largely on our ability to recover such principle 
from complex mixtures in a state sufficiently pure for the application of 
special tests. 
It was not until 1851 that any real progress was made in this direction, 
when Prof, Stas, of Brussels, introduced a systematic method for such 
recovery. This method has proved of the highest importance, and marks 
an era in toxicological science. It is based upon the fact that the salts 
of the alkaloids, as a class, are soluble in water and alcohol, but are in- 
soluble in ether; and that these salts when in solution are readily decom- 
posed by the mineral alkalies with the elimination of the alkaloids, which 
in their free and uncombined state are more or less readily soluble in ether. 
In any given case therefore, in so far as the active principle or alkaloid ADDRESS ON MEDICAL CHEMISTRY. 
67 
is soluble in ether, and this liquid fails to extract foreign animal and 
vegetable matter, in just so far can we obtain the alkaloid in its pure 
state. _ Professor Stas successfully applied his method for the recovery of 
the principal alkaloids likely to be met with in chemico-legal investiga- 
tions, employing for this purpose the usual extracts of the plants in which 
they are found. Professor Otto, of Brunswick, proposed to modify the 
method of Stas, in the case of the fixed alkaloids, by first washing the 
acid aqueous solution of the alkaloidal salt with ether as long as this fluid 
was colored ; the solution is then rendered alkaline and the liberated alka- 
loid extracted with ether as before proposed. Professor Otto claimed, 
and justly, that in this manner the alkaloid might be obtained in a state 
of greater purity, and almost invariably in a crystallized condition. 
In 1853, Professors Graham and Hoffman, of London, proposed a method 
for the recovery of strychnine from organic mixtures, which wqs after- 
wards extended to other alkaloids; it is based upon the fact that when 
a solution of strychnine in its free state is agitated with charcoal, the 
charcoal absorbs the poison and yields it up to boiling alcohol (Quart. 
Journ. Chem. Soc., 1858). In practice, in chemico-legal investigations, 
tins method is inferior to that of Stas. In 1856, Messrs. Rogers and 
Grirdwood, of London, proposed the use of chloroform instead of ether, 
as advised by Stas, for the extraction of the alkaloids. They also pro- 
posed to destroy the last traces" of foreign matter by charring the chloro- 
form residue with concentrated sulphuric acid over a water-bath (Lancet, 
-London, June, 1856). The use of chloroform as advised by these gentle- 
nien has proved of value in researches of this kind, since it is a better 
s°lvent of most of the alkaloids than ether, and has therefore an advan- 
tage in certain cases; but, on the other hand, it has sometimes the dis- 
advantage of taking up more freely than ether foreign animal and vege- 
table matters. Another method for the extraction of the alkaloids from 
complex mixtures is that of Usler and Erdmann, who proposed the use 
°t amylic alcohol, the principle of the process being much the same as in 
'e method of Stas. Amylic alcohol is especially adapted to the recovery 
° morphine, solanine, and certain other alkaloids, which are more or less 
mely soluble in this liquid, whereas they are but very sparingly soluble 
}°tli in ether and chloroform, and therefore are but imperfectly extracted 
Y these liquids. 
f*l 1862, Professor Thomas Graham, of London, in his very important 
•Hribujtion.on liquid diffusion, showed that moist organic membranes 
pfethe remarkable property of separating crystallizable substances when 
t]' s°mtion from such as are uncrystallizable, the former readily passing 
j- ,lough such membranes when surrounded by a liquid, whereas the latter 
in1 ?ass or Pass only very slowly. These classes of substances he named 
Pflively crystalloids and colloids, and to this method of separation he 
anq U' ie Grin dialysis. This method is applicable to both inorganic 
+; T’ganic bodies, and is often found very useful in toxicological inves- 
llgations. * J 
Ural1? contribution to this department of research is that of Prof, 
e] a | (^n ClO rH 7 of the University of Dor pat, who, in 1868, proposed a very 
shn-ate and exhaustive method for the extraction of the alkaloids and 
theiraf l,lanU!’les- aild for their separation from each other, based upon 
uleoL ;G^av.ior with petroleum-naphtha, benzole, chloroform, and amylic 
by ’ dividing them into several groups according as they are affected 
ese different liquids under certain specified conditions. 68 
WORMLEY, 
From this brief historical sketch, we learn that very considerable 
attention has been directed to this important and essential part of toxi- 
cological chemistry; and, it may be added, the results have been such as 
to leave little to be desired in regard to the recovery of a large number 
of organic poisons. We are now prepared to take a rapid survey of the 
progress made in regard to the special identification of poisons by chem- 
ical and other tests. Even less than a third of a century ago, there were 
but few of the organic poisons for which special and unerring tests were 
known, especially when present in the minute quantity usually met with 
in chemico-legal investigations. 
In September, 1843, E. Marchand made the important discovery that 
if strychnine be treated with concentrated sulphuric acid containing a 
little nitric acid and peroxide of lead, it dissolves with the production 
of a series of colors peculiar to that alkaloid. The tests employed for 
the detection of this poison prior to the discovery of this color reaction, 
which has since been known as the color-test, gave reactions more or less 
common to substances other than strychnine. In fact, this color-test is 
the only one yet known the reaction of which, taken alone, is peculiar 
to strychnine. It was considered a marvel of delicacy of reaction when 
Marchand announced that this test would reveal the presence of a quan- 
tity of strychnine not exceeding the one-thousandth of a grain in weight. 
This test has since been modified by Mack, Otto, and others, by substi- 
tuting for the nitric acid and lead compound other oxidizing com- 
pounds; and it will now, in the hands of a skilful manipulator, show the 
presence of strychnine when in quantity not exceeding, perhaps, the one- 
millionth of a grain. 
The discovery of this test did much to stimulate chemists to search for 
special or characteristic tests for other alkaloids and vegetable principles 
likely to be encountered in chemico-legal investigations, and in many 
instances with success. Much remains, however, to be done in this 
direction, even in regard to some very well known poisons of this class. 
There are some poisons, the presence of which may be determined by what 
is known as a combination of tests, no one of which is in itself peculiar 
or exclusive; but there are others for which we have as yet neither 
peculiar and distinctive tests, nor any peculiar combination of tests for 
their detection, especially when present in minute quantity. 
It is less than a quarter of a century since the aid of the microscope 
was, to any marked extent, invoked in this department of research, yet 
within this comparatively brief period its use has very greatly extended 
our means of determining the specific nature of the results of chemical 
tests. This instrument not only often enables us to determine the true 
nature of a precipitate or sublimate by its crystalline or other form, the 
character of which would otherwise be doubtful, but it enables us to 
recognize and identify certain substances when present in quantities so 
minute as to be far beyond the reach of the ordinary methods of exami- 
nation, Thus by micro-chemical analysis we are able to identify with 
absolute certainty the reaction of the one hundred thousandth part of a 
grain of hydrocyanic acid, and of certain other poisons in quantity 
equally minute. Even a sublimate, consisting of a few crystals, each of 
which does not exceed the one hundred millionth of a grain in weight, 
may, under certain conditions, serve to characterize the presence of 
arsenic beyond a question of doubt. The chief contributors to the micro- 
chemistry of poisons have been Professors Guy and Taylor, the eminent ADDRESS ON MEDICAL CHEMISTRY. 
69 
toxicologists of England; Drs. Helwig and Earhard, of Germany; and 
Professor Worraley, of the ETnited States. 
For the final purification and subsequent examination by means of the 
microscope either directly or under the action of reagents, the process of 
sublimation has been proposed, as applicable to both inorganic and 
organic substances. In 1858, Professor Wm. A. Guy, of London, called 
special attention to the process of sublimation for the detection of arsenic, 
corrosive sublimate, and certain other inorganic poisons; and in 1865, 
E>r, Helwig, of Mayence, announced that in like manner certain alkaloids 
and vegetable principles furnished sublimates, some of which were cha- 
racteristic in their microscopic forms and in their behavior with reagents, 
and he gave photographic illustrations of many of the forms thus 
obtained. In 1867, Hr. Guy modified somewhat Helwig’s method, 
extended it to a much larger class of objects, and proposed to add to the 
diagnostic value of the method by a simple arrangement for noting the 
temperature at which changes in form and color, and sublimation itself, 
occur. 
The brilliant discoveries of Bunsen and Kirchhoff, in 1859, which 
enable us by means of spectrum analysis to recognize and identify with 
unerring certainty the elementary forms of matter and certain com- 
pounds, even when present in quantities so minute as to be far beyond 
the reach of the ordinary methods of analysis, have not been without 
some fruit in the department of chemico-legal investigations. Thus Dr, 
Pence Jones found by this method thallium in the liver, when the ordi- 
-11 ary chemical tests failed to reveal its presence. 
It is a proof of the great activity and sagacity displayed in modern 
science that the spectroscope with its amazing capabilities should so soon 
op combined with the microscope, an instrument of scarcely less capabili- 
ties, thus forming the micro-spectroscope, by which we are enabled to 
uiake new discoveries of the highest value in Medico-legal Chemistry. 
this combination of the two instruments we are chiefly indebted to 
Mr. H. C. Sorby, who has with its aid determined the spectra of a large 
number of organic coloring principles when in solutions. One of the 
niost important applications of this instrument thus far made in legal 
niedicine, is that for the detection of blood, its delicacy being such as, 
according to Mr. Sorby, and as confirmed by our own observations, to 
jeveal the presence of a single corpuscle, or less than the one thirteen mil- 
-IQnth of a milligramme, or one five hundred millionth of a grain, of that 
Uld. Although this method will serve to discriminate the coloring 
Matter of the blood from other coloring principles, yet it does not enable 
to distinguish the blood of any one animal, including man, from that 
. pother. This, however, can be done within certain limits, but only 
1 i|n certain limits, by means of the microscope; this instrument 
fables us to specify with great certainty certain animals, even of the 
nie class, from which the blood was not derived, but it does not enable 
0 positively individualize the animal from which it was derived. 
UofUr (^SCUSiP°n °f toxicology would be very incomplete without some 
100I00 P]e subject of the absorption of poisons. Prior to the important 
of Magendie on venous absorption, in 1809, it was believed 
cl all poisons produced their effects by impressions transmitted through 
rat)iI|?rves-i The chief argument in support of this view, was that the 
Uio acPqn °f certain poisons wTas incompatible with any other 
.transm^ss\on‘ Hr. Blake successfully met this argument, and 
e< L’om experiments that sufficient time elapsed for absorption even 70 
WORMLEY, 
in the case of those substances the most rapid in their action, such as 
hydrocyanic acid and conine. Through the labors and experiments of 
Dr. Blake, Sir Benj, Brodie, Sir Robert Christison, M. Bernard, and 
other physiologists, the views of Magendie were continued, and it was 
accepted that the entrance of the poison into the blood was a condition 
essential to its action. 
That certain substances were absorbed and widely distributed, was 
early observed from the color imparted to various tissues of the body, 
and to the urine, by certain coloring principles, as indigo, picric acid, 
and the like; and by the characteristic odor perceived throughout the 
body in poisoning by prussic acid and other odorous substances. When 
we consider how minute is the quantity of certain poisons required to 
destroy life, the imperfect character of the methods of analysis early 
employed, and the fact that certain poisons may soon jiass beyond 
recovery, it is not surprising that the progress in recovering poisons from 
the blood and tissues was somewhat slow. We find, however, that in 
1821, Tiedeman and Ganelin found lead, mercury, and barium in the blood 
of animals poisoned by salts of these metals; that, in 1827, Woehler 
recovered certain administered poisons from the urine; and that, in 1829, 
Wibmer satisfactorily proved the presence of lead in the tissues of 
animals poisoned by that metal. It was reserved, however, for Professor 
Orfila, whose original and profound labors in this department have 
brought honor upon science, to show the absorption and distribution of 
arsenic throughout the animal body. In January, 1839, this distin- 
guished investigator announced to the Parisian Academy of Medicine, 
that in poisoning by this substance, the arsenic diffuses itself in such 
quantity that it may be recovered by chemical methods from the blood, 
tissues, and various secretions of the body. In 1840, he proved these 
facts to the satisfaction of a committee of the Academy. This discovery 
inaugurated a new era in medical jurisprudence. Subsequently, Orfila 
proved that the same wide distribution of poison throughout the body 
held in regard to mercury, antimony, lead, and other metallic poisons. 
It has generally been believed that in the absorption of metallic poisons, 
and in their deposition in the soft tissues of the body, a larger proportion 
is to be found in the liver than in any other part, the least proportion 
being found in the muscles; but, according to the quite recent researches 
of M. Scolosubroff, absorbed arsenic, both in acute and chronic poisoning, 
is deposited specially in the nervous system. Thus, if the quantity found 
in the fresh muscle be taken as 1, that in the liver is 10.8; that in the 
brain 36.5; and that in the spinal marrow 37.3 (Ann, d’llygiene, Jan. 
1876). Under the present improved methods of analysis, it now rarely 
happens, in cases of poisoning by mineral substances, that the poison 
cannot readily be detected in the various organs and tissues of the body ; 
yet it is well known that even in this kind of poisoning the toxic agent 
may be entirely removed from the body prior to death. 
Our experience in regard to the recovery of the vegetable poisons has 
not been so satisfactory. While there are some of this class which may 
be readily detected in the blood and tissues, and others that have been 
found only rarely, there is still a large number that have never as yet 
been found in the absorbed state. 
That all the organic poisons enter the blood and are diffused through- 
out the body is no longer doubted. The first instance of the recovery of 
a vegetable alkaloid, after it had undergone absorption, was announced 
by Stas, as late as in 1845, and less than a third of a century ago ; in this ADDRESS ON MEDICAL CHEMISTRY. 
71 
case he recovered morphine from the viscera of a body that had been buried 
for thirteen months. Many instances have occurred since, however, in 
which, even under more favorable conditions, there lias been a total failure 
to recover this alkaloid from any part of the body. So, also, in 1851, Stas 
detected nicotine in the blood of a dog poisoned by that substance, employ- 
ing his ether process for the extraction of the alkaloid. 
Perhaps no one circumstance did so much to call the attention of toxi- 
cologists to the subject of the detection of the vegetable poisons in the 
blood and tissues, as the remarkable trial, in London, of Palmer for the 
poisoning of Cook by strychnine, in 1856. Prior to May, 1856, according 
to Prof. A. S. Taylor, in no instance had strychnine been recovered in an 
absorbed state from the blood, tissues, or soft organs of the body. This 
trial directed special attention to this poison, and led to its more careful 
investigation, and from that time instances of its recovery after absorp- 
tion have become quite frequent. In fact, under the recent improved 
methods of analysis, a failure to recover this poison in its absorbed state, 
should rarely happen. Since this time, chemists have been gradually 
adding to their triumphs in this important department of research, and 
now authentic instances have been recorded of the recovery and identifi- 
cation by chemical tests, of at least the following alkaloids: morphine, 
nicotine, strychnine, brucine, atropine, daturine, veratrine, jervine, and 
nonine. It may be added, that considerable difference exists in regard to 
the readiness with which the different poisons just mentioned may be 
recovered when in the absorbed state. 
That all poisons, except those endowed with corrosive action, have to 
enter the circulation in certain quantity before producing their peculiar 
effects, is now universally conceded. We may now inquire what is known 
°f the mode or manner in which when diffused in the blood they destroy 
|ife. It is well known that some poisons produce an appreciable change 
lr} the physical and chemical properties of the blood, as shown in the 
difference of color and consistency of that fluid. These changes are well 
Marked in the cases of sulphuretted hydrogen, prussic acid, carbonic acid, 
chloroform, and conine, under the action of which the blood becomes 
more liquid and of a darker color. In most of these cases the poisoned 
bjood, when examined by the spectroscope, gives the spectrum of deoxi- 
dized blood. 
. It was long since observed that certain poisons on being introduced 
the blood were either wholly, or in great part, decomposed. Thus, 
mR. Christison failed to obtain any chemical evidence of the presence 
°i oxalic acid in the blood of the vena cava of a dog, killed in thirty 
seconds by the injection of eight grains and a half of that poison into 
ile Amoral vein. Even with the improved methods of analysis, chemists 
ave never yet been able to recover this poison, as such, from the blood, 
n some cases we can very clearly trace the changes which take place in 
.j "O femM that cinnamic acid was converted during its progress through 
16 animal system into hippuric acid; and in 1862, Dr. Letheby found 
under like conditions nitro-benzole was changed into aniline. In 
P ve fanner it has been found that hydride of benzole is changed into 
„ac\d, which in its turn becomes converted into hippuric acid. In 
a|i ’. Rfebig showed that hydrate of chloral under the action of an 
I 1 ’ was changed into chloroform and formic acid ; and in 1868, 
e uch showed that the same change took place when this substance 72 
WOEMLEY, ADDRESS ON MEDICAL CHEMISTRY. 
entered the blood by absorption, and to this change is attributed the 
peculiar sedative effects of chloral. 
Even in regard to the action of strychnine, brucine, morphine, vera- 
trine, nicotine, and certain other organic poisons, which may be recovered 
from the blood in their unchanged state, it has been claimed by some that 
they are changed in part at least before they produce their toxic effect, 
but of this there is no direct proof. When we consider the extremely 
minute quantity of substances of this kind which may destroy life (a 
quantity sometimes certainly not exceeding in weight the one three 
hundred thousandth part of the blood), and the ready demonstration of 
their presence in the blood after death, it would appear that in certain 
instances at least, the fatal issue is not dependent upon the decomposi- 
tion of any part of the toxic agent. 
Although the various facts that have been presented are of great value 
and interest, yet it must be admitted that the whole subject of the final 
action of poisons is left in great obscurity. While it is believed by all 
that poisons are absorbed and taken into the circulation, it is found that 
only some produce any marked changes, physical or chemical, in the 
blood ; and on the other hand, while some poisons are themselves decom- 
posed in that liquid, yet others equally fatal, appear to suffer little or no 
change. We may trace the destroyer in all its subtle insinuations through 
the blood and tissues, and see life quickly driven from the body, but we 
know not where nor how the fatal stroke is given. These are questions 
which modern science, with all its refined methods of research, has left 
unanswered. 
In conclusion, it may be said that the field in which the toxicological 
chemist labors, is one of the highest responsibility. He must not only 
be consecrated to his science, know all its best methods, and be able to 
practise them in all their most delicate and skilful manipulations; but 
he should have a higher consecration to truth, ever remembering that in 
toxicological jurisprudence his Words should be weighed in balances even 
more delicate and exact than those in which he weighs his material sub- 
stances. Human life on the one hand, and the security of society and 
the vindication of law on the other, may hang upon the slender thread 
of a chemical reaction, or tremble in the final adjustment of a most deli- 
cate instrument. The highest skill, and a regard for truth that knows 
no shadow of turning, can alone fit the toxicological chemist to meet the 
grave responsibilities of his profession. 73 
ADDRESS ON SURGERY. 
BY 
PAUL F. EYE, M.U., 
PROFESSOR OF OPERATIVE AND CLINICAL SURGERY IN THE UNIVERSITY OF NASHVILLE. 
Gentlemen of the International Medical Congress ; 
The language of the Aborigines of America has ever been admired for 
its simplicity and significance. In the State of Mississippi, itself imply- 
ing the father of all waters, is a County called Itawambi, derived from 
the title given an Indian Chief, upon whom all possible honors had been 
conferred, so that nothing more could be done for him. Standing here 
this day, the representative of the most demonstrative and efficient de- 
partment of the healing art; the recipient too of many unmerited favors ; 
fully conscious of the inability to do justice to the subject proposed, 
or satisfactorily improve the illustrious occasion—an event without pre- 
cedent, and which no living man will ever see again—language fails to 
convey or words express what is now felt. 'With all the simplicity of 
the Indian and the sincerity of the Christian, I would say to you, my 
professional brethren, who have done so much for me, Itawambi. 
Precisely fifty years ago, he who is now to address you, landed on 
Chestnut Street wharf of this city, enquiring for the office of the late 
distinguished accoucheur, Charles D. Meigs, to become his private pupil; 
fifty 
years before that, his father, born in Philadelphia, had been the 
associate of Rush, Shippen, and James; and now, at the end of those 
hundred years, the son is invited back to declare before this Interna- 
tional Medical Congress, and at the celebration of the first Centennial of 
these United States, what his countrymen have done for Surgery. Here 
Yo in the Medical Department of the University of Pennsylvania, the 
ijt chartered Medical College on this Continent, where so many have 
leeu taught by Rush and Chapman, Hare and Jackson, Physick and 
ibson. To me it is but the coming back to my dear old Alma Mater. 
k Urely “ There’s a divinity that shapes our ends, rough hew them how 
We will.” 
“ God moves in a mysterious way, 
His wonders to perform ; 
He plants his footsteps in the seas, 
And rides upon the storm.” 
mere enumeration of what we have contributed to Surgery, even 
J’cre that possible during the hour assigned to the subject, might not 
Hove the most profitable occupation of it; and moreover, while this may 
s-e "e>Centennial of our Rational existence, it is not that of our profes- 
’ *'ori as is well known, the War of Independence left us an impover- 
i People, almost destitute as regards the sciences, certainly without 
medical literature. Even the reputed father of American 
L l£ei’J was not admitted a house-surgeon in St. George’s Hospital, 
Uc on, though a private pupil of the celebrated John Hunter, until 74 
EVE, 
1790 ; nor was he elected Professor of Surgery in the University of Penn- 
sylvania until 1805. It was as late, too, as 1820, forty-four years after 
the Declaration of Independence, that the taunt was uttered, with pro- 
bably as much truth as sarcasm, “what does the world }ret owe to an 
American Physician or Surgeon!” Then again, all our early teachers 
had of necessity to be educated abroad, so that in the very nature of 
things no national characteristics could have been given to medicine 
until years after the colonies became the United States. Notwithstand- 
ing all this, in a little over fifty years, the sarcasm of Sydney Smith wTas 
answered by a professor of Surgery in the city of Paris, M. Chassaignac, 
remarking as is said to an American medical student, “Sir, you ought 
to be proud of your country, for at this moment she holds the sceptre of 
Surgery in the world.” 
He whom we have ever regarded as the father of American Surgery, 
Philip Syng Physick, wTas born in Philadelphia in 1768, and was there- 
fore only eight years old at the declaration of our Independence ; he 
graduated in the literary department of the University of Pennsylvania, 
received his diploma at the Royal College of Surgeons, London, and the 
degree of doctor of medicine in Edinburgh, in 1792. Returning home 
soon after, the appearance of yellow fever, for the first time in Philadel- 
phia, brought him prominently before the public. For services rendered 
the city hospital in 1794, Dr. Physick was presented with silver plate 
valued at one thousand dollars. 
As early as 1794, he recommended curved forceps holding a needle to 
secure deep seated arteries. In 1802, he proposed the seton for ununited 
fractures. In 1836, Mr. Liston gave him credit for this valuable sugges- 
tion ; and in the Contributions to Practical Surgery, published by Dr. 
Norris, formerly Surgeon to the Pennsylvania Hospital, in 1878, the 
seton and its modifications are declared to be safer, sjieedier and more 
successful than resection or the caustic. 
In 1809, Dr. Physick by a suture removed the projecting duplicated 
portion of the intestine in Artificial Anus, and thus re-established the 
integrity of the alimentary canal. Dupuytren’s enterotome has since 
somewhat supplanted the seton. 
Physick improved Desault’s splint by extending it higher up on the 
fractured side, thus making extension and counter-extension more in the 
axis of the broken limb. He was among the first to apply animal liga- 
tures; employing buckskin for this purpose, while his nephew and favor- 
ite pupil, Prof. Dorsey, preferred French kid deprived of its tanned cuticle, 
a substance with which he successfully ligated the femoral artery. Deer 
sinew torn into shreds of suitable size for the vessel to be ligated, is pre- 
ferred by others, though silk is generally employed. Animal ligatures 
certainly irritate less, are readily absorbed, and thereby promote reunion 
of wounds. In the use of them for some forty years, though not exclu- 
sively, the knot of a deer sinew has never been seen, while the metallic 
ligature or suture ever remains a foreign body in the flesh. 
Dr. Physick was the first to employ blisters in gangrene threatening 
mortification, as in anthrax, or over an inflamed vein The late Prof. 
Chapman, long his colleague in the University of Pennsylvania, published 
a case in which he attributed the life of the patient to this suggestion. 
He improved the gorget, an instrument employed in his day in litho- 
tomy. 
He invented the tonsillotome, in 1848, by which a hazardous operation ADDRESS ON SURGERY. 
75 
has been greatly simplified and made safe. Formerly, attempts were 
made to cut out the entire tonsils at the imminent risk of fatal hemor- 
rhage, or they were painfully strangulated with a double canula. For- 
tunately the day has passed for the total excision of these bodies, except 
when malignant. Intra or extra-oral this is a dangerous proceeding. In 
a recent attempt twelve arteries had to be tied ; now we are content to 
remove the projecting portion beyond the lateral half arches of the fauces. 
When reminded that it is the internal carotid which is exposed in these 
operations, the value of Dr. Physick’s method must be greatly enhanced. 
Of course the recent modifications of the tonsillotorne, some of them 
quite ingenious, are due to the original forceps containing his concealed 
blades. 
Dr. Physick early advocated putting inflamed joints and diseased bones, 
as in cases of coxalgia, caries of the spine, etc., in perfect repose, as if in 
splints. 
To him also Monsieur Reybard, then surgeon to the hospital of Lyons, 
France, declares that the profession is indebted for the first accurate 
account of cystic or sacculated rectum, which he described in the early 
part of the present century ; Reybard moreover asserts that to Dr. 
Physick was due the starting point of all improvement which has been 
made in the treatment of abnormal anus. 
It fell to his lot to remove successfully, in one case, a greater number 
of urinary calculi than has ever been clone before or since in Surgery. 
They amounted to upwards of a thousand, varying in size from a small 
bean to a bird shot. The patient, who was quite aged, held at the time 
the office of Chief Justice of the United States, and subsequently resumed 
bis seat on the bench. 
A striking proof of Dr. Physick’s great influence even in Europe was 
the fact that, when his nephew, then the Professor of Anatomy in the 
University of Pennsylvania, published his Elements of Surgery, in two 
v<>lumes, containing, as was well known, the peculiar views and practice 
°f his uncle, that work, the first of the kind ever issued from the Ameri- 
can press, actually became the text-book of Surgery in the University of 
Edinburgh ; which was certainly a high compliment to our distinguished 
countryman. 
Physick’s name has ever been the most familiar and favorably known 
all American surgeons in Europe ; and, in 1825, he was electee! a mem- 
ber of the Royal Academy of Medicine of France. He was also an early 
advocate of conservative Surgery ; was a favorite pupil of the renowned 
John Hunter, the great anatomist, physiologist, and surgeon. As he 
krew older, Dr. Physick became more chary with instruments, and trusted 
to the recuperative powers of nature. Of him, it has been said, 
that he never spilt a drop of blood uselessly, nor wasted a word in his 
.ectures. With the simplicity of a child, the modesty of a maiden, the 
’’•d us try and integrity of a martyr, he quietly worked out a surgical 
character which will endure so long as his loved science shall be culti- 
vated. 
Intimately connected with the origin, rise, and progress of Surgery in 
were four other professional gentlemen, the contemporaries of 
1' Physick, who were long spared beyond the allotted period of man on 
arth, as if to illustrate in "their lives and characters the beneflts.of tem- 
pciance, industry, arid benevolence. These were Warren, Mott, Dudley, 
11 Hibson, whose average age was eighty-three years. 76 
EYE, 
There were three distinguished Drs. Warren, of Boston, Mass.; Joseph, 
the early martyr of American Independence, was the senior, the most 
talented, most patriotic, most heroic. He it was who fell—musket in 
hand, having declined the position of commander-in-chief—at Bunker’s 
Hill. Hr. John Warren, his brother, studied medicine under him, and 
graduated in letters in 1771. He gave the first course of dissections in 
Boston, which, no doubt, led to the organization of the Medical De- 
partment of the well-known Harvard University, in which he was the 
Professor of Anatomy and Surgery for a quarter of a century. His son, 
the third of the name, John Collins Warren, was horn in 1778, and 
died in 1856. After the advantages of a thorough education in this 
country and Europe, he succeeded his father in 1815. He was a liberal 
contributor to our literature, and author of a work on Tumors, which is 
said to have shed lustre on our science. His last contribution was pub- 
lished when in his seventy-seventh year. He was the first to operate on 
a patient put in the anaesthetic condition from ether, and was thereby 
connected with one of the greatest professional events in the world. Of 
him Velpeau declared that he first performed the operation for dropsy 
of the pericardium, for he declared that of all the cases then published, 
his alone was worthy of full credence; and well he might, for the War- 
rens were ever the soul of integrity. Mr. George Pollock, in the Me- 
dico-Chirurgical Transactions of London for 1888, gives credit to Dr. 
Warren for first closing the fissure in the vault of the mouth. Of him 
and his son, J. Mason Warren, the worthy representative of the family, 
and, we deeply regret now to add, deceased, Sir Wm. Eergusson, the 
prominent worthy representative of British Surgery, recently declared 
that in regard to the claim of priority in operations for cleft palate, “ the 
first idea I had of this portion of the operation was obtained from 
Mason Warren. I deem it but fair,” he continues, “to the reputation of 
that distinguished surgeon to state that I know of no originality before 
his, and that I look upon all modern claims to such originality as arising 
either from ignorance or the desire to rob the fair reputation of a name, 
which in son as in father, will stand for generations among the brightest 
in Surgery.” It is certainly a nice point to decide which is the most 
honored, he who utters such magnanimous sentiments, or the recipient 
of so disinterested a compliment. 
Valentine Mott, a native of Long Island, near the city of Hew 
York, was born in 1785, graduated in 1806, and went immediately to 
Europe, where he remained pursuing his professional studies three years. 
On his return home he was elected in rapid succession to the chairs of 
Surgery in Columbia University, Rutgers Medical College, and the Col- 
lege of Physicians and Surgeons, all in the city of Hew York. When 
only twelve years in practice he performed one of the boldest, most ori- 
ginal, and difficult operations in Surgery, one too, never attempted before, 
and yet, to the wonder and astonishment of the profession, the patient 
survived to the twenty-sixth day, and then died, in our opinion, from im- 
prudence in being permitted to exercise in the hospital grounds. Dr. 
Mott first tied successfully the common iliac artery, doing this in 1827. 
He first exsected the clavicle, tying, as he said, over forty arteries, besides 
the external jugular vein twice, and dissecting out the thoracic duct from 
the diseased mass. This, which he always considered his most formid- 
able operation, required four hours for its performance. Dr. Gross adds 
that, as a brilliant and daring operation, it is without a parallel in the ADDRESS ON SURGERY. 
77 
annals of Surgery. Dr. Mott was the first to exsect the inferior maxilla, 
except its articulations, doing this successfully in 1833. He is said to 
have tied the carotid fifty-one times, and to have amputated about a 
thousand limbs. Dr. Gross declares that no surgeon, living or dead, ever 
tied so many vessels or so successfully, whether for the cure of aneurism, 
the relief of injury, or arrest of morbid growth. And of him, England’s 
greatest Surgeon, Sir Astley Cooper, generously confessed that Dr. Mott 
had performed more of the great operations than any man that ever lived. 
His axiom too, through life, was the liberal one of operating in every 
ease which allowed a rational hope of success, either to improve the 
patient’s appearance or to preserve life. Ho one probably ever handled 
an instrument more gracefully, was more nimble fingered, or more skil- 
ful than the late Valentine Mott. As an operator, he was probably never 
surpassed. 
Benjamin Winslow Dudley, the great Surgeon of the West, was a 
native of Virginia, born in 1785, the same year, and graduated the same 
time that Dr. Mott did, viz., in 1806; he, however, in Philadelphia and 
the latter in Hew York. Dudley also spent years in Europe, chiefly 
under Cline, Abernethy, and Cooper in London, and Larrey, Dubois, 
und Boyer in Paris. Soon after returning home, he organized the Medi- 
?al Department of the Transylvania University, at Lexington, Kentucky, 
ln which he occupied the chairs of Anatomy and Surgery, and was ever 
lts ruling spirit. Dr, Dudley was the strenuous advocate of thoroughly 
Preparing for all operations; and taught that if the chylopoetic viscera 
Were properly cared for they would provide for the rest of the system. 
He gave little medicine, but insisted upon the observance of hygiene, 
cdet, rest, travelling, and even sea-voyages. An Englishman, alluding 
|° Dr. Dudley, is said to have remarked that it had been reserved for a 
backwoodsman of America to teach how to prepare the patient for a 
Capital operation. He justly claims to have first cured a case—and it was 
a lormidable one too—of intracranial aneurism by due preparation and 
ugature of the carotid. Ho one ever did so much with the roller—re- 
Amg Upon it even in fractures—of which he was emphatically the master. 
Was best known, however, as the lithotomist of the West, if not of 
rnei‘ica. We unfortunately have no statistics of his operations. If a 
ecorcl of his cases operated upon was ever kept, it must have been lost 
t()U‘I;'g the late war. We know that he used the gorget, and he is said 
nave cut two hundred and twenty-five patients, only six of whom are 
1(?wn to have died. He was truly a surgeon of the conservative school, 
Ind was for years the surgical patriarch of the West. 
reiYIbLIAM Gibson was born in Baltimore, Maryland, in 1784, and after 
in a classical education went abroad. He took his medical degree 
©xt > in-Urgh, and through the friendship of Sir Charles Bell obtained 
jyjDaordinary advantages. He was at Corunna, Spain, when Sir John 
It \°re / and at Waterloo, where he himself was slightly wounded, 
at TaS to° extracted the ball from Gen. Scott, long after the battle 
IWjUIKp 8 Hane* He had met Sir Astley Cooper, Sir Henry Halford, Aber- 
o Daron Dupuytren, Hapoleon Bonaparte, Velpeau, Lord Byron, and 
dean CTVerities. Such was his influence in the profession, that, upon the 
Die TT- Hr. Dorsey in 1818, Dr. Gibson, though Professor of Surgery in 
Uuiv ni.versDj of Maryland, actually secured that professorship in the 
eisity of Pennsylvania, which was then occupied by the father of 78 
EVE’ 
American Surgery, Dr. Physick consenting to take the chair of Anatomy 
with an adjunct. Dr. Gibson was probably the best lecturer on Ins branc 
in the United States; in addition to oral instruction, he illustrated his 
course by splendid collections of paintings, models and other appliances. 
His memory was so retentive that he had been known to repeat tut 
hundred lines of Virgil. He was also a bold and successful operator; he 
was the first to tie the common iliac artery, toy a gunshot wound in t 
streets of Baltimore, the patient surviving thirteen days. He also per- 
formed the Caesarean operation twice upon the same patient saving each 
time the mother and child; an operation since repeated by DrsVWil i< 
Byrd Page, and John Neill, with like success, so that the good city ot 
Philadelphia has been peculiarly favored in this respect Miich has 
recently been said—this being the Centennial year—ot those who hist 
rocke/the cradle of American Liberty; but not a word in commendation 
of those, who resorted to such extraordinary measures, to keep in mot o 
the little one called into requisition at each accession to her intai 
population. Alas 1 for the glory of poor doctors. 
In the brief biographical sketches of those to whom we are so much 
indebted for the present position of Surgery in our country, reference has 
been made to what they did on the kindred subjects ot Aneurism and 
the Ligation of Large Arteries; and while we may not yet lepoit 
successful tying of the aorta, notwithstanding the encouragement implied 
by finding that vessel occasionally obliterated, and the success by compres- 
sion reported by Dr. Murray, of Newcastle-upon-Tyne, England, we can, 
nevertheless quote what Mr. Erichsen, the well-known author and sur- 
geon has recently published—“ the bold and difficult operation of auest- 
fr ihe circulation through the brachio-cephahc, is one of the most 
remarkable and the only one found recorded in the annals ot Surgery 
h™S’to what wasVne by Dr Andrew Voods Bmjl'Dhanty 
Hospital, New Orleans, Louisiana, the 15th ot May, 1864. Ihe pat.e t 
wf)Si a mulatto aged 22, a steward on a steamei, the tumor, winch 
was of the size of an orange, was developed in four months after a 
collision at sea, to which it was attributed. On the 15th of May, 1864, 
a ligature was applied on the innominate artery, a quarter of an inch 
below its bifurcation; and one also on the right carotid an inch above 
its origin. Pulsation returned at the wrist in forty-eight hours. On the 
28th the ligature came away from the carotid, and the next c ay, \ 
fourteenth after the operation, hemorrhage occurred to syncope. Ins 
recurring the two following days, the wound was hi ed with small shot. 
On June 1 the detached ligature was removed from tire brachio-cephahc. 
Hemorriiages stil 1 continuing at intervals, on July 9 the right vertebral 
was tied* being the fifty-third day after the original operation, and to 
Ts, He succesf in the Jase is fairiy attributable. The sliot m 
the wound thirty-eight days. The patient now moved to Ga 
Texas, but returned in 1874, ten years afterwards, to New Oileans with 
another tumor in the neck causing great pain Dr. Smyth now detec 
an aneurism larger than the former one, which the patient said had been 
developing for about a year. On October 5,1874 he tied the internal 
mammary artery in the third intercostal space. Abscesses now began to 
form under the clavicle and were cautiously opened. The patient again 
returned to Galveston, and then once more to New Orleans, where he 
lingered until the 6th of April, 1871. A post-mortem examination ADDRESS ON SURGERY. 
79 
revealed the facts, confirming the history above given of this deeply 
interesting case. 
The patient lived within a few days of ten years after the innominate 
was tied; enjoyed the best of health, and had gained twenty pounds. In 
this case Dr. Smyth tied not only the innominate, but the common caro- 
tid, vertebral, and internal mammary arteries, and did more to relieve 
the affection than was ever attempted before in Surgery. This patient 
lived in a hot, moist climate, and was probably purpuric. 
Attempts to ligate the aorta successfully thus far have failed. In this 
country, Prof. Hunter McGluire, of Richmond, Ya., tied it unsuccessfully 
u} 1868; and the next year, Dr. Stokes, of Dublin, Ireland, met with a 
similar result, though he reached the vessel by an almost bloodless inci- 
sion through the lumbar region. 
Maisonneuve is reported to have tied the vertebral artery. We know 
that Prof. Willard Parker, of Hew York, did this in 1863, and as has 
been noticed, Dr. Smyth, of Hew Orleans, tied it in 1864. Prof. Warren 
ktone, of Hew Orleans, is reported, in a case of gunshot wound of the 
vertebral artery, to have arrested the hemorrhage by compression with 
Pledgets of lint. 
The common carotid, Dr. Gross claims was first secured by Dr. Cogs- 
well, of Hartford, Conn., who in exsecting a scirrhous tumor from the 
in 1803, applied two ligatures to that vessel. Heretofore Sir Astley 
hooper’s case in 1805, had been considered the first one. In 1875, a sur- 
geon recently from Europe, now Prof. Frothingham, of Ann Arbor, Michi- 
gan, boldly laid open a traumatic aneurism of the common carotid, 
nrned out the clots, with a piece of glass, tied both ends of the wounded 
rp(f\Sel, as also the internal jugular and lingual veins, and saved his patient, 
his was certainly a very creditable operation. Dr. Mussey, in 1829, 
led both carotids successfully after an interval of twelve days. In Dr. 
t°tt s case the simultaneous application of ligatures to these vessels 
Pr°ved fatal. 
Of the branches of the common trunk, the internal and external Care- 
ys >s’ fbo latter is the one which is most frequently tied. Indeed Mr. 
y a,]f in his Practical Surgery, in 1872, declares that, owing to the diffi- 
j T Ending the bleeding point, the ligature to the internal branch 
(ypS Jeen abandoned, nevertheless it has been tied by some 
Pr°fUl' Prao,titioners. In 1845, Dr. J. H. B. McClellan, son of the late 
,’ori eorge fib McClellan, founder of the Jefferson Medical College, in 
art 'oVlug a portion of the parotid gland found it necessary to ligate this 
qeeA >so did Prof. Gurdon Buck, of the Hew York University, for a 
vv°mid in the parotid region, tie successfully the common and inter- 
hadCiU.(lt'fis5 Dr. Stephen Smith, in 1864, secured this vessel after pressure 
ton ai ed, and he performed a similar operation for sloughing of the 
°f if'10)’ my colleague in the chair of Surgery in the University 
]jo,at‘lS lcihe, Dr. William T. Briggs, has the credit of first applying two 
°ne on eacb s'fi® °f a wound which resulted in an aneurism, 
rgat also the common carotid at the same time. This was done in Feb- 
of pn ’ . Then again Dr. Sands, Professor of Anatomy in the College 
Brio- y®I(fians and Surgeons of Hew York, without knowing what Dr. 
lateraf one’ the same thing in October, 1872, besides securing a 
The 'Vounfi rnade in the internal jugular vein. 
°f ]\pr pGtb°fi adopted in these latter cases was carrying out the principle 
c°ntrap U- aPPPcaD°n of two ligatures to a wounded artery in 
c t istinction to the one only insisted upon by John Hunter. This 80 
EYE, 
then is an American illustration of a new principle in tying wounded 
arteries, which fortunately has occurred in the practice of two of our 
best anatomists. 
The late Prof. Wright Post, of New York, succeeded first with liga- 
ture to the left subclavian artery in 1817, a feat which made him quite 
famous, since some of the most distinguished surgeons of Europe had 
failed to do this. In 1866, Dr. T. G. Morton also tied the left subclavian, 
when the upper extremity of that side becoming gangrenous, he ampu- 
tated it at the shoulder-joint and saved the patient. In two cases of 
subclavian aneurism, Dr. J. Mason Warren succeeded with ice and direct 
compression, when the disease was too far advanced for the ligature. 
To Dr. Warren Stone, in 1850, is given the credit of first applying a 
metallic ligature to a human artery, and in 1866, Dr. Claudius 11. Mastin, 
of Mobile, Alabama, applied one successfully to the external iliac. Dr 
S. W. Gross, son of the professor, has recently proven by numerous expert 
ments how innocuous are ligatures to veins; and the late Dr. Levert, at the 
suggestion of Dr. Physick, published his thesis, in 1829, proving thus 
early, the advantage of metallic sutures. 
It is difficult to decide who first suggested the ligature to arteries 
supplying the extremities for affections threatening mortification. Our 
English friends have generally given us the credit, but it does seem that 
tying the carotid for internal aneurism, as was done by Dudley, or the 
femoral for elephantiasis, as was done by Oarnochan ; the use of pressure 
to check the redundant supply of blood to a vascular tumor; or even 
elevating the inflamed part—all apparently illustrate one and the same 
principle of cutting off the redundant supply of blood. 
Arterial compression as an antiphlogistic has long been recognized in 
the profession. Dr. March published a brochure on the value of compress- 
ing the brachial artery in cases of whitlow, a notice of which may be 
seen in the American Journal of the Medical Sciences, Vol. 18, for 1849. 
It is there stated that this seemed to be more efficacious than the plan 
proposed by Mons. Gerdy, of keeping the limb elevated. 
Sir James Paget, moreover, declares that the proposition to treat cases 
of active inflammation threatening gangrene by putting a ligature on 
the main arterial suppljq emanated from the American School of Surgery. 
In the Lettsomian Lectures on Surgery, published in the London Lancet, 
Mr. C. 11. Maunder, Surgeon to the London Hospital, expressly declares 
that the operation originated in America; and in Holmes’s System of 
Surgery, Mr. Simon mentions that Henry Campbell, of Augusta, Georgia, 
then Professor of Anatomy in the New Orleans School of Medicine, and 
who was an army surgeon during the late war, had even raised the 
question whether the hand or foot, wrist or ankle, forearm or leg, should 
ever be amputated for destructive inflammation, specially resulting from 
traumatic causes, whenever the state of the patient admitted this to be 
done, without first resorting to previous experimental ligation of the 
artery supplying the affected region. Dr. Druitt, who contributed the 
article on Inflammation to the last edition of Cooper’s well-known Sur- 
gical Dictionary, in 1872, refers, moreover, to Dr. Campbell as the in- 
troducer of what he terms the Hunterian ligation of arteries to prevent 
or relieve destructive inflammation. The operation, first practised by 
Onderdonk, in 1813, and D. L. Rogers, in 1824, has been revived and 
systematized by Prof. Campbell, who recommends it as a definite mode 
of treatment. 
Prof. Campbell claims that (1) Compression prevents drainage; liga- ADDRESS ON SURGERY. 
81 
tion prevents blood going to a part. (2) Ligation to prevent inflamma- 
tion be repudiates as unjustifiable and dangerous, and even liable to 
produce mortification; while ligation to cure inflammation already 
existing, he says is invariably safe, and will prevent mortification, or 
even stop it after it has begun. These distinctions he declares were 
never brought previously before the profession. He believes that no one 
before himself ever tied an artery with the distinct view of curing 
inflammation and preventing gangrene. 
One of the most remarkable cases connected with the subject of aneu- 
rism, whether considered in reference to its origin, the organ affected, 
or the extent of the disease and the result of treatment, was reported to 
the American Medical Association by the late Prof. Mussey, of Cincin- 
nati, when chairman of the Committee on Surgery in 1850. It was that 
of a mechanic of St. Louis, Missouri, aged 25 years, whose right eye pro- 
truded and pulsated ; the transverse suture near the external angle of the 
eyed admitted the tip of a finger, and the functions of both ear and eye 
°f the affected side were no longer performed. After thorough prepara- 
tion by Hr. Dudley, and ligation of the right common carotid, the patient 
so completely recovered that he actually resumed the labor of a black- 
smith. 
Mr. Erichsen acknowledged, in 1851, that to Prof. Carnochan, of Hew 
Pork, was due the credit of recommending a ligature to the femoral 
ai’tery to cure elephantiasis; when this gave way from the extension of 
fhe disease, he tied the external iliac, and finally had to resort to cora- 
-1 session on the distal side of the bleeding orifice. Sixteen months after 
the first operation, the patient was in robust health. 
American surgeons have not faffed to try compression for the cure of true 
aneurisms. The late Prof. Jonathan Knight, of Hew Haven, Connecticut, 
than whom few ever had a better record, has the credit of first relieving 
a case of popliteal aneurism by digital compression, the case being pub- 
lished in the Transactions of the American Medical Association for 1848. 
fn the Philadelphia Medical Times for 1875, Dr. R. J. Levis, one of the 
surgeons of the Pennsylvania Hospital, published a very creditable case 
compression for aneurism of the internal iliac. This was 
eJected by means of a simple steel baud, having a hollow pad for counter 
Dessure and a convex one with a screw upon the artery. In five and a 
>a|t hours the current of blood was totally arrested through the tumor; 
icre was some oedema and discoloration, yet the patient fully recovered 
n thirty-seven days. 
pJt twenty-three cases of digital compression, comprising a successful 
rlle bis own, collated by Dr. S. W. Gross, of Philadelphia, fifteen were 
eportefi as cured. In two cases of inguinal aneurism, compression failed. 
MTy hi*l a few days a pamphlet has been received from Walter Reid, 
*. •’ Staft Surgeon Royal Havy, Plymouth, England, in which the 
q r I(R' proposes to cure external aneurism by compression in a few hours. 
a finding from Cohnheim’s experiments that in warm-blooded animals 
ho "ISIS may be safely continued for from six to eight 
IHrri'S’ kf mac^e a successful experiment in a case of popliteal aneurism. 
a r lai>cb’s elastic bandage was alone applied with the usual pressure of 
tun° ?1' ab°ve and below, while the pressure was diminished upon the 
I °iQ^ r^ie Pl’°Pos^i°n certainly deserves further consideration, 
i'Wn j r* d°hn H. Brinton, of Philadelphia, published in the Ame- 
°cs, of the valve at the termination of the right spermatic vein in the 82 
EVE, 
vena cava ascendens, and its absence on the left side, where the corre- 
sponding vein terminates in the renal. Here then is an obvious and satis- 
factory reason, though it may not be the only one, of the frequency of 
varicocele on the left side as compared with the right. A suggestion for 
the treatment of varicocele, originating, if I mistake not, with myself, 
is the application of animal ligatures to the spermatic cord, excluding, of 
course, the vas deferens ; then the ablation of some four inches square of 
the scrotum; and the closure of the wound with pin sutures. By this 
operation, both pathological conditions, the varicose veins and redundant 
scrotum, are removed. 
In the treatment of affections of Bones and Joints, we claim to have 
made valuable suggestions, if not important additions. An unusual 
recovery from undoubted fracture at the base of the cranium, which 
recently occurred on one of our national ships, may deserve brief notice. 
The sailor was seen to fall from a spar to the main deck, and was taken 
up insensible; he had stertorous breathing, followed by a copious flow of 
colored serum from the right ear, estimated at fifty or sixty ounces; and 
became partially comatose. Brain substance was also detected in the 
discharges. He, however, gradually improved under treatment, and was 
returned to duty a little over a month after his fall, though slightly 
epileptic, and with some little discharge still from the ear. 
We find in an early number of the Hew England Journal of Medicine 
and Surgery, that Dr. Luke Howe treated a fracture of the inferior 
extremity by the means now employed, excepting the omission of the 
sand bags to prevent the rolling of the injured limb; and believed it to 
be original. His case is reported in 1823, more than half a century ago. 
In the American Journal of the Medical Sciences for August, 1829, Dr. 
William C. Daniel, then an eminent practitioner of Savannah, Georgia, 
described how he applied a silk handkerchief around the ankle and tied it 
at the sole of the foot, a weight being then attached and passed over a 
roller for extension. That veteran of American Medical Journalism, Dr. 
Isaac Hays, says that Dr. Daniel has precedence of all modern claimants 
for introducing the weight and pulley as a means of extension in treating 
fractures ; for he himself had published two cases thus successfully treated, 
one in 1819 and the other in 1824. Dr. Hartshorne also, formerly one 
of the surgeons to the Pennsylvania Hospital, declared in 1869, in the 
same journal, that the credit of priority in introducing the weight 
extension in practice was justly due to this gentleman. 
To Dr. Gurdon Buck, of Hew York, credit is given for introducing 
adhesive plaster to secure extension in the treatment of fractures of the 
inferior extremity. Prof. Gross, however, in his account of American 
Surgery, claims this for his preceptor, Dr. Joseph K. Swift, of Easton, 
Pennsylvania, who employed it as early as 1829. 
Dr. William Gibson, of St. Louis, Missouri, devised in 1867, a ring for 
fractures of the patella; and Dr. P. S. O’Reilly, of the same city, in 1871, 
described what he calls a new splint for fractures and dislocations of this 
bone. This consists in an open ring, with a thumb screw, that it may fit 
the more accurately; to which a strap extending under the sole of the foot 
may be added, and also a posterior padded splint for the thigh and leg. 
This seems the perfection of an apparatus for these injuries. 
On the subject of deformities after fractures of the thigh, two of our 
most distinguished Professors and Surgeons in the Jefferson Medical 
College hold the position which we also sustain; that a fractured ADDRESS ON SUKGERY. 
83 
femur cannot be fully extended to its normal length, nor could it be so 
retained without impairing its nutrition. They declare that a certain 
degree of shortening, and perhaps deformity, cannot be prevented, what- 
ever may be the treatment. And it may be added that no measurement 
whatever can detect the difference in some cases, though one to a limited 
extent actually exists, as may be verified in a post-mortem examination. 
The method of reducing dislocations by manipulation was first systema- 
tized and proposed as such by the late Dr. William R. Reid, of Rochester, 
New York, and published in 1859; though probably first suggested by the 
late Nathan Smith, of Connecticut, This seems to have created a new 
era on the subject, notwithstanding that it had occasionally occurred to 
some practitioners how easily reduction was effected, sometimes even 
during the examination of the case. Prof. Spence, of Edinburgh, in his 
Lectures published in 1875-76, calls this the rotatory or circumduction 
method, and adds, “we generally hear it spoken of as the American 
method.” He also admits that it is undoubtedly to the writings of 
Drs. Reid and Bigelow, of the United States, that we owe the more 
general use of the practice. He notices too, specially, the ilio-femoral, 
°r inverted Y ligament, and the different views entertained by Mons. 
Chassaignac, of Paris, from those expressed by Dr. Bigelow, who was the 
first to note minutely its functions. Dr. Reid’s conclusions regarding dis- 
locations are: (1) That the impediment to reduction is due to the stretch 
°f the muscles, by the malposition of the dislocated bone, and not to their 
contraction; (2) That in reducing luxations these muscles should be re- 
laxed; (3) That dislocation on the dorsum of the ilium is reduced simply 
'A flexing the leg upon the thigh, and carrying the thigh over the sound 
°ne, upwards over the pelvis as high as the umbilicus, and then rotating it. 
As is well known to the profession, Prof. Nathan Smith, of New Haven, 
mid taught and published similar views to those of Dr. Reid. The late 
J; rof. B rainard, of Chicago, Illinois, reported, in 1852, the reduction of 
°u>’ cases of dislocation of the head of the femur into the thyroid fora- 
men, with the aid of a billet of wood four inches in diameter, well 
Padded, placed in the perineum as a fulcrum, the displaced limb being 
mu carried as a lever across the sound one. 
The substitution of manipulation to reduce dislocation at the hip, is 
c aimed therefore to be American, and in connection with anaesthesia, 
great boon to suffering humanity, also introduced by us, to be iuesti- 
pld as the world may be, it has been reserved for an American to 
1 °mt out a pathognomonic sign by which a fractured clavicle can always 
distinguished from a dislocation at the shoulder joint. Prof. L. A. 
uS’as, ot the Medical College of Augusta, Georgia, asserts that if the 
ers m Lie injured limb can be placed by the patient or surgeon upon 
m sound shoulder, while the elbow touches the thorax, there can be no 
ocation; in other words, he asserts that it is physically impossible to 
)^le e^K)w iu contact with the sternum, or front of the thorax, if 
iiid1 e JG a an(l that no other injury of the shoulder-joint can 
lUatR0 Liability. Ample experience has shown this rule to be axio- 
rpi ’ 
met Jate Prof. Crosby, of New Hampshire, in dislocations at the 
it a^CtlrP°-phalangeal articulation pushed the phalanx backward until 
a PosiLon perpendicular to the metacarpus; then pressing for- 
Levb q6 ase Lie dislocated finger, reduction was easily effected. Dr. 
S5 burgeon to the Pennsylvania Hospital, suggested a small splint, 84 
EYE, 
having four large gimlet holes bored in it through which tapes are 
passed to secure a luxated finger or thumb, by which means extension 
can be effectually made. 
As a substitute for the pulley, Dr. Fahnestock, of Pennsylvania, sug- 
gested a rope doubled several times upon itself, which by a stick—a 
walking cane—placed in its centre could be twisted gradually so as to 
produce extension in dislocations. 
In reference to resections and exsections of the bones and joints, our 
surgeons have been active and ingenious. As early as November, 1826, 
Dr. John Rhea Barton, then one of the surgeons of the Pennsylvania 
Hospital, sawed through the femur just between the trochanters, and 
then straightened the limb, which became so useful that the patient 
went out gunning and actually brought home his own game; owing, 
however, to his habits, those of a common sailor, he did not derive the 
full benefit expected from the operation ; but a similar one, in which, how- 
ever, a disk of bone was removed, performed by Dr. J. Kearney Rogers, 
of New York, in 1830, resulted by gentle manipulation in the formation 
of an artificial joint, and in an excellent recovery: good success has 
attended other cases similarly treated by our practitioners. Mr. Erichsen 
declares that the first operation for osseous angular anchylosis was per- 
formed by Dr. Barton. He also asserts that, in 1837, Dr. Mussey excised 
the whole of the scapula and clavicle for an enormous osteo-sarcoma, the 
patient being in good health fifteen years afterwards. These successes no 
doubt induced others to enter the new field of investigation, and resulted 
in Dr. Brainard, then Professor in the Rush Medical College, Chicago, 
Illinois, submitting, in 1854, to the American Medical Association, an 
essay on a new method of treating ununited fractures, and certain de- 
formities of the osseous system, which secured the prize for that year. 
The main feature in Dr. Brainard’s method was that by making perfo- 
rations in the osseous structure with drills, and then waiting for the 
softening process of inflammation, almost any bone, or anchylosed joint, 
might be straightened, broken up, or the deformity relieved. Barton, 
Brainard, and Buck, were undoubtedly the pioneers in correcting de- 
formity and restoring to usefulness, limbs, which before their day were 
considered hopelessly useless, or were sacrificed by amputation. 
The first resection of the inferior maxilla was performed in what was 
then known as the back-woods of America, and this too without known 
precedence, or even professional counsel or assistance. The case is ad- 
mitted by Mr. South, who translated Chelius’s Surgery, Drs. Mott, Gib- 
son, Gross, and others. The operator was William 11. Deadrick, then of 
Rogersville, East Tennessee, who in February, 1810, exsected about three 
inches of the lower jaw, including the whole of its circumference and one 
of its angles, from a boy, fourteen years old, who recovered and was alive 
years afterwards. Dr. Carnochan, of New York, is believed to have first 
disarticulated this bone in its entirety in the Emigrants’ Hospital, of 
New York, in 1851; and this was again done the next year, by Prof. 
Wedderburn, then in the Medical College at New Orleans. 
The late Prof. Horatio G. Jameson, of Baltimore, claimed for his 
country the honor of having led the way in resections of the superior 
maxilla. Dr. Gross admits that the first severe and difficult operation of 
this kind was performed by him successfully in 1829, by removing nearly 
the entire bone on one side. 
The removal of the clavicle, or a portion of it, was probably first 
attempted by Dr. Charles McCreary, of Hartford, Kentucky, and was ADDRESS ON SURGERY. 
85 
reported by James H. Johnson, in the Medical Journal then published 
in Hew Orleans, in 1850. In his System of Surgery, Dr. Gross mentions 
tliat the operation was performed in 1815, on a boy who survived long 
afterwards. 
As early as 1858, Dr. Compton, of Hew Orleans, exsected the entire 
ulna and all of the radius, except its lower extremity, in a patient fif- 
teen years old, who made an excellent recovery. 
In 1843 Josiah C. Hott, then Professor of Surgery in the Mobile Me- 
dical College, excised two segments of the coccyx, for neuralgia, in a 
lady after twenty-five years of great suffering. The case, first published 
in the Hew Orleans Medical Journal for 1844, was copied into the 
American Journal of the Medical Sciences, and Prof. T. Gaillard Thomas 
has added that this was fifteen years before a similar operation was per- 
formed by the late Sir James Y. Simpson. 
Prof. Lewis A. Sayre, of Hew York, reports that, up to January, 1876, 
he had exsected the head of the femur fifty-one times, with a mortality 
of only twenty; eight of these fatal cases too had recovered from the 
operation. He removed also portions of the acetabulum in some of these 
instances. At the late meeting of the American Medical Association 
Hr Philadelphia, he introduced a little patient, suspending him by the 
shoulders and head ; plaster of Paris bandages were then applied, and in 
a few minutes the little boy walked about the room, though he had not 
done so for months before. 
In connection with affections of bones and joints, did time permit, 
there might be noticed what has been done here in Ivyllosis and Ortho- 
psedy. Dr. James A, Dickson, of Horth Carolina, is believed to have 
first performed tenotomy by dividing the tendo Achillis in 1835, fol- 
lowed by Dr, D. L. Rogers, of Hew York, in 1845. Then came Dr. Det- 
faold, a pupil of Stromeyer, who in 1837 settled in Hew York, where he 
introduced myotomy. Dr. Mott, however, founded the first Orthopaedic 
Institution in America. In 1844, Dr. Henry J. Bigelow, of Boston, 
Massachusetts, obtained the Boylston prize for that year for his work on 
Orthopaedy. Dr. Sayre, however, has done more on this subject than any 
pther American. His work just published is undoubtedly the best ever 
issued from the press. He has called particular attention to genital irrita- 
\on, even in very young children, in connection with deformity. He 
gives special credit to Mr. Barwell, of London, and Dr. PL G. Davis, of 
>ew York, for devising apparatus for extension while the little patients 
exercise in the open air; and has himself introduced a new method of 
oing this by plasters, elastic cords, or artificial muscles, as they are 
tlded. Por contracted limbs and congenital deformity much is being 
( °ne here by early attention, so as to prevent development in unnatural 
positions, by gradual or forced flexion and extension under ether, elec- 
l'city, etc., before resorting to tenotomy or myotomy, 
p,/ n the Compendium of Practical Surgery, published in 1851 by 
Giard, Denonvilliers, and Gosselin, of Paris, in referring to a paper 
by Dr. M. Smith, son of the celebrated Dr. Hathan Smith, cora- 
j,'eating on incisions of the periosteum and trephining of bones in suppu- 
v., lv,e inflammation, is found a compliment to the heroic measures pro- 
filed by the Americans. 
Reference to the Genito-urinary Organs, we refer first to the case of 
the 1•\aares Stoddard, of Wisconsin, who is reported to have exsected 
Sidney successfully in 1861, eight years previous to the operation of 86 
EYE, 
Prof. Simon, of Heidelberg, who operated in 1869. In 18 /0 Prof. Gil- 
more, of the Mobile Medical College, successfully cut out an atrophied 
kidney from a colored woman, then five months pregnant, who, never- 
theless, went to her full term, and was safely delivered of a hying child. 
Our earlv surgeons performed almost exclusively the lateral operation 
for urinary calculus, and almost as exclusively employed the gorget—an 
instrument of which it can happily be said reguiescat in pace.. _ 
Ribes of Paris, first described accurately the bilateral operation tor 
stone in the bladder. Dupuytren, however, gave it character by proving 
its advantages to be easy and more direct access to the bladder, and t la 
the prostate is cut in its central portion, and in double the extent of the 
section in the lateral operation, without endangering nerves, vessels or 
other important structures. Dr. Ashmead,_of 1 hiladelphia, in 1804, fust 
performed the bilateral operation in the United States. . 
Mr. Erichsen asserts that Civiale recommended a combination of the 
median and bilateral operations, for in this way, he declares, the chief 
objections to both are removed. The medio-bilateral is gaining gtound 
as an operation for urinary calculus. 
As is well known, when Mr. Erichsen, among others, denied the possi- 
bility of the intromission of foreign bodies below the vocal cords, Di. 
Horace Green passed a tube through the riraa glottidis some inches into 
the trachea, and then withdrawing the stilet, directed the patient to close 
his lips and blow through the canula. This he did several times, eyen so 
forcibly as to extinguish a candle. Sponging below the vocal cords was 
first done in October, 1854, by the same gentleman. 
The case reported by Profs. Crosby and Peaslee, of Hew Hampshiie, 
of a sponge one inch and three-quarters m breadth and fifteen-six- 
teenths of an inch in thickness, passing the r.ma glottidis, in a patient 
aged forty-five, on July 28, 1850, and who lived fifty-four hours ought 
surely to have convinced every one of the possibility of at least mtio- 
ducing sponge-probangs into the larynx. 
In 1844 Dr. Charles Hall, of Burlington, Connecticut, removed, after 
tracheotomy, a piece of pipe-stem by means of a probe which fortunate y 
entered the hollow or canal of the pipe-stem and stuck fast. 1 his certainly 
was a fortunate hit. Mr. Liston once extracted a piece of sponge from 
the right bronchus of an adult; and Mr. Dickin, in 1882, a bell button 
from the right bronchus of a child eight years old. _ 
Mr Spence, Professor of Surgery in the University of Edinburgh, 
succeeded, in June, 1862, in extracting, by tracheotomy, the inner portion 
of a tracheal tube which had lodged in the bronchus, and concluded that 
it was the first and only instance of the kind thus relieved. A child, 
however, was brought from Alabama in May, 1858, to Augusta, Georgia, 
where after the trachea had been opened, a four-penny nail was removed 
from the left bronchus with a pair of dressing forceps lengthened in the 
blades. 
American surgeons present a creditable report on amputations. Sta- 
tistics on the subject, whether derived from hospital records or army 
reports, or more especially from private practice, sustain t ns posi ion. 
Much, no doubt, is due to our open climate, sunny country, cleanly habits 
.rood nourishment, and free exercise. Even in regard to the dreadful 
operation of amputation at the hip-joint, it is probable that the second 
successful case, if not the very first ever performed, was that of Dr. V\ alter ADDRESS ON SURGERY. 
87 
Brashear, of Bardstown, Kentucky. This was done in August, 1806, 
on a youth of seventeen years, who survived long after it. His method 
was the circular, as if for the upper third of the thigh ; and, after secur- 
ing the arteries, then the head of the bone was disarticulated through a 
long incision over the trochanter major. May not this prove to be the 
best method for this amputation? The case of Perault, of St. Maure, 
France, in 1773, was only the semblance of an amputation, since the limb 
had been destroyed by mortification up to the hip. 
Mr. Erichsen, Baron Larrey the second, and M. Legouest, of the 
French army, declared most emphatically that there had not been a 
case of recovery from primary hip-joint amputation recorded in military 
surgery previous to our late war. In the Schleswig-Holstein, French, 
German, and Italian wars, not a case survived, whether operated upon 
by German, English, French, Italian, or Eussian surgeons; whereas, 
during the late war between the States, some three or four were reported 
as successful, though subsequently this number was reduced, because, on 
account of the difficulty in the condition of the country, after our 
gigantic internecine war, these cases could not be accurately determined. 
We may judge, however, of the impression of our success in operations at 
the hip-joint in Europe, when the Surgeon-General of the Prussian army, 
the distinguished Dr. Yon Langenbeck, declared that, but for these 
operations, it might be questioned if immediate amputations and resec- 
tions at the hip should not be hereafter prohibited. 
In the Yew York Journal of Medicine, for 1852, it is stated that up 
t° that date there had been on the Continent of Europe thirty-five ampu- 
tations at the hip, with fourteen recoveries, or forty per cent.; in Eng- 
hind twenty-five, with eleven recoveries, or forty-four per cent.; and in 
the United States eleven, with eight recoveries, or seventy-three per 
cent. 
In civil practice, we have the recent remarkable case of Dr. Jerome 
of Portchester, Yew York, who, without waiting for reaction 
alter the injury by a passing train, performed hip-joint amputation by 
antero-posterior flaps, on a boy eleven years old. The administration 
°t ether, performing operation, and dressing-wound, all consumed only 
hree hours. Prof. Spence, of Edinburgh, under similar circumstances, 
}vaited several hours before he operated; his case too, was a success, and 
J may be the first and only one of the kind in Europe. In Philadelphia, 
where surgery has been so successfully practised, two of her Professors in 
Ue College, Drs. Gross and Pancoast, have each performed two amputa- 
J°us at this articulation, and saved the four patients. Yet this is the opera- 
JL°n, it will be remembered, of which the great English military surgeon 
ennen, asserted, only fifty years ago, that there was not one in a thousand 
' 10 would not prefer instant death to the attempt. 
onc can be expected to do justice to so prolific a subject as the 
'istory ot American Surgery, in the brief space allowed the occasion. 
11 enumeration of our contributions to this department of medicine 
rii°l. aJone require a volume. Time will permit now only a brief surn- 
£iiy of some suggestions or improvements not yet noticed, 
do I*6 e?hensive use of silver wire in surgery and gynaecology is un- 
SuUo-t0dly Ue r- 'I- Marion Sims. This is acknowledged in Holmes’s 
eve^l'“T* a^so a’Wen the credit of publishing the first work 
p lssiled on Uterine Surgery in the English language. 
aiacentesis thoracis was made a safe operation by Drs. Bowditch 88 
EYE, 
and Wyman, of Boston, before the introduction of Dieulafoy’s aspira- 
te ur. 
Dr. A. L. Pierson, of Salem, Massachusetts, was the first to operate for 
hare-lip with scissors and sutures, within six to twelve hours after birth. 
Prof. Alex, H. Stevens first suggested the important principles to be 
observed in exsecting tumors, viz., by the first incision to expose fairly 
the morbid growth, and secondly to remove it and nothing more. 
The oesophagus forceps of Dr. Bond, of Philadelphia, are so constructed 
that, by narrow bevelled edges, a pin or fish-bone can be removed without 
pinching the mucous coat. 
Of Dr. Sayre’s vertebrated probe, Mr. Erichsen declares that it is a most 
ingenious and valuable one, by accommodating itself to the tortuosities 
of a canal or sinus. 
Dr. Levis, of the Pennsylvania Hospital, recommended pure carbolic 
acid liquefied, as a local anaesthetic, before using the actual cautery, and 
the late Prof. Josiah C. Hott, of Mobile, declared that this same agent 
in carbuncle was antiseptic, escharotic and anaesthetic. 
Prof. Joseph Jones, of the University of Louisiana, Hew Orleans, 
one of the most indefatigable laborers in the profession, after a most 
thorough examination of the important subject of traumatic tetanus, 
concludes that the remedial agents most to be relied upon, are chloral 
hydrate, Calabar bean, chloroform, sulphuric ether, cannabis Indica, 
tobacco, bromide of potassium, and opium. He also suggests that im- 
portant advances will be made in the therapeutics of this affection, if the 
attention of the entire profession can be concentrated on a few remedial 
agents, as chloral hydrate, Calabar bean, and bromide of potassium. In 
regard to the prevalence of this terrible affection, the census of the 
United States for 1850 gave six cases for the six Hew England States, 
while for Louisiana alone there had been two hundred and fifteen. 
Prof. F. H. Hamilton, of Bellevue Hospital, Hew York, is the author 
of a well-known Treatise on Fractures and Dislocations, which has 
reached its fifth edition. He has recently issued a System of General 
Surgery, of about one thousand pages, with illustrations; and has also pub- 
lished a Treatise on Military Surgery and Hygiene. During the war, he 
held a high rank, and has long been known as one of our ablest surgeons. 
The Principles and Practice of Surgery, by John Ashhurst, Jr., M.D., 
issued by Henry C. Lea, Philadelphia, 1871, a volume of a thousand pages, 
containing five hundred and thirty illustrations, has probably done more 
than any other publication to announce what Americans have done for 
surgery. 
The founder of the Jefferson Medical College, Prof. George McClellan, 
reported, long ago, eleven excisions of the parotid gland with only one 
fatal case. 
Prof. Yan Buren, M.D., of Bellevue Hospital, recommended the French 
method of relieving anal fissure, by sudden dilatation from within out- 
ward with the thumbs, so as to rupture or tear open the sphincter muscles. 
The British and Foreign Medico-Chirurgical Review stated in 1870 that, 
in plastic operations on the face, and in closing of wounds and unnatu- 
ral openings in the urinary organs and parts of generation, Americans 
must have the position of precedence. 
Another surgeon, Professor Gouley, of Hew York, has distinguished 
himself in external urethrotomy without a guide, and in relieving stric- 
tures. 
Dr. John T. Hodgen, Professor of Surgery in the St. Louis Medical ADDRESS OX SURGERY. 
89 
College, proposed a few years ago the removal of calculi lodged in the 
urethra, by passing a double wire concealed in a catheter, and expanding 
it after its introduction into that canal. 
Prof. Henry J. Bigelow has recently published an article on “ The true 
Keck of the Femur,” another on “ Exstrophy of the Bladder,” and a 
third on “ Turbinated Corpora Cavernosa.” 
Dr. Addinell Hewson, Surgeon to the Pennsylvania Hospital, found a 
mortality, after amputations performed with an ascending barometer, of 
about eleven per cent.; when it was stationary, some twenty ; and when 
descending, amounting to twenty-eight per cent. This certainly deserves 
investigation. 
In proof of the industry exhibited, and of the contributions made by 
Americans to Medical Science, a long catalogue of periodicals, numerous 
monographs, and extensive systems in the three practical departments of 
the profession might be enumerated. One of these, on Surgery alone, 
has reached the fifth edition, contains fourteen hundred engravings, and 
requires a text of more than two thousand pages in small t}7pe; being 
equivalent to more than half a dozen volumes of ordinary size. Then 
there are some forty Journals devoted to medical science, from the weekly 
to the quarterly, containing reports of cases, lectures, movements in the 
profession, etc. 
We can point, too, to the admirable publications issued from the 
office of the Surgeon-General U. S. A., pronounced to be incomparably 
the most minute, comprehensive, and valuable ever issued from the press. 
And, as evidence of the industry and efficiency of our corps of Surgeons, 
!t is said in the official reports of the late war between the States, that 
the mortality in the medical staff was greater than in any other. 
The commendations from foreign sources respecting these publications, 
have been most gratifying to our national pride. The Medical Inspector 
°t the French army, and director of the school for the Medical Staff of 
that army, Mons. S6dillot, wrote, in 1866, that American Surgery had 
proved itself equal to cope with the exigencies of a war of incomparable 
magnitudesurgeons everywhere, said he, were proud of the marvels 
accomplished in science and self-devotedness. 
In Circular Ko. 6, are classified 87,822 wounds and injuries, and 17,125 
operations. These reports have been translated into the German, French, 
and Italian languages. The Director-General of the British Medical 
Department returned thanks for the gift of a work so replete with interest 
°1 the highest professional value. Sir Wm. Fergusson said in the fifth 
edition of his standard work on Surgery, that modern surgery owed much 
P °ur American brethren—referring to conservatism, which he says was 
signally displayed both in the United States Army, and by their gallant 
contemporaries in the Confederate service. Baron Yon Haurowt, chief 
k. Ul’geon of the Russian Marine, in a report for 1867, after an official 
inspection of the medical institutions of this country, speaks of the Army 
| edical Museum, at Washington, as the most valuable collection of the 
in existence. 
an address to the students of St. Thomas’s Hospital, London, Oct. 
Mr. McCo rraac said, no European nation, probably, can point to 
cU(p', a monument of industry, or so great a mass of valuable material, 
ully preserved and digested, as the records of the Medical Depart- 
o-io’11 Army. It is> ho continues, an undertaking simply 
yjant'c> reflecting credit on the government that originated, and the 
11 who carried it out. Such records, he says, are of the utmost value 90 
EYE, ADDRESS ON SURGERY. 
both to the military and civil service. ]STo less than fourteen foreign 
medical journals noticed our Army medical reports. 
In 1875, Dr. Crothers, of Albany, Hew York, stated that Dr. Swin- 
burne’s attachments for extension and counter-extension were being intro- 
duced into the French army, with the American pattern and minutiae for 
the battle-field. Dr. Swinburne, himself, formerly Port Physician of Hew 
York, while travelling in Europe in 1870-71, by request took charge of 
a hospital, and he and Dr. Evans, Dentist to the French Emperor, received 
the Cross of Honor for services rendered. Dr. Monsereau declared before 
the Faculty of Paris, that the American Ambulance was the best of all. 
In the Prussian Service, our ambulance was also adopted. So again, 
Mons. Sarcey, who wrote the “Siege of Paris,” announced the superiority 
of this method of treating the wounded on the battle-field. It was freely 
confessed that American Surgeons had done more for Military Surgery 
than the ordinary experience of a century, and that never before was the 
business of life-saving done more thoroughly and successfully than during 
our great war. 
The discovery of the circulation of the blood in 1628, and the intro- 
duction of vaccination in 1796, were the significant events of the past 
two centuries in our profession. That of the present one will, in all 
probability, prove to be the crowning glory of American Surgery. For 
it is that which Poets and Philosophers, Philanthropists and Physicians, 
and the Humane of all ages, had sought for in vain for six thousand 
years. Ihe search had been for that agent which could suspend con- 
sciousness and obtund sensibility, so that the most painful manipulations 
might be made, or capital operations performed, with little or no risk to 
life. It has been reserved for American Surgery to teach the world how 
to prevent or relieve human suffering. God i n his mercy has condescended 
to teach us how to relieve pain. We can now say to the agonized mother, 
Awake! behold your babe; to the tetanic limb, Peace! be still. 
Well has it been said that no imagination can conceive and no tongue 
express, the accumulated woe that anaesthesia has assuaged, and is yet 
destined to prevent or relieve. 
Fifty years ago, there were probably not a half-dozen Americans known 
abroad as Surgeons. As early, however, as 1830, Dr. Reese, in preparing 
an American Edition of Cooper’s Surgical Dictionary, introduced no less 
than one hundred and nine American contributions to it; and Mr, Cooper, 
himself, soon after, publicly expressed his regret for not having noticed 
what we had done in this department of medicine; admitting, too, that 
we had performed operations never attempted in Europe, and had led the 
way by our splendid achievements in operative Surgery, and demonstrated 
their practicability and success. The hour assigned me for presenting 
what we have done in Surgery, during the past century, especially its 
latter half, has expired; the result, however imperfect, is before you. Time, 
if nothing else, has prevented even the naming of all that is worthy of 
special mention. I trust, however, that quite enough has been shown to 
warrant us in committing the interests of our time-honored calling, the 
noblest of earth, to our successors of a second centennial, in the full per- 
suasion that all its interests, its usefulness, its honor, and its dignity, 
will be fully sustained. 91 
ADDRESS ON MEDICAL BIOGRAPHY. 
BY 
J. M. TOILER, M.D., 
OF WASHINGTON, D. C. 
Gentlemen of the Centennial International Medical Congress ; 
I appear before you to discharge the duty assigned me of preparing a 
biographical retrospect of the medical profession of the United States 
during the centennial period just past. Though apparently an easy task, 
I cannot approach it without hesitation. Apart from the feelings of 
diffidence, which under any circumstance this occasion and this audience 
must inspire, I am fully aware of the caution with which the office of 
the biographer should be assumed, and that his best efforts are never 
above criticism. 
It is admitted that the measure and the character of the renown which 
attaches to the hero is, in a great degree, qualified by the fitness of the 
chronicler who undertakes to record and perpetuate his achievements. 
With what intimate knowledge and forecast, then, should even the most 
ready pen essay the work of writing the life of the good and great; 
■when, through natural inability for the task, or want of care, the noblest 
actions may be placed in a false light, obscuring what should be dis- 
played, or obtruding defects that the mantle of prudence and charity 
should cover! Conscious of the many difficulties and the very brief 
fiine allotted to the reading of this discourse, I shall confine myself to 
the narration of a few simple facts in the lives of the more illustrious, 
mffi to a record of the names of physicians who attained distinction 
during the century,.and I trust that this limitation may be some excuse 
0l’ the dryness which must necessarily characterize such details. 
fa glancing over the period to be embraced in this retrospect, I am 
struck by the paucity of really striking events which have influenced 
he practice of medicine, and which have left special marks at the end of 
flmf century of our national existence. 
Vy ars have generally been promotive of medical science, and our pro- 
cssion was no doubt much benefited by the contest for Independence, 
or the first quarter of a century after this armed struggle, the leading 
Physicians and surgeons were those who had served in the army.1 The 
most notable event of this period was the occurrence of epidemics of 
}e ow fever, which appeared in the summers of 1793 and 1798 in nearly 
our Atlantic cities. This disease tested the courage and taxed the 
neigieg and best skill of the profession, and prompted the more eminent 
r)W^ a.re the names of the leading practitioners in each State who served 
Beorih i evo^utionary War: Connecticut, Aneas Munson; Delaware, James Tilton; 
Darunn. ?ar? > Maryland, John Archer; Massachusetts, John Warren; New 
Kniaht-U\T ’^os*a'1 Bartlett; New Jersey, William Burnett; New York, Charles Mc- 
Isiuu-. W orßi Carolina, Charles Harris; Pennsylvania. Benjamin Rush; Rhode Island, 
er; South Carolina, Peter Fayssoux ; Virginia, James McClurg. 92 
TONER, 
to reduce their observations to writing, and to have them published, 
either in defence of their practice, or for the laudable purpose of making 
contributions to medical science. To us of the present day, it is an 
agreeable surprise to find that there were then so many medical men of 
literary ability1 in our country. 
The second quarter of the centennial period was distinguished by the 
introduction of vaccination, the occurrence of spotted fever, and the war 
of 1812. All of these were events which stimulated the profession to 
more extended studies, and became incentives to authorship; this was 
especially true of the disease known as spotted fever.2 The war of 1812 
proved to be another great school of experience, although it was not 
fruitful in medical reports or publications. The aspirations which it 
aroused in the profession, however, gave an impetus to the establishment 
of medical periodicals, and to the founding of medical colleges3 and 
hospitals. 
In following out the plan of dividing the century of our independence 
into quarters, the third may be marked as noted for the discovery of 
anaesthesia, the epidemics of Asiatic cholera of 1832 and 1848, and the 
war with Mexico, as well as the discovery and the application of many 
new and improved methods of physical exploration in the search of dis- 
ease. These aids to diagnosis encouraged more than ever the recording 
of clinical observations and their publication. Medical journals multi- 
plied,4 and new medical colleges were founded in most of the States.5 
The last quarter, which has just closed, is specially distinguished by 
the vast experience of the late war, which was a great school, and which 
1 In my own library I find pamphlets on the epidemics of yellow fever of 1793, and 1798 
published before 1800, by the following authors: Dr. J. S. Addoms, Dr. Richard Bayley ; 
Dr. Thaddeus Brown, Dr. C. Caldwell, Mathew Carey, Dr. Isaac Cathrall, Dr. W. G. 
Chadwell, Dr. Colin Chisholm, Dr. Thomas Condie. Dr. William Currie, Dr. John Beale 
Davidge, Dr. M. S. Davis, Dr. Jean Deveze, Dr. Richard Folwell, Dr. James Hardie, Dr. 
J. Henry C. Helmuth, Dr. Charles Holt. Dr. Alexander Hosack, Dr. William Linn, W. 
Marshall, Dr. D. Nassy, Dr. Pascalis, Dr. J. Patterson. Dr. Benjamin Rush. Dr. Charles 
Scot, Dr. James Tytler, Dr. Washington Watts, Dr. Noah Webster, and Dr. Nathaniel 
Weeks. There are also many reports by committees and boards of health, besides numerous 
articles on the subject in the “New York Medical Repository.” 
2 The following are a few of the most noted writers on spotted fever: Elisha North, Job 
Wilson, Thomas Miner, William Tully, L. Danielson and E. Mann, Elijah Lyman, Samuel 
Woodward, Abraham Haskell, Mason Spooner and Jacob Holmes, John Bestor, Q. Fiske, 
and G-. Williamson. 
3 In 1800, there were in the United States but four medical colleges organized and giving 
instruction, viz.; University of Pennsylvania, Pa.; Columbia College, N. Y.; Harvard 
College, Mass.; and Dartmouth College. N. IT. The number of medical colleges fully 
organized and giving instructions in the United States in 1825, was eighteen, viz,; Univer- 
sity of Pennsylvania, Pa.; College of Physicians and Surgeons, N. Y.; Harvard College, 
M ass.; Dartmouth College, N.H.; University of Maryland, Md.; College of Physicians 
and Surgeons Western N.Y., N.Y.; Yale College, Conn.; Medical College of Ohio, Ohio; 
Vermont Academy of Medicine, Vt.; Transylvania University, Ky.; Brown University, 
R. I.; Medical School of Maine, Me.; University of Vermont, Yt.; Berkshire Medical 
College, Mass.; Medical College, S. C.; Jefferson Medical College, Pa.; Columbian Medi- 
cal College, D. C.; University of Virginia, Va. 
4 It has been ascertained that about two hundred medical journals have been started in 
the interest of regular medicine in the United States within the centennial period. Of this 
number, about thirty are now being published. From an estimate, based on pretty good 
data, I am persuaded that something over seven hundred medical men have been engaged 
as editors and assistant editors of journals within this period. Medical editors, as a class, 
are ready writers, well informed, enterprising, and progressive in their profession. The 
influence of medical journal literature is elevating, and encourages study and the reporting 
of cases. 
5 At the end of the third quarter, 1850, the United States census gave a list of thirty- 
seven medical colleges fully organized and giving instruction. ADDRESS OX MEDICAL BIOGRAPHY. 
93 
lias benefited the medical profession of the whole country;1 by the ex- 
tended use of anaesthesia in painful surgical operations; by the increase 
of scientific means for exact diagnosis, and the introduction of new and 
potent remedies and modes of administration; and by the founding of 
hospitals and medical colleges in nearly all the large cities.2 
It is from the professional men who labored not only in these more 
notable scenes, but from the whole profession who practised during this 
period, that I shall select for comment those who acquired honorable 
distinction among their contemporaries. It is well known to you that 
owing to the peculiar condition and growth of our country, from thir- 
teen Colonies to forty-nine States and Territories during the century, it 
is difficult to so treat the subject as to be entirely impartial, and not to 
neglect the claims of any section of the country, old or new. 
I will first speak of the medical men of the United States who have 
by their discoveries, writings, or special skill and devotion to their pro 
fesson, won national fame, and then of those who have attained distinc- 
tion within the several States. Having an earnest desire to make the 
address acceptable to this Congress, and for the sake of making it worthy 
of the occasion, I have collected formal biographies of one hundred of 
the most eminent medical men of the United States for the century. 
These sketches have been prepared at ray request by physicians of note 
in possession of the requisite data.3 
We know that greatness in any avocation, and particularly in the 
medical profession, is not a birthright, nor can it be thrust upon the 
undeserving, A kind of popular transitory applause may be achieved 
without merit, but only those who have done something to advance 
medical knowledge or to improve the methods of cure, will live in 
history. The discoverer or the expounder of a new truth, the recorder 
°f an additional fact or a hitherto unobserved symptom, or of an im- 
proved procedure in surgery or in the treatment of disease, deserves and 
will secure a more enduring place in history than he who has gained 
great popularity or the largest fortune. The qualities and acquirements 
mid the degree of these which can make a medical man illustrious either 
m his day or in history, I shall not attempt to define. The talent differs 
111 kind and degree that attains eminence in different periods of time, 
and iii the city as compared with the rural districts, in the surgeon4 as 
compared with the physician,5 and in the writer6 as compared with the 
the late war did for us what the wars of Europe in 1848 and 1856 did there. It im- 
proved surgery much, and developed pathology wonderfully, brought hygiene into active 
exercise, improved the treatment of bone injuries by exsection and resection, and the treat- 
ment of wounded joints. The conservative treatment of limbs, the postponement of the 
period ot operation, and the improvement in hospital construction and treatment, mark this 
aniestl eSS au ie ac^ number of operations performed by the extended use of 
■ P1® clpse of the last quarter of the centennial period records sixty-five medical colleges, 
3 schools or colleges of pharmacy. 
Editor ] 10®raP^les referred to in the text, are necessarily omitted for want of space.— 
An \-10 essor Samuel 1). Gross, in the “ Century of American Medicine,” published in the 
wh'^'ca11, ourila* of Medical Sciences, names nearly three hundred American surgeons, 
r.f y their operations and reported cases, have won an enduring place in the literature 
s Profession. 
Anie-1' Thomas, in the “Century of American Medicine,” published in the 
physjU?au of Medical Sciences, names nearly one hundred and thirty American 
s p ,laPs who have won distinction in obstetrical practice and gynaecological surgery, 
cat lu° fhSor AD. Gross, in his Introductory Lecture entitled “ History of American Medi- 
eiature,” names nearly three hundred medical authors for the century. From an 94 
TONER, 
teacher.1 But that there is a something in talent or character which 
commands success, and that this element stands m the relation of cause 
to effect, is generally conceded. Even when an elevated standard of pro- 
fessional ability has been adopted, I am embarrassed not only by the 
difficulty of selection, but by the superabundance of good material. 
The names here presented as having won pre-eminence in the medical 
profession of America, have acquired their distinction chiefly by the 
possession of high natural endowments and of good education and medi- 
cal knowledge, with the exercise of unceasing study, and devotion to 
professional duty. My study is too limited to assume that names not 
included may not be equally deserving. 
The natural ability, habits of industry and systematic study, and 
scientific knowledge of Dr. Benjamin Rush, added to his acquaintance 
with men and public affairs, easily place him at the head of the list of 
the eminent medical men of the century. His professional skill, high 
moral and benevolent character, and frequent participation in the attana 
of his country, rendered him popular with the profession and endeared 
him to the people. His fame has suffered but little by the lapse of time 
His writings are numerous and valuable, (b. December 24,1745 , d. jui 
19,1813.) "But as the subject of medical literature has been assigned to 
an'abler pen, I shall leave that branch entirely to him.2 _ 
Dr. Valentine Mott, by his daring and brilliant operations in surgery, 
held for many years the front rank. He had the physical and mental 
endowments, as well as scientific acquirements, application, and profes- 
sional training, essential to a great surgeon. There is scarcely an opera- 
tion, however hazardous or delicate, that he did not peiform with 
surnmate skill and success. His genius, too, was equal to devising new 
operations and important surgical procedures, and undertaking and 
executing some operations which before his day were passed over as too 
formidable to be attempted. He was scarcely less eminent as a writer 
and teacher than as a surgeon and no A™erlACaai"^e7oS. 
to the profession throughout the world, (h. August 1/85 , d. Apni -b, 
-i \ . 
Dr. Philip Syng Physick was a surgeon of rare ability, self-possession, 
and fortitude. As was usual, when he commenced practice, he attended 
to the general business of physician and surgeon, but as early as 1 / 94 e 
was appointed one of the surgeons to the Pennsylvania Hospital, and in 
1805 Professor of Surgery in the University of Pennsylvania. He 
always carefully prepared his lectures, and was therefore particularly 
impressive, for he had thought over and mastered the subjects he pre- 
sented. Pie was the author of so many improvements in the depaitmeut 
estimate I have made on this subject, I conclude that there are some four hundred authors 
who have published works, which from their size are entitled to be termed books. 1 
imdude pamphlets it is probable that there are over fifteen hundred medical authors 
> I have made of the teachers of medicine in our country, for 
the century I am inclined to think that the list will include nearly two thousand names. 
- “™S,r L P Yandell. of Kentucky, has been designated to a«lmr ft. 
“ American Medical Literature” for the centennial of our national existenceh a“d ™ 
N. S. Davis, of Illinois, has been given the task of preparing an on^Amencan 
diUy1 of1 preparhig'a hfstory'of m™didne°in our country for s^Ticitoit 
no fG to traverse°their biographical detail at the risk of 
being tiresome. ADDRESS ON MEDICAL BIOGRAPHY. 
95 
of surgery that he was justly entitled to the appellation given him of 
“ The Father of American Surgery.” His influence upon practice is 
felt to the present day. (b. July 7, 1768 ; d. Dec. 15, 1837.) 
Hr. John Warren was an eminent physician and surgeon, and medical 
teacher. He acquired experience and reputation in the hospitals of the 
Revolution. While attached to the hospital at Boston, in 1782, he 
founded the Medical Department of Harvard College, in which he was 
Professor of Anatomy and Surgery. He was a man of great industry, 
and enthusiastically attached to his profession, and was during his life- 
time the leading surgeon of Hew England. His genius and aptitude for 
this branch of the profession has continued to show itself in his descend- 
ants. (h. July 27, 1753; d. April 4,1815.) 
Dr. Daniel Drake possessed wonderful powers of original observation, 
and was the most indefatigable worker for the accumulation of know- 
ledge and the elevation of the profession, that our country has produced. 
He was the founder of medical colleges in the West, and a writer and 
teacher of great force and ability. "His systematic inquiries into the 
causes.of disease are models worthy of study. The Doctor’s valuable 
labors are certain to be appreciated in the future, (b. Oct. 20, 1785 ; d. 
Nov. 6,1852.) 
Dr. John Collins Warren was one of the founders of the Massachusetts 
General Hospital, and the surgeon in daily attendance to the time of his 
death. He was the first to use ether, and did much to hasten its intro- 
duction into general use in surgery. He was a brilliant operator, popu- 
lar as a lecturer, and wrote on a great variety of subjects, in all of which 
he showed his exact knowledge and extensive scientific acquirements, 
(b. Ist Aug. 1778; d. May 4, 1856.) 
Dr. Nathan Smith was a man of extraordinary natural endowments. 
His ability to acquire knowledge, his industry, perseverance, and success 
under almost insurmountable difficulties, have rarely been equalled. His 
founding of the Medical Department of Dartmouth College, and his teach- 
ing, by himself, for ten years, all the usual branches, show the character 
°f the man. He was an admirable anatomist, a bold and successful sur- 
geon, and a good general practitioner. By his teachings he did much to 
advance medicine, (b. Sept. 30, 1762: d. Jan. 26, 1829.) 
Hr. Reuben Dimond Mussey was a distinguished surgeon and good 
general practitioner. His experiments on cutaneous absorption would 
have of themselves entitled him to a high rank, had he not become still 
111 ore eminent as a surgeon. For daring and success, some of his capital 
operations have never been excelled. He was also a popular and success- 
ful teacher of surgery. The esteem in which he was held by the pro- 
fession may be inferred from his election to the presidency of the Ame- 
rican Medical Association, (b. June 23, 1780; d. June 21, 1866.) 
Hr, James Jackson was a noted physician and author. _ He was one of 
the founders of the Massachusetts General Hospital. His great skill in 
diagnosis, and his eminent success in the treatment of disease, led to his 
appointment to the professorship of Theory and Practice in Harvard 
College. His observations, teaching, and writings, almost mark an epoch 
]n uiedicine in this country. His professional life and labors were great 
lessons to the profession of high and honorable principles, (b. Oct. 3, 
17p; cl. Aug. 27, 1867.) 
Hr. Nathaniel Chapman was a learned and eminent physician, and 
teacher of medicine. His special qualifications and success as a physi- 
dau speedily attracted attention, so that his business was very large and 96 
TONER, 
responsible He was for a long time a professor in the University of 
Pennsylvania, and was in some respects the most popnlw Iwturer wrth 
students ever resident in that great centre ot medical education. Uis 
writings have had much influence over the medical 
He was President of the American Philosophical Soc f 28 1780 d. 
President of the American Medical Association, (b. May , ’ 
Jah.lTh8eodorio R. Beck was a prominent physician, author and teacher. 
He was narticularly notable for his literary and scientific attainments, 
power ot classification, and scope of studies. Professor in sereraUol^lege , 
he filled one of the first chairs of medical t0 
conntrv His work on this science would ot itself entitle mm 
■a“k with the most cultivated medical men of the Union, and has been 
for years the class-book in foreign schools of medicine, (b. Aug. 11, 
179dV Samuel Jackson was a learned and accomplished medical man and 
teachrHn every department, whether at the bedside, or as President 
of the Board of Health, or in the lecture room, he showed himself the 
o-rcnt physician. He tilled a chair with eminent success in the Univei- 
fity of Pennsylvania from 1825 till 1868 when he resigned His membei- 
slifpt learnh societies as well as his able stings testify to h.s distm- 
p-uished ability, (b. March 22,1787 ; d. April 4, 1872.) . . , 
& Hr Wm. Potts Hewees deserves prominent notice as a physician an 
author He possessed a methodical and discerning mind and was an 
extensive and careful reader of the best works in the profession. His 
were HwTnS thfpte^f 
“Ltkf aTcLri 7fomen ™ 
thb°klarrGdiMorton(b“aahons;ficuous pfean an] naturalist 
He was ahost careful and laborious student, and did a prodigious amount 
original scientific work. His love for science, however did 
not lessen his devotion to his profession, as his writings on consumption, 
and other medical works, prove. His fame is enduring,and 
bis original observations in medicine and cramology. (b. Jan. -6,17JJ , 
d'Dra'Blithf Bartlett was a highly accomplished scholar and physician. 
He was a very popular medical teacher, and a ready lecturer holding 
chaira in several leading medical colleges. His work on the ‘ Fevers ot 
the United States,” published in 1842, at once secured him a place in the 
front rank of physicians. His parity of life and eminence as a clinical 
physician as well as the high character of all his writings, have secured 
for Wa name an abiding place in the history ot h.s profession, (b. Oct b, 
John i'v. Mitchell was an able physician and a polished writer. 
He nossessed a vigorous intellect, which was well trained and by carefu 
study stored witlf facte. In the sick room he is said to have had a mos 
encouraeino- influence over patients and their ti lends. He was an ong 
nal thinkep with a vivid imagination, and one of the ”o®kithiTaWlitv 
lecturers. His writings cover a variety ot subjects, all exhibiting ability 
and versatility of talent, (b. May 12 1796 ; d. April 4 .1856.) 
Dr Rene La Roche was a learned physician and author. Me was a 
most laborious and conscientious student, exhausting all sources of infor- 
mation to* the fullest extent on whatever subject he took up. He was for ADDRESS ON MEDICAL BIOGRAPHY. 
97 
many years connected with the Board of Health of Philadelphia, and was 
a most valuable member. His practice for years was large and responsi- 
ble. His studies and writings on j-ellow fever are a marvel of labor and 
systematic presentation of all the known facts relating to this disease, 
(b. 1795 ; d. December 9, 1872.) 
Dr. David Hosack was a celebrated physician, botanist, and author. 
He had a large practice, and yet found time to lecture in different col- 
leges, and to write exhaustive treatises on medical subjects. He held 
important positions in the Almshouse, in the Hew York Hospital, and in 
the Bloomingdale Asylum. His contributions to medical science are 
numerous and valuable, (b. August 31, 1769 ; d. December 22, 1835.) 
Dr. John Morgan was a man of learning and an eminent physician 
and surgeon. He enjoyed the distinction of being the founderof the first 
medical school in America. At that time he was perhaps the most 
thoroughly educated and accomplished physician in this country. He 
was a good writer, and was the first to suggest that pus was formed by 
a secretory process. Pie was surgeon-general of the Continental Army, 
and one of the founders of the American Philosophical Society, (b. 1735; 
d. Oct. 15, 1789.) 
Dr. Josiah C. Hott was a prominent physician and surgeon, and a 
learned ethnologist. He was a man of commanding powers of intellect, 
with great industry and capacity for study. While he won a world-wide 
fame as an ethnologist, he did not neglect the duties of a large practice. 
He was eminent as a teacher, and as the founder of the Medical College 
°f Mobile. His ethnological writings,however,are those which are best 
known, but he was equally distinguished as a physician and surgeon, 
(b. March 31, 1804; d. March 31,1873.) 
Want of time will prevent comment upon all our medical worthies. 
I however present the following list of names, incomplete though it be, 
1,1 which it would be difficult to assign a precedence, for all of them have 
won national reputations, and are eminently deserving of commemoration. 
I am persuaded that I might more than double the list, and yet not 
include all who have won reputations that have extended beyond the 
confines of their own country:—J. Mason Warren, Caspar Wistar, Wm. 
olnppen, Samuel Bard, Wright Post, Chas. Caldwell, Benjamin S. Barton, 
Henjamin Waterhouse, David Ramsay, John D. G-odman, Wm. E. Horner, 
P ranklin Bache, Robley Dunglison, Warren Stone, John Ware, James 
lhacher, Wm. W. Gerhard, C. D. Meigs, Hugh L. Hodge, Edward 
Miller, Wm. Gibson, J. W. Francis, George McClellan, Henry Miller, 
• S. Dorsey, B. W. Dudley, J. B. Davidge, J. A. Swett, Samuel Jackson, 
E Green, C. A. Pope, Jeffries Wyman, John Eberle, T. Miner, John 
Jones, G. T. Elliot, A. A. Gould, S. L. Mitchell, S. IE Dickson, J. P. 
arrison, Jonathan Knight, Ernest Krackowizer, Daniel Brainard, 
Charles Prick, G. C. Blackman, J. W. Heustis, Alexander PL Stevens, 
f Hale, Erasmus Fenner, B. R. Welford, J. M. Galt, James McClurg, 
arnes Moultrie, Henry F. Askew, G. Mendenhall, Nicholas Romayne, J. 
S’ Harton, R. S. Kissara, A. Brigham, T. D. Mutter, Ephraim McDowell, 
p Hajley, W. Curry, John Jeffries. J. A. Cartwright, L. Y. Bell, D. F. 
wondie, S. Forry, J. A. Gallup, S. G. Morton, W. Beaumont, Thomas 
mewaU, E. H. Barton, S. Brown, J. Watson, Jos. Parrish, C. A. Lee, J. 
D? -'Helen March, Lyman Spalding, Josiah Bartlett, J. M, Smith, 
Snr!-i r?®ky, Valentine Seaman, E. A."Holyoke, Amos Twitchell, E. H. 
1 1,,~* H. Beck, Usher Parsons, Caleb Fiske, J. E. Holbrook, William 98 
TONER, 
Baynham, F. T. Stribling, L. M. Lawson, J. R. Coxe, T. C. James, R. 
W. Gibbes, John P. Mettauer. 
In looking over the available records of the lives of the medical men 
who have labored in the several States during the century, I am struck 
with the evidence of the high average professional ability, and wonder- 
ful fidelity, with which they have discharged their duties. The testi- 
mony, too, is ample as to the high esteem in which the vast majority of 
medical men have been held by the communities in which they resided. 
I am aware there are those who would draw this picture less rosy. 
And I will concede that the opinion held on the point depends to some 
extent upon the temperament and motive of the inquirer. If he seeks to 
find the illiterate, the incompetent, or the unworthy, hearing the title of 
doctor, lam sorry to say such can be found. But if, on the contrary ,he 
looks as I have done to find the educated, the intelligent, the skilful, 
the conscientious and faithful physicians, they are to be found in great 
numbers in every city and village in our broad and prosperous republic. 
I am persuaded that the medical profession of the United States, not- 
withstanding all that has been said by its friends in their desire to ele- 
vate it, really has within its ranks proportionately more talent, nobility 
of character, and high scientific acquirements, than are to be found in 
any other profession in this or any land. 
The number of great physicians who have by their discoveries and 
writings added new facts and extended the boundaries of medical science, 
is limited in any century and every country. This fact ought not to be 
lost sight of. 
To the young and to the inconsiderate only do great reputations seem 
a matter of course. To the conceited nothing seems beyond their untried 
powers. Age and experience, however, demonstrate the limitations and 
possibilities of human intelligence and acquirements, which, it is con- 
ceded by the wisest, are comparatively narrow and circumscribed. 
Medical science and the medical profession in America have made vast 
progress in the hundred years just passed, and have brought into promi- 
nence during that time many medical men of genius and rare abilities, 
and sometimes from unexpected quarters. If there is any one thing in 
which the American people has a united faith, it is in progress. As a 
nation and a people we believe we shall be better physically, morally, 
and intellectually, in the future than we have been in the past. 
From a careful study of the average proportion of physicians to popu- 
lation, it is rendered probable that about 65,000 physicians have died in 
the United States during the century. Of even the few whose genius, 
skill, and devotion to medicine, in the several States, have rendered 
their lives notable, it is not possible to present more than the merest 
outline; little, indeed, beyond an imperfect list of names. To do even 
this meagre justice to my subject, I was obliged to correspond with phy- 
sicians in different parts of our country, and beg them to assist me in 
collecting the necessary facts; and to these gentlemen I wish to return 
my most sincere acknowledgments for their valuable assistance. What- 
ever defects appear in this paper, and doubtless there are many, they are 
my own. 
Alabama.I—ln this State Josiah Clark JSTott, a native of South Caro- 
1 Alabama was visited by Be Soto as early as 1541. The first successful settlement was 
made upon Mobile Bay in 1702, by Bienville. This State formed a part of Georgia until ADDRESS ON MEDICAL BIOGRAPHY. 
99 
lina, was for years the leading medical spirit. Ills eminence as a surgeon, 
author, and teacher, placed him in the front rank; he has already been men- 
tioned. (b. March 31, 1801; d. March 81, 1873.) Dr. J. W. Heustis 
wrote on the diseases of the South as early as 1817. In 1825 he pub- 
lished a more systematic treatise on the “Bilious and Remittent Fevers 
of Alabama.” (b. 1784; d. 1841.) Dr. Wm. M. Boling, of Montgomery, 
was a physician of education, and extensively patronized. Dr. Thomas 
Fearn and his brother Dr. Richard Lee Fearn, of Mobile, were natives of 
V irginia, and accomplished physicians. Dr. Silas Ames, of Mobile, was 
a physician of skill, and esteemed remarkably successful in the treatment 
of fevers. The following also deserve mention, viz.: Drs, Samuel D. 
Holt, Leroy Anderson, A. Lopez, A. G. Mabry, IT. S. Levert, James C. 
Harris, Nicholas Merriwether, P. H. Lewis, Edward Gant, and R. C. 
Armstrong. 
Arkansas.I—Dr. Benj. P. Jett, of Washington, Hempstead Co., came 
from Yir ginia, and enjoyed a large and responsible practice, (b. Oct. 25, 
1808; d. Dec. 29,1865.) Dr. Craven Peyton, of Little Rock, served as a 
surgeon in the war with Mexico, and thereafter retained a preference 
lor the practice of surgery, in which he was very successful. The great 
esteem in which he was held was manifested by the closure of the banks 
uud business houses, in order that their employes might attend his 
funeral, (d. Nov. 7, 1872.) Dr. Charles B. Mitchell, a native of Ten- 
uessee, practised in Washington. Ilis business habits, intelligence, and 
enterprise, made him many friends, and caused him to be elected U. S. 
Senator, 1860-61. (b. Sept. 19, 1815; d. Sept. 20, 1864.) Dr. Shephard 
Laurie, a native of the District of Columbia, was for many years one of 
Ihe leading physicians and surgeons of Little Rock. I will also men- 
tion Drs. Geo. Eving, Bumford, G. G. Shumard, Alden Sprague, Burton, 
and Gibson. 
California.2—This new State holds out such golden promises as to 
; from this time till 1817 it was included in the Mississippi territory, and was then 
organized into a separate territorial government, and admitted as an independent State to 
A Union in 1819. Alabama has advanced rapidly in population and wealth, and has 
?A°,U much encouragement to general education and the advancement of the sciences. In 
‘ J she had 996,992 inhabitants. She has no large cities; about one in twelve of her 
people live in cities and towns of over five thousand inhabitants. One medical college 
ists, located at Mobile. (Note.—Summer schools, as adjuncts to colleges, are in no in- 
duce enumerated.) A State Medical Association, formed in 1847, has, by recent legisla- 
-0n’ a^so the legal powers of a State board of health, and publishes a volume of Transac- 
n 0118 anm'ally. Institutions, sufficient for the care and treatment of unfortunates, have 
been established. 
L' Arkansas settlements were first made about 1685 ;it wras a part of the Louisiana 
purchase of 1803. In 1819 it was formed into a territory, and was admitted as an inde- 
®ta,te fn 1836. The population in 1870 was 484,471. It has no large cities, and 
anJ ar)p,’ Bne8ne 111 thirty of its people live in cities and towns of over five thousand inhabit- 
gt bhe State in 1870 had 1206 physicians. Its population is gradually increasing. A 
I ‘ -et beelical Association, formed in 1870, publishes annually a volume of Transactions. 
2 felons |or the care of the insane and other unfortunates have been founded. 
10 earliest settlement in the territory of the present State of California was in 1769r 
1821 >a'i “ Franciscan friars who came from the Peninsula of Lower California In 
Li~lB4r kcame a territory of Royal Mexico, and continued a province under the republic, 
control f i American navy seized Monterey, and from that time it has been under the 
°nce ? A ,e Baited States. The gold mines were discovered in 1848, population was at 
fore °,. em, an(i California was admitted as a State in 1850. She has been, there- 
-1870 w over a quarter of a century a member of the Union. Her population in 
inhabit a§t Nearly one-third of her people live in cities of over five thousand1 
have bpp S" had ab the date mentioned 1257 physicians. Two medical colleges 
11 established, and a State Medical Society, formed in 1870, publishes annually a 100 
TONER, 
attract to it many able physicians. Dr. Thomas M. Logan, a native of 
South Carolina, in 1849 located at Sacramento. He was a close observer 
of the causes of disease, and a frequent contributor to the medical jour- 
nals. He was influential in organizing the Medical Society of California 
and the State Board of Health, and was president of the latter at the 
time of his death. He was President of the State Medical Society in 
1871, and of the American Medical Association in 1873. (b. Jan. 31, 
1808; d. Feb. 13, 1876.) Dr. E. S. Cooper, a native of Ohio, was an excel- 
lent surgeon and a successful medical teacher in San Francisco. He 
founded and published the San Francisco Medical Press, and made valu- 
able suggestions as to the physiological mode of repair in wounded joints 
and tendons. He was a careful student, a bold surgeon, and a frequent 
contributor to medical serial literature, (d. Oct. 13, 1862, set. 40.) Dr. 
Isaac Rowell, a native of Hew Hampshire, enjoyed an extensive practice 
in San Francisco, and was particularly influential in organizing the Uni- 
versity of the Pacific, in which he was a professor, (b, 1818; d. Jan, 4, 
1871.) Dr. Win. Burnett, of Petaluma, was a physician of culture. The 
following also deserve mention ; Drs. Henry M. Gray and John T. Morse, 
of San Francisco. 
Connecticut,I—Dr.1—Dr. Aneas Munson, of Hew Haven, served as a sur- 
geon in the Revolutionary war. He was an observing and successful 
practitioner and surgeon. He contributed papers to the Connecticut 
Medical Society, and was an active promoter of art and science. He was 
■one of the originators of the State Medical Society, and for some years 
its president, (b. June 24, 1734; d. June 16, 1826.) Dr. Jared Potter, 
of Wallingford, was a scholar, and had a passion for acquiring knowl- 
edge. His office was much frequented, and his instruction eagerly 
sought by young men entering the profession, (d. 1810, ret. 67.) Dr. 
Jonathan Knight, of Hew Haven, was remarkable for his urbanity and 
sound professional judgment. He held a chair in Yale College for 
twenty-five years. He was the first president of the American Medical 
Association, (b. Sept. 4, 1789 ;d. Aug. 25, 1864.) Dr. Win. Tully was 
an earnest cultivator of the science of medicine. He was an author of 
merit, and published, along with Dr. Thomas Miner, in 1823, a work on 
fevers, (d. Feb. 28, 1859.) Dr. Thomas Miner was one of the founders 
volume of Transactions. A State board of health, which also publishes annual Transac- 
tions, has been established by law. Institutions for the care of unfortunates have been 
created by the State, sufficient for the wants of the people. 
The following medical journals have been published; California Medical Gazette, 1868 ; 
California State Medical Journal, 1856; Medical Gazette, 1870; Pacific Medical and Sur- 
gical Journal. 1858; San Francisco Medical Journal, 1858; San Francisco Medical Press, 
I860; Western Lancet, 1872. 
1 Connecticut is one of the thirteen original States. The Dutch had a trading house at 
Hartford as early as 1631. An offshoot of Plymouth had also a settlement at Windsor 
about the same time. New Haven was for some years an independent colony. All the 
separate interests, however, were consolidated in 1665. The State took an early and an 
active stand in favor of American Independence. The population in 1870 wras 537,454, 
with about two-thirds of the people living in cities and towns of over five thousand inhabi- 
tants. At the same time there were 680 physicians. Great encouragement has been 
given to education and the advancement of science. A State Medical Society was founded 
in 1792, and was one of the first in the country to publish Transactions. There is one 
medical college, a department of Yale. It was in this State that anaesthesia in surgical 
operations was first tried. The first school in America for the education of the deaf and 
dumb was organized at Hartford. Institutions for the care of the insane and other unfor- 
tunates have been founded by the State, sufficient for the wants of the people. 
The following journal of a medical and scientific character has been published in Con- 
necticut: American Journal of Sciences and Arts, 1846. ADDRESS ON MEDICAL BIOGRAPHY. 
101 
of the Medical Department of Yale College. He was particularly in- 
terested in the cure and treatment of the" insane. His life and labors 
were important to his day and generation, (d. April 23, 1841.) Dr. Eli 
Todd, of Hartford, was an educated and intelligent physician. He was 
much interested in the treatment of the insane, and was chosen superin- 
tendent of the Retreat at Hartford, (d. Hov. 17, 1833.) Dr. Lemuel 
Hopkins, ot Hartford, was a scholarly physician, writer, and wit. He 
was devoted to scientific studies and to the elevation of the profession, 
(h. June 19, 1/50 ; d. April 14, 1801.) Dr. Eli Ives, of Hew Haven, was 
a distinguished physician and botanist. He was a man of quick percep- 
tions, sound judgment, great industry and perseverance. Eor years he 
filled with ability a professorship in A ale College, and in was Presi- 
dent of the American Medical Association, (b. Feb. 7, 1779 ; d. Oct. 8, 
1861.) Dr. Mason F. Cogswell was a surgeon of the Revolution, and 
during his day the leading surgeon in Connecticut; he was the first per- 
son in this country to ligate the carotid artery, (b. 1761; d. Dec. 1836.) 
Dr, Thomas Hubbard succeeded to the chair of surgery in Yale College 
°n the death of Dr. H a than Smith, and was a worthy successor to one 
of America’s most eminent surgeons, (d. June 18, 1838, set. 63.) Dr. 
Vv orthington Hooker, of Hew Haven, was an accomplished physician 
mid a writer of many educational works of merit. His brother Charles 
1 eiWed an eilvialjle reputation, (b. March 3, 1806 ;d. Hov. 6, 
186 /.) I will also name Drs. Seth Bird, George Sumner, Samuel Wood- 
ward, Daniel Worden, and Horace Wells, the dentist and discoverer of 
anaesthesia. 
Delaware.I—Dr. Edward Miller was an accomplished writer. He 
practised at Dover until 1796, when he removed to the city of Hew York. 
Dis reputation had preceded him, so that he rapidly acquired a lucra- 
tive business. In connection with Drs. E. H. Smith and S. L. Mitchell, 
•le funded in 1797 the Hew York Medical Repository, the first medical 
in our country, (b. May 9, 1760 ; d. March 17, 1812.) Dr. 
* anies Tilton, of Wilmington, served as a surgeon in the hospitals of the 
evolution, and proved himself remarkably well informed on the subject 
p 110spital construction and management. He was a member of the 
ontinental Congress from 1783 to 1785. During the war of 1812 he 
yas appointed Surgeon-General of the 11. S. Army. In 1813 he pub- 
-18 Je<] a pamphlet on Military Hospitals, He was a man of clear per- 
to'l* loliS and Practical good sense, and in his official position did much 
w prSrno.te tde efficiency of the medical department of the army. He 
d a\f reeddent fke Delaware State Medical Society, (b. June 1,1745 ; 
aiKl Dr. James Sykes was a physician of great personal 
c piofessioual popularity; and was chosen to represent his district in 
evcent m aiJ Was one the thirteen original States. It lias the smallest area of any State 
1627 T|10 n Island: hhe earliest settlements were made by the Swedes and Finns in 
the Eno-f-f • York held the government in the year 1655, but it passed to 
the nam f ' Delaware formed a part of the Pennsylvania grant of 1682, under 
to have 6 ° * hree Lower Counties of Delaware.” In 1701 it was permitted, in part, 
the Ro>vniSecarate ttovernment, but was subject to the Governor of Pennsylvania down to 
people li UtlOI?‘ Delaware’s population in 1870 was 125,015, about one in four of her 
hundred In!f m Cltf‘s ?f over five thousand inhabitants. She had at the same time one 
Pelaware PavSeVentnPllySlClanS' Her Proximity t° Philadelphia, and her position on the 
and wealth „I’ glye her great commercial and manufacturing advantages. Her population 
Publishes “‘creasing. She has a State Medical Society, formed in 1789, which 
went of herD- 10nSjan, ly’ and she has made amPle provisions for the care and treat- 
oi ner insane and other unfortunates. 102 
TONER, 
the State Legislature, and also in the State Senate for fifteen consecutive 
years, being much of the time the presiding officer. In 1801-2 he was 
acting Governor. He practised for a few years in the city of Hew York, 
but returned to Delaware, where he ended his days. (b. March 27,1761; 
d. October 18, 1822.) Dr. James Couper, of Hew Castle, was a highly 
gifted physician. In 1840 he was a delegate from the State Medical 
Society to the Convention for revising the IT. S. Pharmacopoeia. He was 
President of the Delaware State Medical Society, and Vice-President of 
the American Medical Association in 1863. (b. Oct. 3, 1803.; d. 1865.) 
Dr. Henry F. Askew was a physician of sound judgment and great expe- 
rience. idis professional life was characterized by close attention to pro- 
fessional duties. He had a well-trained mind, was a constant reader of 
the latest literature, and had a high regard for the dignity of the profes- 
sion. He was President of the American Medical Association in 1867. 
(d. March 6,1876.) Dr. George Munroe was a surgeon in the Revolu- 
tionary War. He practised at Wilmington, and was through life one of 
the foremost medical men of the State, and an occasional contributor to 
the “Hew York Medical Repository.” (d. Oct. 11, 1819.) Dr. John 
Vaughn, a native of Pennsylvania, was a man of science and physician of 
ability. His manners in the sick room were gentle and assuring. In the 
winter of 1778-79 he delivered a course of lectures on Chemistry and 
Hatural Philosophy. In the following year he published a “ Chemical 
Syllabus;” he also contributed articles to the “Hew York Medical Re- 
pository.” (d. March 25,1807.) I will also name the following; Drs. 
Charles Ridegley, Allin McLane, Win. Gibbons, Henry Latimer, Hicholas 
Way, John McKinley, Ebenezer Smith, Joseph Hall. 
District of Columbia.I—Dr. Thomas Sewall, a native of Maine, was 
for many years extensively engaged in practice in Washington. He held 
the chair of Anatomy in the "Medical Department of Columbia College 
from its organization in 1825 until 1839, and from that time to his death 
the chair of Pathology and Theory and Practice. His address at the 
opening of the schoof in 1825 gave a history of the Medical Colleges of 
the country up to that time. He was a good writer, and published a 
number of papers on Phrenology, Temperance, and Medicine, (d. April 
10, 1845.) Dr. Tobias Watkins, a native of Maryland, was a physician, 
scholar, and author. He published in Baltimore, in 1809, “ The Medical 
and Philosophical Recorder,” and was for a time one of the editors of 
the “Portfolio,” He served as a surgeon in the war of 1812, and was 
acting Surgeon-General from 1818 to 1821, and Fourth Auditor of the 
Treasury from 1824 to 1829. He translated a number of medical works 
from the French, (d. Hov. 14, 1855.) Dr. Thomas Henderson wTas a 
physician and surgeon of the U. S. Army, and an author. From 1825 
to 1833 he was Professor of Theory and Practice in the Medical Depart- 
1 For three-quarters of a century Washington has been the seat of the government of 
the United States. Originally, the District or Territory of Columbia comprised a territory 
of ten miles square, but that part of it lying south of the Potomac River, containing thirty- 
six square miles, was retroceded to Virginia in 1844. The population in 1870 was 131,700. 
At the same time there were three hundred and twenty-six physicians. There are three 
medical colleges now giving instruction. A district medical society was organized in 1817, 
and publishes Transactions. Institutions for the care of insane and other unfortunates, 
sufficient for the wants of the District, have been established by the United States 
government. 
The following Medical Journals have been published in the District of Columbia: American 
Botanical Register; National Med. Journal, 1870; Register and Library of Medical and 
Chirurgical Science, 1835. ADDRESS ON MEDICAL BIOGRAPHY. 
103 
merit of Columbia College. After bis admission to the army he pub- 
lished “Hints on Examination of Recruits for the Army,” which has 
gone through several editions, (b. Jan. 6, 1789 ; d. Aug. 11, 1854.) Hr. 
B. S. Bohrer, of Georgetown, was a fine scholar and an accomplished 
physician. He held for some years a chair in the Ohio Medical College. 
He possessed a fine library of medical and classical literature. He was a 
good practitioner, and a man of most courteous and agreeable manners, 
(d. Aug. 19, 1862.) Hr. Joseph Lovell, a native of Massachusetts, was 
Surgeon-General of the Army, and long a resident of Washington. 
Although not engaged in private practice, he was a member and 
supporter of the local medical organization, and was frequently called 
in consultation, (b. 1788 ; d. Oct. 17, 1836.) Hr. Thomas Lawson, a 
native of Virginia, was a surgeon in the army, and held the office of 
Surgeon-General. He was a man of great professional abilities and 
personal worth, and made a number of valuable reports on the diseases 
of the army and the climate of the western military posts, (d. May 15, 
1861.) Hr. Frederick Hawes was a physician of fine abilities, and en- 
joyed for years an extensive practice, (d. Feb. 10, 1852.) To these I 
will add the names of Hrs. Frederick May, Bailey Washington, R. 3L 
Stone, Thomas Miller, John M. Thomas, the two Worthingtons, R. H. 
Coolidge, J. A. Brereton, and Joshua Riley. 
Florida,I—Hr. Bosquet was a physician of note at St, Augustine, as 
early as 1800. Hr. Thomas Travers was in practice there in 1812. About 
the time the territory was purchased from Spain, Hr. Harcy was a leading 
physician. Hr. Henry Perrine was a physician, and a man of scientific 
attainments. The United States gave him a township of land near 
Biscayne Bay, for the purpose of encouraging the introduction and culti- 
yation of tropical plants. The “ Sisal Hemp” is now growing abundantly 
in Florida, the result of his enterprise. The Hoctor was murdered at the 
Fght-house, by the Indians, during the Florida war (1841). Hr. Lewis 
practised as early as 1813, at Fernandina, and enjoys the distinction of 
having introduced vaccination into that section of country. Hr. Charles 
W. McCroskey wTas a good physician. He was connected with the army 
at St. Augustine, and died of yellow fever. Hr. W. H. Simmons, a native 
°1 South Carolina, lived at St. Augustine. He was a physician of skill, 
and a man of literary accomplishments. Hr. Richard Weightman, a 
La five of Washington city, after serving in the army, settled on the St. 
John’s River, and engaged for years in the practice of his profession. 
Br. Seth Peck was also a physician of note in Florida. To the names 
already mentioned, I will add those of Hrs. Lewis Willis, W. W. Wad- 
dell, Andrew Anderson, Theodore Turnbull, and William Havis. 
Georgia.2—Hr. Lyman Hall wTas a well-educated physician, a member 
Florida was visited by Ponce De Leon in 1512, and in 1536 by De Soto. A settlement 
was made in 1564, the earliest by Europeans in any State of the Union. Florida belonged to 
Uaitl 1820, when it was purchased by the United States, and admitted as an indepen- 
, eni ‘Mate in the Union in 1845. It has a large territory with almost tropical climate, but 
a sparse^population. In 1870 it had 188,248 inhabitants. The census gave it 240 physi- 
ians. j here are no ]arge cßies jn the State. The United States Government maintains a 
a\y yard, and also a military garrison. The State has a Medical Association, formed in 
t1 ’ wHch publishes annual Transactions. Provision has been made lor the care and 
oa merit of the insane, and other unfortunates, 
in i 18 0116 of' 6*6 thirteen original States. The first settlement by the English was 
Dp. i ’.the latest of any of the American Colonies. The population at the close of the 
ev V° f 1011 not reach 30,000. The population in 1870 was 1,184,109, with about one in 
eiy fourteen living in cities and towns of over five thousand inhabitants. It had at the 104 
TONER, 
of the Continental Congress, and a signer of the Declaration of Indepen- 
dence. (b. 1725; d. Oct. 19, 1790.) Dr. Milton Antony, of Augusta, 
was a teacher and practitioner of ability. He was the founder of the 
Medical Academy at Augusta, in 1828, and of the Medical College of 
Georgia. In 1831 he started the first medical journal published in’ the 
Southern States, (b. August 7, 1789 ; d. Sept. 19, 1839.) Dr. Hoble 
Wimberly Jones was a physician and a patriot. In the discharge of his 
professional duties he was attentive and skilful. Dr. W. C. Daniell, of 
Savannah, was a physician and author of note. His best known work is 
entitled, “ Observations on the Autumnal Fevers of Savannah.” In 1826 
he advocated the use of capsicum internally and externally in yellow 
fever, (b. January, 1792 : d, Dec. 28, 1868.) Dr. Richard Banks, of 
Savannah, and a native of Georgia, was a physician and surgeon of 
ability, and filled the chair of Surgery in the Savannah Medical College, 
(d. May, 1856, aged 62.) Dr. R, D. Arnold, of Savannah, a native of 
Georgia, was an accomplished physician and writer. He was one of the 
original members of the American Medical Association, and its Vice 
President in 1852. He was for many years Professor in the Savannah 
Medical College. He wrote and published papers of decided merit in the 
Transactions of the American Medical Association, and in the Medical 
Journals, (d. July 10, 1876, set. 68.) Dr. W. R. Waring was for many 
years a leading physician of Savannah, and Professor in the Medical 
College. Dr. George M. Hewton was a physician and successful teacher 
of Anatomy at Augusta. He left a fortune of about $200,000, to found 
an orphan asylum, (b. Jan, 30, 1810; d. Jan. 6, 1859.) In addition 
to the foregoing, I will name Drs. Tomlinson Fort, of Milledgeville, 
Thomas H. Hamilton, of Rome, G. B. Gorman, Charles W. West, Joseph 
FI. Eve, of Augusta, Dr. Wildman, of Savannah, and Dr. Curtis B. Hot- 
ingham. 
Illinois.I—Dr. Daniel Brainard, a native of Hew York, was a physician 
and surgeon of distinction. He settled in Chicago as early as 1835, and 
soon acquired a leading professional business, especially in Surgery. He 
was one of the founders of the Rush Medical College, and long one of its 
same time 1537 physicians. It has one good seaport, but no large cities. It has three 
medical colleges, distributed, one each, at Atlanta, Augusta, and Savannah ; a State 
Medical Association was formed in 1849, and a State Board of Health has been organized 
and publishes reports. Institutions for the care of the insane and other unfortunates have 
been established. 
The following medical journals have been published in Georgia: Atlanta Medical and 
Surgical Journal, 185$; Georgia Medical Companion, 1871; Georgia Medical and Surgical 
Encyclopaedia, 1860 ; Oglethorpe Medical and Surgical Journal, 1861; Savannah Journal 
of Medicine, 1858; Southern Medical and Surgical Journal, 1837. 
1 the French had trading posts in Illinois as early as 1700, The earliest permanent 
settlement, however, was by the French about 1763. In 1783 this State formed a part of 
the “Northwestern Territory.” In 1800 it was a part of the territory under the name of 
Indiana. Illinois was admitted as an independent State in the Union in 1818. Her popu- 
lation in 1870 was 2,539,891, with about one in five of her people living in cities and towns 
of over five thousand inhabitants. She then had 4861 physicians. Population and wealth 
are rapidly accumulating in this State. Three medical colleges are now giving instruction. 
A State Medical Society was organized in 1851, and publishes a volume of Transactions 
annually. Institutions for the care of unfortunates have been established, sufficient for the 
wants of the people. 
The following medical journals have been published in Illinois: American Journal of 
Materia Medica, 1860; Chicago Journal of Nervous and Mental Diseases, 1874; Chicago 
Medical Examiner, I860; Chicago Medical Journal, 1858; Chicago Times, 1869; Illinois 
and Indiana Medical and Surgical Journal, 1846; Illinois Medical and Surgical Journal, 
1844; Lens, 1872 ; Northwestern Medical and Surgical Journal, 1849; Pharmacist, 1868- 
Tripod, 1871. ’ ADDRESS OK MEDICAL BIOGRAPHY. 
105 
professors. He contributed articles of value to the Medical Journals, 
and to the Illinois State Medical Society’s Transactions, (b. 1812; d. Oct. 
10,1866.) Dr. Wm. B. Herrick, a native of Maine, was one of the early 
physicians of Chicago. He served as a surgeon in the Mexican war, 
and was a physician of extensive experience and skill. He filled the 
chair of Anatomy in Rush Medical College with ability for twenty 
years, (d. Dec. 81, 1865.) Dr. Henry Wing settled in practice in Col- 
linsville. He was a physician of education, and a scientist of extensive 
acquirements. He was one of the founders of the Chicago Medical 
College, and for years, held in it a professorship. His notes on the Botany 
of the Rocky Mountains form a part of Prof. Powell’s Geological Report 
of that region, (b. 1822; d. Feb. 18, 1871.) Dr. Elijah D. Harmon, a 
native of Vermont, was one of the earliest physicians to settle in Chicago. 
He was physician to the Military Post of Fort Dearborn in 1832. He 
was a good physician and surgeon, and for his day, and the demands 
made upon his skill, was an efficient and successful practitioner, (b. 
Aug. 20, 1782 ;d. July 3, 1869.) Dr. J. V. Z. Blaney, a native of Dela- 
ware, was an educated and successful physician. He was one of the 
founders of the Rush Medical College, and the originator and publisher, 
in 1844, of the “ Illinois Medical and Surgical Journal.” (b. 1820 ; d. 
Hec. 11, 1874.) Dr. Rudolphus Rouse, a surgeon of the war of 1812, 
settled in practice in Peoria. He deserved, and soon attained, the first 
wink among physicians in that part of the State, (b. July 20, 1793; d. 
April 30,1873.) The following physicians are also deserving of mention : 
Hrs. Samuel Thompson, George W. Richards, Nicholas Hard, Harrison 
Hoble, Stephen W. Noble, Levi T. Hewins, Josiah Goodhue, Alexander 
Walcott. 
Indiana.I—Dr. John Thomas Plummer, a native of Maryland, was a 
learned physician and excellent practitioner. He enjoyed in Indianapolis 
a°d its vicinity, a high reputation for skill and devotion to professional 
duty. In the natural sciences he was quite proficient, and was an excellent 
philologist; he assisted Noah Webster in collecting and defining the mean- 
lng of Western words for his unabridged Dictionary, (d. April 10, 1865, 
aged 58.) Dr. Isaac Casselberry, a native of Indiana, and long a leading 
physician in Evansville, added to skill in his profession a love of study, 
and good business habits. He was a successful promoter of medical or- 
ganizations, and in every new enterprise worked with great intelligence 
and success. He was a member of the Board of Health, and a trustee of 
the Evansville Medical College, also President of the State Medical So- 
fletV (b. Nov. 26,1821; d. July 9,1873.) Dr. Charles Parry, of Indian- 
apolis, was especiallj7 careful in diagnosis, and was a superior surgeon. 
m possessed the ability to make original observations, and was a writer 
G force. Prof. Geo. B. Wood quotes from a paper of his on pernicious 
ever. (d. August, 1861.) Dr. Asahel Clapp, a native of Massachusetts, 
piactised with great success in New Albany, where he settled in 1817, 
iidiana, was admitted to the Union in 1816. 'there were in it a few French settlements 
early as about 1700. Immigration from the old States commenced about 1802. The 
I Pu.at}on T 1870 was 1,680,637. It has no very large cities, about one in eight of its 
tiri|)Vl•m! k'1 v*ngin cities and towns of over five thousand inhabitants. It had at the same 
ann A10 physicians. It has a State Medical Society, formed in 1849, which publishes 
stitn'r a vo*ume °i Transactions, and has three medical colleges giving instruction. In- 
i’] 10l?.s efficient for the care of unfortunates have been established. 
obowing medical journals have been published in Indiana: Indiana Journal of 
1854 ’ Indiana Journal of Medicine and Surgery, 1855 ; Indiana Medical Journal, 
i nchana Scalpel, 1860; Western Retrospect of Medicine and Surgery, 1872. 106 
TONER, 
and was for forty years actively engaged in the duties of his profession. 
He was a good botanist, and made a report to the American Medical 
Association on the medicinal plants of the United States. He was fond 
of the study of the natural sciences, and collected a large cabinet of spe- 
cimens which he presented to Yale College. Dr. John L. Richmond, a 
native of Massachusetts, although a well-read and intelligent physician, 
won his reputation by a single operation. He performed the Caesarean 
section on the 23d of April, 1827, in a log cabin in the country, with no 
assistance except that rendered by the husband of the patient, and two 
women. The operation was successful, saving the mother’s life. The 
child died. (b. April 5, 1785 ; d. Oct. 12, 1855.) Dr. John S. Dobbs, a 
native of Pennsylvania, was a successful physician and teacher of medi- 
cine in Indianapolis. Pie was for some years Professor of Surgery in the 
Indiana Central Medical College. In his will he left means for the 
establishment of a public Dispensary. He was President of the State 
Medical Society in 1868, (b. Dec. 28, 1809 ; d. 1870.) In addition to 
the above list, I will name Drs. T. Fry, E. Demming, Y. Kersey, and J. 
W. Moody. 
lowa.I—Dr. David L. McGugin, a native of Pennsylvania, served as 
a surgeon in the Mexican war, and was for years the leading physician 
of Keokuk. He filled a chair in the University of lowa at the time of 
his death. The State Medical Society in 1851 elected him President. 
As a practitioner he had no superior in the State, (b. 1807; d. June 23, 
1865.) Dr. George Reeder, a native of Maryland, and a graduate of 
William and Mary College, Va., was a successful practitioner of medicine 
at Muscatine. He was one of the founders of the State Medical Society, 
and its President in 1854. The following also deserve mention; Drs. 
Ezra T. Fountain and G. W. Richards. 
Kentucky.2—Dr. Benjamin W. Dudley, a native of Virginia, was 
an eminent surgeon and teacher at Lexington, After graduating, he 
spent four years' in Europe perfecting himself in his professional studies. 
In 1817 he was elected Professor of Anatomy and Surgery in Transyl- 
1 lowa was admitted into the Union in 1846. It was a part of the Louisiana purchase 
of 1803. Us earliest settlements were by the French. In 1870 it had a population of 
1,194,320, with about one in ten of the population living in cities and towns of over five 
thousand inhabitants. It had at that time 1865 physicians. It has a rich and productive 
soil, and is rapidly increasing in wealth and population. Two medical colleges are giving 
instruction. A State Medical Society was founded in 1850, and publishes an annual volume 
of Transactions. Institutions sufficient for the care of the insane and other unfortunates 
have been established. 
The following medical journal has been published in lowa : lowa Medical Journal, 1855. 
2 Kentucky was admitted to the Union in 1792. The first account we have of this region 
was by Dr. Thomas Walker, of Virginia, who visited it in 1745, and again in 1750. Dr. 
John Connolly had made location of a tract of land at the falls of the Ohio as early as 1770. 
The earliest emigrations to Kentucky were under Daniel Boone, who made a settlement 
at Harrodsburgh in 1774. The soil is very rich and productive; wealth and population 
are rapidly flowing in. The population in 1870 was 1,321,011, with about one in seven of 
her people living in cities and towns of over five thousand inhabitants. She had then 2414 
physicians. Four medical colleges are now giving instruction in the State, and a State 
Medical Society, formed in 1851, publishes Transactions annually. Institutions for the care 
of unfortunates, demanded by enlightened humanity, have been established. 
The following medical journals have been published : American Medical News, 1876 ; 
American Medical Weekly, 1874; American Practitioner, 1869; Kentucky Medical Re- 
corder, 1853; Louisville Journal of Medicine and Surgery, 1838; Louisville Medical Jour- 
nal, 1860; Louisville Medical Gazette, 1859 ; Louisville Review, 1856; Richmond and 
Louisville Medical Journal, 1868; Transylvania Medical Journal, 1849; Transylvania 
Journal of Medicine and Science, 1828; Western Journal of Medicine and Surgery, 1840 
Western Lancet, 1842; Western and Southern Medical Recorder, 1841. ADDRESS ON MEDICAL BIOGRAPHY. 
107 
vania University. Through life he devoted himself strictly to the duties 
of his profession. He remained connected with Transylvania Univemi y 
till 1850, when he retired from practice, and lived in quiet on Ins harm. 
He was a bold surgeon and successful operator. He performed lithotomy 
225 times, and did not lose a patient until after he had operated more than 
100 times. He had a genius for originating new operations and devices. 
He contributed many articles of great value to medical journals, duetty 
on surgery, but wrote no large work. (b. 1/85 ; d. Jan. 20, 18/0.) Hr. 
Charles W. Short, of Lexington, was a learned botanist, and an accom- 
plished ph vsician and teacher. He held the chair of Botany and Materia 
Medica in the Transylvania University. He published but little. His 
best known writings are his contributions to the Flora of Kentucky, in. 
Ephraim McDowell, a native of Virginia, originated the surgical opera- 
tion of ovariotomy, which at first was severely condemned but which is 
fully justified by the success attending the proceeding, (b. November li, 
1771 •' d. July 25 1830.) Dr. Henry Miller, a native of Kentuckywas an 
obstetrician, writer, and teacher of ability. In 1835 he was appointed to 
the chair of Obstetrics in the Medical Institute at Louisville. He was 
the first physician in the West to use the speculum, and to practise local 
applications in diseases of the uterus. He was in many respects one ot 
the most original and skilful physicians that Kentucky has produced, 
(b. Nov. 1 1800; d. Feb. 8, 1874.) Dr. Samuel Brown, a native ot Vir- 
ginia, introduced vaccination in Lexington, as early as 1802. He was a 
man of decided ability, but exhibited a restless disposition removing to 
Hew Orleans, then to Natchez, Miss., then to Huntsville, Ala and 
finally returning to Lexington. He held the chair of Theory and F rac- 
Lce in Transylvania University. He was very entertaining as a lecturer. 
Contributions from his pen were published by the American Philosophica 
Society, and in the New York Medical Repository and other medical 
journals. As early as 1820 he suggested the formation ot an American 
■Medical Association, (b. Jan. 80, 1769; d. July 12, 183 .) _ 
Dr. James Bush, of Lexington, filled with ability the chair °f Sur ery 
m Transylvania University from 1839 to the time of his death, (b. 1808, 
J. Feb. 9, 1875.) Dr. Wra. H. Richardson was a physician ot high cul- 
ture, and Professor of Obstetrics in the Transylvania University, tie 
was a man of superior education and address, and enjoyed a large prac- 
tice. Dr. Joshua Barker Flint, a native of Massachusetts practised tor 
s°me years in Boston, but removed to Louisville, where he held the cnaii 
°f Surgery in the Louisville Medical College from 1837 to ’ an ’ 
Horn this time to his death, the same chair in the Kentucky bchooi ot 
Medicine. In 1868 he published a work on Practice. He was the List 
surgeon in Kentucky who administered ether to produce insensibility 
lor surgical operations, which he did in 1847. Dr, Charles ac we A|as 
an eminent physician, author, and teacher. As early as 18 l J ie n e 
the chair of Natural History in the University of Pennsylvania. In 
IMS he was elected to the chair of Theory and Practice in the Tran- 
sylvania University, which he held till 1837. He was a ready and volu- 
minous writer. {b. May 14,1772; d. July 9,1853.) Dr. John Esten Cooke 
Was a physician, author, and teacher of ability, and practised with suc- 
cess in the Shenandoah Valley of Virginia, and assisted in establishing 
the Winchester school, before removing to Kentucky. In 1827 he was 
elected to the chair of Theory and Practice in the Transylvania Uni- 
versity. In connection with Prof. Short he founded the following } eai 
‘ Ihe Transylvania Journal of Medicine.” In 1828 he published a woik 108 
TONER, 
entitled “ Pathology and Therapeutics.” Dr. Lewis Rogers fairly won 
his high reputation by his intelligence and devotion to professional 
duties. From 1849 he filled a chair in the University of Louisville. 
He was President of the State Medical Society in 1873, and gave in his 
opening address an admirable history of medicine in Kentucky, (b. Oct. 
12, 1812; d. June 17, 1875.) Hr, J. H. Jackson, of Danville, was, for his 
age, one of the most accomplished physicians and surgeons of Kentucky. 
He originated the movement for the erection of a monument to Ephraim 
McDowell. He performed with success many capital operations, includ- 
ing ovariotomy and tracheotomy, (b. Dec. 12,1834; d. Feb. 8,1874.) 
Beside the physicians named, I will mention Drs. Joseph Buchanan, 
Daniel L. Metcalf, Ethelbert L. Dudley, Robert Breckenridge, W. A. 
McDowell, James Fishback, Elisha 'Warfield, T. L. McLary, Walter 
Brashiers, Charles McCreary, and Frederick Ridgley. 
Louisiana.I—Dr. Rouanet w7as a native of France, but in 1844 settled 
in Hew Orleans, where he soon acquired a leading position in the profes- 
sion. He won high encomiums for his studies of the diseases of the heart 
in Paris, and contributed a number of papers to the French Academy on 
the physiological and pathological sounds of the heart. In Hew Orleans 
he gave office instruction to medical men and advanced students, but 
was not a teacher in any medical college. His practice for years was 
large and responsible, and he was recognized by the profession every- 
where as a leading authority on diseases of the heart, (d. 1865.) Dr. 
Warren Stone, a native of Vermont, settled in Hew Orleans in 1832, and 
rapidly acquired business and professional reputation. In 1836 he was 
chosen to lecture on Anatomy in the University of Louisiana, and in 1837 
was elected Professor of Anatomy and Surgery, continuing to hold this 
chair until he resigned in 1872. Throughout the South he was without 
a rival as a surgeon. In 1870 he was Vice-President of the American 
Medical Association, (b. 1808 ; d. Dec. 6,1872.) Dr. John Hoffman Har- 
rison, a native of Washington, D.C., was surgeon to Charity Hospital from 
1833 to 1836. He originated and edited the Hew Orleans Medical and 
Surgical Journal. He contributed a number of papers on yellow fever, 
and wrote a work on the Hervous System, (b. Aug. 30,1808 ; d. March 
19,1849.) Dr. Thomas Hunt, a native of South Carolina, settled in Hew 
Orleans in 1833. He was one of the founders of the Louisiana Medical 
College, was popular as a teacher, and a good writer. He was esteemed 
' Louisiana was admitted to the Union in 1812. Settlements were made at Biloxi as 
early as 1699, but the earliest successful settlement was at New Orleans in 1712. Louisiana 
was purchased by the United States from France in 1803. It included all the territory west 
of the Mississippi, east of Mexico, and south of the British possessions. In 1810 the 
United States Census gave a population of 76,576. The population in 1870 was 726,915, 
with about one-fourth of her people living in cities and towns of over five thousand 
inhabitants. There were at this time 936 physicians. The soil of the State is alluvial 
and exceedingly rich, but much of it is rendered unfit for cultivation by overflow, 
checking agricultural production and the increase of population. The situation of New 
Orleans, at the mouth of the largest river in the world, gives it great commercial impor- 
tance. A large and well-conducted hospital, known as “ Charity Hospital,” was rebuilt 
in 1815. Two medical colleges are now giving instruction. For many years a State 
Board of Health, having also cognizance of the health of the city of New Orleans, has 
existed, which reports to the Legislature and publishes a volume of Transactions annually. 
There is no State medical society, though medical organizations exist in the large cities. 
The following medical journals have been published : New Orleans Journal of Medicine, 
1868; New Orleans Medical Journal, 1844; New Orleans Medical News and Hospital 
Gazette, 1854; New Orleans Medical Record, 1866; New Orleans Medical and Surgical 
Journal, 1844; New Orleans Medical Times, 1861; New Orleans Monthly Medical Regis- 
ter, 1851; Union Medicale de la Louisiane, 1852. ADDRESS ON MEDICAL BIOGRAPHY. 
109 
specially successful in the treatment of yellow fever, (b. May 18, 1808 , 
d. March 20, 1867.) Dr. Edward Barton, a native of Virginia, practised 
with success in Hew Orleans. He filled the chair of Materia Medica and 
Therapeutics in the University of Louisiana from 1835 to 1840. Ilis 
writings on Meteorology, on Hygiene, and on Yellow lever, show much 
research and professional experience. In addition I will name Drs. John 
Leonard Riddell, the inventor of the binocular microscope, J. Jones, 
Win. M. Carpenter, Charles A. Luzenburg, and Frank Hawthorn. 
Maine.I—Dr. Stephen Cummings, of Portland, was a leading physi- 
cian in extensive practice as early as 1800, and continued actively en- 
gaged in his profession for over 50 years, (b. 1773 ; d. 1854.) Dr. James 
C. Bradbury, a native of Maine, settled in practice at Oldtown, and for 
35 years enjoyed the confidence of the community. Although not a sur- 
geon, he performed such operations as became necessary in his practice, 
and on Oct. 11, 1851, amputated at the hip-joint with success. This was 
the fourth operation of the kind in America, (b. 1806 pd. Oct. 3, I860.) 
Dr. Amos Hourse, a native of Hew Hampshire, a physician of Belfast, 
Maine, and a surgeon of ability, although advanced in years, served 
hi the late war as surgeon of the 20th Maine He had been 
honored by the Presidency of the State Medical Society. Dr. Job 
Holmes, a native of Maine, settled in Paris, where he enjoy ed a Luge 
practice. In a few vears he removed to Calais, where he passed the 
remainder of his life "in the active duties of his profession. _ Dr. Hosea 
Rich, a native of Massachusetts, was a practitioner of note in Langoi. 
His professional career began as early as 1805, and was continued till 
1865. During the war of "1812, he was the surgeon of the 4th Maine 
Regiment. I will also name Dr. James Parker, who was a physician of 
ability, and in active practice for over 50 years. He served two teims in 
Congress. . 
Maryland.2—Dr. John Beale Davidge was a fine classical scholai and 
an extensive reader of the early masters in medicine. As early as 1/98, 
he published an essay on autumnal and intermittent fevers. He was 
Conspicuous and influential in the founding of the Medical Department 
1 Maine was admitted into the Union in 1820. From its settlement, in 1607, it was a 
part of Massachusetts, and remained under her control till admitted as an independent 
State. The population in 1870 was 626,915, about one-third of the people living m 
cities and towns of over five thousand inhabitants. The number of physicians was 818. 
°ne medical college, a department of Bowdoin College, is giving instruction, there is a 
State Medical Society, formed in 1834, that publishes Transactions annually. Institutions 
Ci' the care of unfortunates have been founded, sufficient for the wants of the people. 
The following medical journals have been published in Maine ; Journal ot the Medical 
Society of Maine, 1834: Maine Medical and Surgical Reporter, 1858. . 
rr 2 Maryland is one of the thirteen original States. Its earliest settlement was in 1634. 
He population in 1870 was 780,892, one-third of her people living in cities and towns 
°t over five thousand inhabitants. The number of physicians was 1251. Ihe State has 
great advantages for ocean commerce, owing to its situation on the Chesapeake Bay. it 
Is rapidly increasing in wealth and population. There are three medical colleges giving 
instruction. Institutions for the relief of the insane and other unfortunates, have been 
established. There are also a State Medical Society, formed in liB9undei the name of 
the Medical and Ohirurgical Faculty of Maryland, and a State Board ot Health. 
Ihe following medical journals have been published in Maryland. Baltimore Journal 
of Medicine, 1861; Baltimore Medical Journal, 1870; Baltimore Medical and Philo- 
sophical Lyceum, 1811; Baltimore Medical and Physical Recorder, 1808 ; Baltimore 
Medical and Surgical Journal, 1833; Baltimore Monthly Journal of Medicine and Sur- 
-Bery, 1830; Baltimore Philosophical Journal and Review, 1823; Baltimore Physician 
ami Surgeon, 1872 ; Maryland Medical Recorder, 1829; Medical Bulletin, 1868; North 
American Archives of Medical and Surgical Science, 1834; Vaccine Inquirer, 1822. TONER, 
of the University of Maryland. In 1813, he published a new classifica- 
tion and nomenclature of diseases, in Latin. From 1814 to 1816, he 
published a work in parts, entitled “Physical Sketches,” and was a con- 
tributor to Medical Journals, (d. 1829, set. 60.) Dr. Horatio Jameson, 
of Baltimore, was a native of Maryland, and Professor of Surgery in 
the University of Maryland. In 1829 he started and edited with ability 
the Maryland Medical Recorder, which he continued until 1882. 
One of his best known works is on cholera. He published a pamphlet 
on the parts concerned in lithotomy. He was fond of the study oi the 
natural sciences, and was a good geologist. In 1880, he attended a meet- 
ing of naturalists and physicians, in Hamburg, Germany. Dr. Hathaniel 
Potter was one of the original founders of, and filled for over thirty 
years, with distinguished ability, a chair in, the University of Maryland. 
His writings show much erudition as well as original observation. In 
1805, he published a paper on the medical and deleterious properties of 
arsenic. The best known work from his pen is one on contagion and 
yellow fever, published in 1817. (b. 1770; d. July 2, 1843.) Dr. Iris- 
tram Thomas was a physician of large practice and great influence, on 
the Eastern Shore of Maryland. He was actively engaged in practice for 
over 50 years, and was an ardent lover of his profession, studious and 
observing, and an occasional contributor to the medical journals. _ His 
best known paper was one on Bilious and Remittent Fevers, which is 
referred to favorably in Eberle’s Practice, (b. Dec. 25, 1769 ; d. Aug. 5, 
1847.) 
Drs. John and Thomas H. Buckler, brothers, were men of fine intellect, 
and good practitioners. For many years, they held the very front rank 
as skilful and able physicians. Dr. Philip Thomas, a native of Maryland, 
practised in Frederick, from 1769 to 1815. He attended the second 
course of lectures delivered in Philadelphia, under Morgan and Shippen. 
He was a good scholar, a man of correct habits, and of large influence in 
the profession of the State, (b. June 11, 1747 ;d. April 25, 1815.) Dr. 
John Archer, a native of Maryland, was noted as having introduced the 
use of senega in croup, and enjoyed the distinction of having been the 
first personJhat received a diploma from an American Medical College, 
which he did in Philadelphia, in 1768. He served in the State Legisla- 
ture, and as a member of Congress, from 1801 to 1807. I will also men- 
tion Drs. Charles Frick, Samuel Baker, Frederick Dorsey, Ennals Martin, 
Miles Littlejohn, John Tyler, the two Murrays, of Annapolis, Samuel 
K. Jennings, John Baltzell, Gustavus Brown, Elisha Butts, and R. S. 
Stewart. 
Massachusetts.I—Dr.1—Dr. Edward Augustus Holyoke, a native of Massa- 
1 Massachusetts was one of the thirteen original States, and the first to raise troops and 
to inaugurate the measures that led to armed resistance to the claims of Great Britain, 
and to American Independence. Settlements were made in her territory as early as 1620. 
She soon after began a system of public education, which has been developed and adopted 
in all the States. Her population in 1870 was 1,457,351, nearly one-half of her people living 
in cities of over five thousand inhabitants. She had 2047 physicians. One medical col- 
lege, a department of Harvard University, has existed since 1782. Institutions on the 
most approved plans, for the care of unfortunates of all classes, have been established on a 
liberal scale. A State Medical Society, formed in 1781, publishes Transactions, and a sys- 
tematic registration of vital statistics has been in successful operation for many years. 
The following- medical journals have been published in Massachusetts: Berkshire 
Medical Journal, 1861; Boston Journal of Chemistry, 1866 ; Boston Medical Intelligencer, 
1823 ; Boston Medical and Surgical Journal, 1828 ; Journal of the Gynaecological Society, 
1869; Medical and Agricultural Register, 1806; Medical Magazine, 1832; Monthly 
Journal of Medical Literature, 1832 ; New England Journal of Medicine and Surgery and 
Collateral Sciences, 1812; Worcester Journal of Medicine, 1845. ADDRESS ON MEDICAL BIOGRAPHY. 
chusetts, was a man of learning and accurate observation, and an indus- 
trious and skilful practitioner. He died at the age ot 100 years and b 
months. He was one of the principal founders of the Massachusetts 
Medical Society, and its first President. He published Astronomical 
observations, and articles in the Transactions of the Massachusetts 
Medical Society, and in the Hew York Medical Repository, (b. Aug. ; , 
1728 (0. S.); d. 1829.) Dr. James Lloyd was the first surgeon in 
America to use ligatures, instead of searing wounds with the actual 
cautery, and to use the double flap in amputation. PR also peitoimed 
lithotomy. For nearly 60 years, he was the great physician and surgeon 
of Hew Enoland. He was a warm advocate of inoculation for the small- 
pox. (b. April, 1728; d. March, 1810.) Dr. John Warren acquired much 
reputation as a hospital surgeon in the Revolutionary army. He was the 
head of a family of eminent physicians and surgeons of Massachusetts, 
and the brother of the patriot, Dr. and Gen. Joseph Warren. Dr. War- 
ren was the earliest systematic teacher of Anatomy in Massachusetts, 
and the founder of the Medical Department of Harvard University, in 
which he held a chair up to the time of his death. He was President ot 
the Massachusetts Medical Society, and a member of nearly all the learned 
societies of his time. He published observations on the Meicunal 
practice,” and contributed articles to the Transactions of the Massachu- 
setts Medical Society, and of the American Academy of Arts and Sciences, 
(b. July 27,1758; d. April 4, 1815.) Dr. J. Collins Warren, his son, 
was not inferior to his father. He was the first surgeon to use ether as 
an anaesthetic in surgical operations, and aided much to promote its use. 
He was also an author and teacher ot great ability, (b. Aug. 1,1778 , c. 
May 4,1815.) Dr. Benjamin Waterhouse, a native of Rhode Island, was, 
in 1799, the introducer of vaccination in America. He was a zealous 
and able defender of the practice of vaccination, and published two works 
upon the subject. He held the chair of Theory and Practice ot Medicine, 
in Harvard College, from 1783 to 1812. Pie was a man ot very active 
intellect and varied information, fond of study, and a voluminous writer. 
(b. March 4,1754; d. Oct. 2, 1846.) . 
Dr. James Jackson, a native of Massachusetts, commenced practice in 
the year 1800. In 1810, with Warren and others, he initiated measuies 
which led to the establishment of the McLean Asylum for the Insane, 
and also for the founding of the Massachusetts General Hospital, lie 
was physician to the latter institution until 1835. In 1810, he was ap- 
pointed clinical lecturer to Harvard College, and in 1812, to the chair ot 
Theory and Practice. His contributions to the literature ot medicine 
were numerous and valuable, (b. Oct. 3, 1777 ;d. Aug. 26, 1867.) i. 
John Ware, a native of Massachusetts, was from 1832 to 1858 1 rotessor 
of Theory and Practice in Harvard College. He was a most admirable 
teacher, a close reasouer and original observer, and a beautiful and cor- 
rect writer, (b. Aug. 1, 1778 ; d. May 4, 1854.) Dr. James lhacher, a 
native of Massachusetts, settled in practice in Plymouth, after having 
served as a surgeon in the Revolutionary army. During his military 
bfe, he kept a journal, which he subsequently published, and which has 
become a most valuable contribution to the history ot the times. He 
was the author of the work entitled u The Hew Dispensatory, and of a 
number of other publications. Plis best known work is entitled “Ame- 
rican Medical Biography,” and is a great storehouse tor intorrnation per- 
taining to the early profession in America, (b. 1754 ; d. May 24,1844.) 
Ph'. Elisha Bartlett, a native of Rhode Island, was a leading physician, 112 
TONEE, 
and the first Mayor of the city of Lowell. He was a close student and 
fine classical scholar. He was a sufferer from lead poisoning, but held 
professorships in quite a number of colleges. Although he wrote numer- 
ous works, his most popular one is on the fevers of the United States, pub- 
lished in 1842. (b. 1805 ;d. 1855.) Hr. Luther Y. Bell, a native of Hew 
Hampshire, gained the Boylston Prize when about 30 years of age. By 
his ability in the treatment of the insane, he attracted the special atten- 
tion of his contemporaries, and was placed in charge of the McLean Asy- 
lum, which continued under his control from 1837 to 1856. In 1857, he 
was President of the Massachusetts Medical Society. He wrote on many 
subjects of interest to the medical profession. During the late war, he 
went out as a surgeon and lost his life in the service of his country, (b. 
Dec. 1806 ; d. 1862.) 
The following also deserve mention; Drs. John Brooks, Jeffries Wyman, 
H. H. Childs, A. A. Gould, George Hayward, Oliver Prescott, Lemuel 
Danforth, S. G. Howe, G. Darby, A. L. Peirson, C. T. Jackson, T. W. 
Harris, Enoch Hale, Winslow Lewis, and AY. T. G. Morton, dentist and 
discoverer of the use of ether as an anaesthetic. 
Michigan.l—Dr. Zina Pitcher, a native of Hew York, entered the 
army in 1822 as an assistant surgeon ; was promoted to be full surgeon in 
1832, and resigned in 1886, when he settled in Detroit. He was not only 
a good physician and surgeon, but an energetic and successful business 
man. He was mayor of the city, a faithful and intelligent manager of 
the school fund, and one of the founders of the State Insane Asylum. 
In 1856 he was honored with the presidency of the American Medical 
Association, (b. April 12, 1797; d. April 5, 1872.) Dr. Richard Inglis 
was a good classical scholar, full of information and energy, cheerful in the 
sick-room, and an agreeable companion in society. With the profession 
of the State he was exceedingly popular, and in 1869 was elected Presi- 
dent of the State Medical Society. Mention should also be made of Drs. 
E. M. Clark and Porter, of Detroit; Robinson, of Palmyra; Robert 
Clark, of Monroe; Isaac C. Paddock, of Pontiac, and Denton and Brig- 
ham, of Ann Arbor. 
Minnesota.2—Dr. Samuel Willey, a native of Massachusetts, after 
1 Michigan was admitted as a State in the Union in 1837. The earliest settlements 
within her territory were by the French, in the vicinity of Detroit, in the latter part of the 
seventeenth century. The lands are generally good and heavily timbered. The population 
as given by the census in 1870 was 1,187,234, about one-sixth of the people residing in 
towns and cities of over five thousand inhabitants. The same authority gives the number 
of physicians as 1034. Population and wealth have rapidly flowed into this State. From 
land grants by the United States a large educational fund has been established both for 
general education and colleges of a high grade. There are two medical colleges, a State 
Medical Society, formed in 1819, and publishing Transactions, and an efficient State Board 
of Health. 
The following medical journals have been published in Michigan : Detroit Review of 
Medicine and Pharmacy, 1866; Michigan University Medical Journal, 1870 ; Peninsular 
Independent Medical Journal, 1858; Peninsular Journal of Medicine, 1873; Peninsular 
Journal of Medicine and Collateral Sciences, 1858. 
2 Minnesota was a part of the Louisiana purchase. This region was visited as early as 
1650, the French having had posts in different parts along the Lakes. The United States 
government established, in 1819, a military post*at Fort Smelling. In 1845 settlements 
began to be made, and immigration set in actively, and in 1859 a territorial form of gov- 
ernment was organized. In 1853 Minnesota was admitted into the Union. The population 
as given by the United States Census of 1870 was 446,056, with about one-tenth living in 
towns of over five thousand inhabitants. There were then in the State 402 physicians. 
The population and wealth of Minnesota are steadily increasing. The State is fertile and 
well timbered, and is well situated as to commercial lines, by lakes, rivers, and railroads. A ADDRESS ON MEDICAL BIOGRAPHY. 
113 
graduating; was for two years assistant physician in the State [Lunatic 
Asylum, at Columhus, Ohio. In 1852 he settled in practice in St. Paul, 
and soon acquired a full business. In the tall of 1862 he was appointed 
pension surgeon and medical reteree for the State. Ihe organization of 
the State Medical Society was largely due to his efforts, as was that of 
the State Board of Health. He was twice elected president of the State 
Society, and in 1870 was one of the Vice-Presidents of the American 
Medical Association, (b, 1828; d. Nov. 21, 1872.) Hr. E. Herman 
Smith, a native of Connecticut, after serving a year as surgeon on the 
French steamer u Arugo,” settled at St. Paul, and soon acquiied a tail 
business. He was accurate in diagnosis, and an expert in the use of 
the microscope. Hr. H. C. Hand, a native of New Jersey, settled in 
St. Paul in 1871, and formed a business relation with his brother, Hr. H. 
W. Hand, then in practice in that place. In 1872 he became editor and 
publisher of the Northwestern Medical and Surgical Journal, which he 
conducted with ability. He was one of the physicians to the St. Paul’s 
City Hospital, (b. March 17, 1849; d. March 2, 1876.) Hr. Josiah S. 
Weiser, a native of Pennsylvania, located in 1855 at Shakopee, a settle- 
inent chiefly made up of Germans. He was induced to join Gen. Sib- 
ley’s military expedition, as surgeon, in June, 1868, and was murdered 
by the Indians while holding a parley with them. The following de- 
serve mention: Hrs. N. B. Hill, A. E. Ames, J. K. Reiuei, J. C. Jones, 
J. H. Ford, L. B. Smith, and G. T. Turner. 
Mississippi.l—Hr. Samuel A. Cartwright, a native of Virginia, settled 
at Natchez, Miss.,and was particularly successful in the treatment of fever 
and of cholera, during the epidemic of 1832. He wrote a number ot 
valuable papers, (b. Nov. 30, 1793; d. May 3,1863.) Hr. Erasmus H. 
Fenner, a native of North Carolina, settled in 1832 at Clinton, where 
his ability obtained for him a good practice. In 1840 he removed to 
New Orleans, and in 1844, in connection with Hr. A. Heister, estab- 
lished the New Orleans Medical Journal. He was one ot the original 
members of the American Medical Association, and a Professor in the 
New Orleans School of Medicine. In 1849 he commenced the publi- 
cation of the Southern Medical Reports, which extended to two 
volumes. He also edited the New Orleans Medical News and Hos- 
pital Gazette, (b. 1807; d. May 4, 1866.) Hr. Allen Gillespie, a 
native of Tennessee, after graduating in medicine, served as an as- 
sistant surgeon in the army of the Southwest. In 1824 he removed to 
Mississippi and in 1834 settled at Granada, where he spent his hte in 
the active duties of his profession. He possessed in a high degree the 
qualities that go to make the successful physician. It is claimed that to 
him is due the credit of introducing the practice of giving large doses of 
quinia as an anti-pyretic in miasmatic fevers. Alter treating fevers in 
State Medical Society, organized in 1855, publishes Transactions, and a State Board of 
Health is also in successful operation. , ~ ... , 
the following medical journal has been published in Minnesota: Northwestern Medical 
and Surgical Journal, 1870. , . 
1 Mississippi was admitted into the Union in 1817, having been erected into a territory 
with Alabama in 1798. It had been visited by De Soto in 1540, and by La Salle in 1682, 
but the first successful settlement by Europeans was at Natchez, in ld6, under Bienville. 
According to the United States Census in 1870 the population was 82 <,922, about one-tenth 
of the people living in cities of over five thousand inhabitants. There were at the same 
Bme 1511 physicians. The lands are generally low, alluvial, and subject along the water- 
courses to overflow. A State Medical Association, organized in 1856, publishes Transac- 
tions annually, and institutions for the care of unfortunates have been established. 
8 114 
TONEE, 
this way for years, he made his views public in 1835. The use of quinia 
in large doses has been recommended by others, but only during the 
remission, (b. Aug. 18, 1801; d. 1869.) In addition to the above- 
named, I will mention Drs. Samuel B. Malone and Elvis McCrory. 
Missouri.I—Dr. Win. Beaumont, a native of Connecticut, entered the 
army as assistant surgeon in July, 1812, and resigned in 1839, and settled 
in the city of St. Louis. In 1825, while stationed at the military post 
Michilimackinac, he met the Canadian, St. Martin, who had received a 
wound which left an opening into the stomach, exposing in a measure 
the operation of that organ. The Doctor made a series of experiments 
upon the process of digestion, which he published in 1838. This is one 
of the most complete series of observations ever made on the living 
stomach, (b. 1785; d. April 25,1853.) Dr. Charles A. Pope, a native of 
Alabama, settled in St. Louis in 1841. He was studious, energetic, and 
ambitious in his profession, and soon acquired a leading practice. lie 
was elected to the chair of Anatomy and then to that of Surgery in the 
St. Louis University. His preference in practice was for surgery, and in 
this he was very successful. He was a fluent lecturer, and familiar with 
the history of the various surgical operations and procedures. He was 
surgeon to the St. Louis City Hospital. He identified himself with all 
movements calculated to advance the medical profession, and was Presi- 
dent of the American Medical Association in 1854. (b. March 15, 
1818 ; d. July 6, 1872.) Dr. M. L. Linton, a native of Kentucky, set- 
tled in practice in St. Louis in f842. He was elected to the chair of 
Obstetrics in the St. Louis Medical College, and in 1844, was trans- 
ferred to the chair of Theory and Practice. In 1843 he founded and 
edited the St. Louis Medical and Surgical Journal, the first medical 
periodical published west of the Mississippi Kiver. He possessed high 
intellectual endowments and scientific culture, and wrote well, and on a 
great variety of subjects-—medical, literary, religious, and scientific. He 
was a member of the Academy of Sciences, and contributed many papers 
to it. He had an extensive practice, and was widely known in the 
Southwest, (b. 1808; cl. June 1,1872.) Dr. B. F. Shumard, a native 
of Pennsylvania, commenced to practise in Kentucky, but became con- 
nected with one of the U. S. Government Pacific R. R. surveys and 
explorations. His scientific acquirements led him to be much em- 
ployed in such pursuits. He removed to St. Louis in 1853. In 1860 
he was engaged in a geological survey of the State of Texas, which 
was interrupted by the war, when he returned to St. Louis, and re- 
sumed the duties of his profession. He was elected to the chair of 
Obstetrics in the University of Missouri. He was President of the 
Academy of Sciences at the time of his death, (b. Kov. 24, f820; 
1 Missouri, a part of the Louisiana purchase of 1803, was admitted as a State in the 
Union in 1821. Us earliest settlers were the French, who built a fort on the present site 
of the city of St. Louis as early as 1719. Another point of early settlement was at St. 
Genevieve. The population of Missouri in 1870 was 1,721,295, about one-fifth of the 
people living in towns and cities of over five thousand inhabitants. There were then in the 
State 3560 physicians. Missouri has a large school fund, and a successful system of free 
schools. There are four medical colleges. A State Medical Society, formed in 1850, 
publishes Transactions. Institutions for the care of unfortunates, sufficient for the wants 
of the people, have been established. 
The following medical journals have been published in Missouri; Humboldt Medical 
Archives, 1867; Kansas City Medical Journal, 1871 ; Kansas City Medical and Surgical 
Review, 1860; St. Joseph Journal of Medicine and Surgery, 1859; St. Louis Medical 
Reporter, 1866; St. Louis Medical, and Surgical Journal, 1845; St. Louis Probe, 1850. ADDRESS ON MEDICAL BIOGRAPHY. 
115 
d. April 14, 1868.) Dr. Lewis F. Linn, a native of Kentucky, settled in 
Genevieve in 1819. He served in the war of 1812, and after this took 
an active part in public affairs. He was a liuent and eloquent speaker. 
In 1827 he was elected to the Legislature, and in 1833 to the U. b. 
Senate, which office he held to the time of his death, (b. 1t95 ;d. 1843.) 
I will also mention Dr. John H. Watters, of St. Louis, who was one of 
the earliest to write upon the theory of the Correlation and Conserva- 
tion of Forces, Drs. J. H. McDowell, John A. Chambers, and John 
Edwards. 
Hew Hampshire.I—Dr. Nathan Smith, a native of Massachusetts, first 
practised in Cornish, Hew Hampshire. He suggested the establishment 
of a Medical Department in connection with Dartmouth College, and in 
1797 gave there a course of lectures. In 1798 he was appointed Professor 
in the Medical Department. He tauglE all the branches, and furnished 
all the apparatus needed in teaching until 1810, when he was joined by 
another professor. In a few years, by his genius and indomitable perse- 
verance, fair classes attended this institution. In 1813 he was invited to 
the chair of Surgery in Yale College, which he accepted. He continued, 
however, to lecture at Dartmouth, at the Vermont University, and at 
Bowdoin College. His reputation as a surgeon had by this time become 
national. The credit of having first pointed out that dislocations ot the 
hip and other joints should be reduced by manipulation, is due to Dr. 
Smith. In 1824 he published a particularly valuable essay on typhoid 
fever, in which he made a distinction between typhoid and malarial 
fevers, (b. 1762; d. 1829.) Dr. Amos Twitched, a native of Hew Hamp- 
shire, was a close observer, and an indefatigable student. It seems to be 
well authenticated that he was the first to place a ligature on the com- 
mon carotid artery, which he did six months before the occurrence of the 
case reported by Sir Astley Cooper. I can discover no publications of 
Dr. Twitched, but he was in the habit of taking part in the discussions 
of the Hew Hampshire Medical Society, (b. 1781; d. 1850.)_ Dr. Josiab 
Bartlett, a native of Massachusetts, commenced to practise in Kingston, 
H. H,, in 1750. His intelligence, high moral character, and ability, soon 
brought him a full share of professional business. From 1765 to the 
time of the Devolution he was annually chosen to the Legislature, and 
Was a Lieutenant-Colonel in the State militia. In 1775 he was elected to 
Congress, and in 1776 was the first on the roll call to vote for the Declara- 
tion of Independence. He served as a Justice ot the Supreme Court of 
the State, and was one of the originators and first President of the Hew 
Hampshire Medical Society, (b. 1729; d. 1795.) 
Dr. Ammi E. Cutter, a native of Maine, served as surgeon in the 
Revolutionary war, and part of the time was Physician General to the 
Middle Department of the array. After the war he settled at Ports- 
mouth, where he acquired a large practice, and was greatly esteemed 
throughout the State. For manv years he was president of the State 
Medical Society, (b. 1735; d. 1820.) Dr. Matthew Thornton was a 
mitive of Ireland, and settled at Londonderry. He was a surgeon in 
the expedition in 1745 against Louisburg. In 1775 he was president of 
1 New Hampshire was one of the thirteen original States; its first settlement having 
been near Portsmouth, in 1623. Its population in 1870 was 318.300, nearly one-fifth living 
Hi cities and towns of over five thousand inhabitants. The number of physicians was 565. 
1 hcre is a State Medical Society, formed in 1791, which publishes Transactions annually, 
<md one medical college. There are also institutions for the care of unfortunates, sufficient 
,or the wants of the people. 116 
TONER, 
the convention -which assumed the government of Hew Hampshire in 
the name of the people. lie was a delegate to Congress, and signed the 
Declaration of Independence, though not present to vote for it. (d. June 
24, 1803, aged 88.) Dr. Lyman Spalding, a native of Hew Hampshire, 
began practice at Portsmouth in 1799. He was a good anatomist and 
a learned physician. He published in 1799 a new nomenclature ot 
chemistry. In 1813 he removed to the city of Hew York. He con- 
ceived the idea of publishing a United States Pharmacopoeia, and for 
years advocated the project, and called the convention which formed it 
in 1820, being also one of the committee of publication, (b. June 5, 
1775 ; d. Oct. 31, 1821.) Dr. Dixi Crosby, a native of Hew Hampshire, 
commenced practice at Gilrnanton, where he acquired a large business, 
and established his reputation as a surgeon. _ In 1836 he removed the 
scapula, humerus, and two-thirds of the clavicle at one operation, the 
patient recovering. In 1838 he was elected to the chair of Surgery and 
Obstetrics, in Dartmouth College, which position he held till 1868, 
when he resigned the branch of Surgery in favor of his son, lecturing for 
two years longer on Obstetrics. He contributed a number of able arti- 
cles to the medical journals, and was President of the Hew Hampshire 
State Medical Society, and a member of the American Medical Associa- 
tion. (b. Feb. 9, 1800; d. Sept. 26, 1873.) I will also name Drs. Ma- 
thias Spaulding, Josiah Crosby, Charles P. Gage, W. Graves, Daniel 
Oliver, George B. Twitched, and A. Smalley. 
Hew Jersey.I—Dr. 'William Burnett, a native of Hew Jersey, settled 
in practice at Hewark, and, during the Devolution, took a conspicuous 
part in the events of the day. He"was a member of the “ Committee of 
Safety,” in 1776, and was one of the commissioners for issuing State bills 
of credit. He was physician of the hospitals, and Chief Surgeon of the 
State troops ; and was a member of Congress from 1780 to 1781. In the 
latter year he was again elected to Congress, but resigned, and was 
appointed Chief Physician and Surgeon in the Eastern Department, 
serving till the close of the war. After peace was established he returned 
to private practice, and engaged to some extent in agriculture. He was 
Judge of the Court of Common Pleas and President of the State Medical 
Society, and throughout a long life was greatly beloved and esteemed, 
(b. 1730; d. 1791.) Dr. Moses Scott was a native of Pennsylvania, and 
on the outbreak of the Revolutionary war, took part with the patriots. 
He had been in military service with Braddock’s expedition. In July, 
1776, he was appointed physician and surgeon of the State troops, and in 
1777, when Congress took entire control of the hospital department, was 
appointed Assistant Director General. He was present at all the battles 
tbuo-ht in Hew Jersey. After the war he was esteemed one of the most 
experienced and learned physicians in the State, (b. 1738; d. 1821.) 
Dr. Jonathan Elmer, a native of Hew Jersey, was a surgeon in the 
1 New Jersey is one of the thirteen original States. The Dutch made two settlements 
at Bergen between 1614 and 1624, and a Swedish colony settled near the Delaware River 
in 1627. Some of the most stirring events of the Revolutionary war took place within the 
territory of New Jersey. Her position between the two great cities of New York and 
Philadelphia gives her great commercial advantages. Her population, as given by the 
census of 1870, was 906,096, a little over one-third of her people living in cities of over five 
thousand inhabitants. She had at the same time 1208 physicians. She has a State Medi- 
cal Society, organized in 1766, which publishes 'transactions annually. She has also a 
number of institutions for the care of unfortunates. 
The following medical journal has been published in New Jersey : New Jersey Medical 
Reporter, 1847. ADDRESS ON MEDICAL BIOGRAPHY. 
117 
Revolutionary war, as was his brother Ebenezer. lie a man of 
extensive information, with great power ot detail, and executive ability. 
He was elected to Congress in 1776, serving till 1778 ; again in 1781, 
servino- till 1784; again in 1787, serving till 1788, and was United 
States°Senator from 1789 until 1791. He was a member of the Ameri- 
can Philosophical Society, and held many offices of trust in his native 
State, (b. 1745 ; d. 1817.) Hr. Nicholas Belleville, a native of France, 
settled in' Trenton in 1791. He had a very extensive practice, and was 
physician to Joseph Bonaparte, ex-King of Spain, while he resided in 
New Jersey. His office was the resort of many students who subse- 
quently rose to eminence in their profession. Hr. John N. Woodhull, 
a native of New Jersey, was a man of superior education. He settled 
at Princeton, and enjoyed the reputation through life of being a most 
skilful physician. He endowed a professorship in Princeton College. 
His whole life reflects honor upon himself, as a man, as well as upon 
the medical profession, (b. 1752; d, 1831.) Hr. L. A. Smith, a native 
of New Hampshire, was a physician of superior ability. He settled at 
Newark, and had the esteem of the profession, and was popular with 
the community. He was one of the early movers tor, and an able advo- 
cate of, the establishment of the New Jersey Lunatic Asylum. He was 
devoted to his profession, and was an earnest promoter of medical oigani- 
zations. He was President of the New Jersey State Medical Society, in 
1837, and throughout his life was an active worker for the advancement 
of medicine and the elevation of the profession, (b. Nov. 11, 1795; 
6- Hec. 15, 1865.) The following names are also deserving of mention: 
Hrs. John’Beatty, W. Johnson, Isaac Ogden, Samuel Hayes, J. Ward, 
Isaac P. Coleman, Silas Condit, Isaac Pierson, and J. Lilley. 
New York.I—Hr.1—Hr. Y.alentine Mott, a native of New York, and an 
1 New York is one of the thirteen original States. Its earliest known mention was in 
1609, from the visit of Henry Hudson, who gave his name to the Hudson River, inis is 
now the most populous and wealthy State in the Union. The population m 18(0 was 
4,387,464, nearly one-half living in cities of over five thousand inhabitants, the number 
physicians in the same year was 6810. New York has nine medical colleges, distributed 
as follows, viz.: Albanv, Brooklyn, Buffalo, and Syracuse, each one, and New York Gity 
five. A State Medical Society was organized in 1807. and has published transactions 
almost continuously since. Institutions for the care and treatment of uuioituna es rave 
been provided in different parts of the State, sufficient tor the wants of the people. 
'fhe following medical journals have been published in New York ; Albany Journal ot 
Neurology, 1843; American Chemist, 1870; American Journal of Indigenous Materia 
Medica and Repertory of Med. Science, 1860; American Journal of Insanity, 1844; 
American Journal of Medicine,,-1852 ; American Journal of Obstetrics and Diseases ot 
Women and Children, 1868; American Journal of Ophthalmology, 1862; American 
Journal of Syphilography and Dermatology, 1870; American Lancet, 1831; American 
Medical Monthly, 1854; American Medical and Philosophical Register, 1810; American 
Medical and Surgical Journal, 1851; American Medical Times. 1860; Annalist, 184. ; 
Archives of Ophthalmology and Otology, 1869; Archives of Scientific and Dractical 
Medicine, 1873; Buffalo Medical Journal, 1845; Buffalo Med. and Surgical Reporter, 
1861; Medical Gazette, 1867; Medical Record, 1866; Medical and Surgical Register, 
1818; Nelson’s American Lancet; New York Journal of Medicine, 1839; New York 
Journal of Medicine and Collateral Sciences, 1843; New York Journal of Pharmacy, 
1852; New York Lancet. 1842 ; New York Medical Gazette, 1841; New York Medical 
Gazette and Journal of Health, 1850; New York Medical Independent and Pharmaceu- 
tical Reporter, 1864 • New York Medical Inquirer and Domestic Magazine, 1830 ; New 
York Medical Journal 1831- New York Medical Journal, 1865; New York Medical 
Magazine, 1814: New York Medical and Pathological Journal, 1858; New York Medi- 
cal and Philosophical Journal and Review, 1809; New York Medical and Physical 
Journal, 1822; New York Medical Press, 1860; New York Medical Repository, 1797 ; 
New York Medical Review, 1873 ; New York Medical and Surgical Reporter, 1845 ; New 
York Medical Times. 1851; New York Medico-Chirurgical Bulletin, 1851; New York 118 
TONER, 
eminent surgeon and teacher, settled in New York City in 1809, and 
was appointed to the chair of Surgery in Columbia .College. He was 
elected to fill the same chair in Rutgers College, and also in the College 
of Physicians and Surgeons. In 1818 he passed a ligature around the 
brachio-cephalic artery, about two inches above the heart, for aneurism. 
He excised the entire clavicle, and was the first in America to ligate the 
iliac artery, and to remove the lower jaw. Sir Astley Cooper says of him, 
that lie performed more of the great operations than any other surgeon, 
living or dead. It would be impossible to enumerate here all his great 
achievements. In 1814, in connection with Dr. Onderdonk, he started 
and published the “ New York Medical Magazine,” which only extended 
to two parts. He translated Velpeau’s work on Surgery, and contributed 
articles to the medical journals, and to the Transactions of the New 
York Academy of Medicine, (b, Aug. 20, 1785 ; d. April 26, 1865.) Dr. 
Samuel Bard commenced practice in 1767 in the city of New York. He 
was one of the projectors of the first Medical College organized in New 
York, and held the chair of Theory and Practice. He acted as examining 
surgeon for the admission of surgeons to the Medical Department of the 
Army during the Revolutionary war. In 1774, he was influential in 
founding the New York Hospital, in which he gave a course of clinical 
lectures. In 1791, when the public hospital was opened, he was appointed 
one of the visiting physicians. In 1798, he had retired to his country 
seat, but on the outbreak of the yellow fever returned to the city, and 
resumed practice. He was finally taken down with the fever, but re- 
covered. He was General Washington’s physician, when in New York, 
after the war. He published a compendium of Midwifery, and con- 
tributed to the Philosophical Transactions and to medical journals, (b. 
April 1, 1742; d. May 24, 1821.) 
Dr. David Hosack, a native of New York, settled in practice in the 
city of New York in 1794. The following year he was appointed Pro- 
fessor of Botany in Columbia College, and shortly afterwards published 
a syllabus of the lectures. In 1796, he formed a partnership with Dr. 
Bard, which continued till 1800. In 1797 he was elected to the chair of 
Materia Medica, but in 1811, on the re-organization of the Faculty, was 
assigned to the chair of Theory and Practice, and afterwards held that 
of Obstetrics and Diseases of Women and Children, until 1826. He was 
visiting physician to the Almshouse and to the Insane Asylum. He 
wrote on fevers, and other medical topics, and was elected a member of 
the Royal Society of London, His paper on the causes of contagion was 
able, and received a wide appreciation. In 1810, with Dr. Francis, he 
started the American Medical and Philosophical Register, which was 
conducted with ability, (b. August 31, 1769; d. Dec. 22, 1835.) Dr. 
Theodoric Romeyn Beck, a native of New York, began practice in 
Albany in 1811. In 1813 he wrote a paper on the minerals of the United 
States. In 1815 he was appointed Lecturer on the Institutes of Medi- 
cine, and Professor of Medical Jurisprudence in the College of Physicians 
and Surgeons. He also held a professorship in the Fairfield Medical Col- 
lege from 1826 to 1836. In 1836 he was elected to the chair of Materia 
Monthly Chronicle of Med. and Snrg., 1824; New York Monthly Review of Med. Science 
and Buffalo Medical Journal; New York Register of Medicine and Pharmacy, 1850; 
North American Medical Reporter, 1858 ; Northern Lancet and Gazette of Legal Medicine, 
1850; Opal, 1851; Quarterly Journal of Psychological Medicine, 1867; Sanitarian, 
1873; Syracuse Medical and Surgical Journal. 1854; United States Medical and Surgical 
Journal, 1834. ADDRESS ON MEDICAL BIOGRAPHY. 
119 
Modica in the Albany Medical College. From 1840 to 1800 he was 
President of the Albany Academy, and was the originator ot the Albany 
Institute. He was President of the Hew York State Medical Society 
and was one of the managers of the State Lunatic Asylum, in 18_d 
he published the first edition of his great work on “ Medical Jurispru- 
dence.” He edited for some years the “ American Journal ot Insanity. 
(b. Aim. 11, 1791 ; d. Nov. 19, 1855.) Hr. J. W. Francis, a native of 
New York, commenced to practise in 1811, and formed a partnership with 
Hr. Hosack. They together published the American 1 hi.losophical 
Register. In 1813 he was lecturer in the Institute of Medicine, and 
Professor of Materia Medica in the College of Physicians and burgeons. 
About this time he visited Europe, and on his return was elected to the 
chair of Medical Jurisprudence, and in 1819 filled that of Obstetrics, in 
Puto-ers College. In 1822 he was one of the editors of the Flew York; 
Medical and Physical Journal. He was an accomplished writer, and 
took an active part in promoting the objects of the New York Academy 
of Medicine, the Historical Society, the WOman’s Hospital, etc. (b. JN ov. 
17, 1789; d. Feb. 8, 1861.) t , +. . ~ Q 
Hr. A. H. Stevens, a native of New York, commenced practice in the 
city of New York in 1812. In 1814, he was invited to the chair of 
Surgery in Queen’s, afterwards Rutgers College. He was one of the 
visiting surgeons to the New York Hospital. In 1817, he was assigned 
to a chair in the College of Physicians and Surgeons In 1848, he was 
President of the New York State Medical Society, and also President of 
the American Medical Association. His general as well as his surgical 
practice was very large. His contributions to the Utemture of medicme 
are found in Journals, Reports, and Addresses, (b. 1789 , d. Mai ch 30, 
1869.) Hr. Wright Post, a native of New York, commenced practice in 
1786. The chair of Surgery in Columbia College was tendered him in 
1792, but in 1793 he was transferred to the chair of Anatomy, which he 
continued to hold for twenty years. He was also a member of the 
Faculty of the College of Physicians and Surgeons, and its president 
from 1821 to 1826. He was for thirty years consulting physician of the 
New York Hospital. He was a bold, original, and successful operator. 
He tied the subclavian artery, and also the carotid, (b.leb. IJ, i/oo , 
d. June 14,1828.) Hr. John Torrey, a native of New York, although a 
learned physician, never acquired a large practice, and being giea 
interested in botany and the collateral sciences, his time became occupied 
by them. In 1817, he published a catalogue of plants growing within 
thirty miles of New York city, and in 1831 published the first volume 
of the Flora of North America. In 1824 he was appointed Professoi of 
Botany in the Military Academy at West Point, and from 18-7 to 18uU 
was Professor of Chemistry in the College of Physicians anc 
of New York. He was subsequently appointed director ot t e New 
York Assay Office. The Hoctor was one of the most accomplished 
botanists of our country, and did much to elevate the science by his fife 
and teachings, (b. 1798; d. March 10, 1873.) 
Hr. Samuel L. Mitchell, a native of New York, commenced practice 
in New York city, and, with Hr. E. Miller and Hr. E. H. Smith, started, 
in 1797, the “ New York Medical Repository.” He was connected with 
it as editor for sixteen years, and survived both of his associates. He was 
a member of the State Legislature, and for a number of years a member 
of Congress, and also U. S. Senator. He was a man of very extensive 
scientific acquirements, and of a remarkably retentive memory. He 120 
TONEE, 
wrote on a variety of topics, making substantial additions to scientific 
literature, (b. Aug. 20, 1764; d. Sept. 7, 1881.) Dr. Joseph M. Smith, 
a native of New York, commenced practice in 1811. He was one of the 
original members of the Medico-Philosophical Society, wdiich published 
its first volume in 1817. He was Professor of Theory and Practice in the 
College of Physicians and Surgeons for thirty years. His most noted 
work is perhaps his “ Elements of Etiology, and Philosophy of Epi- 
demics.” He was a frequent and valued contributor to medical serial 
literature, (b. March 14, 1789 ; d. April 22, 1866.) As of almost equal 
merit, I will name Drs. John Watson, J. Kearney Rodgers, J. Stearns, 
Joseph White, Richard Bayley, W. W. Reid, John A. Smith, Charles 
A. Lee, Alden March, John B. Beck, James Stuart, Elisha Smith, PL 
D. Bulkley, John A. Swett, Amasa Trowbridge, Amariah Brigham, 
George T. Elliot, James McNaughton, H. Green, J. H. Armsby, Alban 
Goldsmith, R. S. Kissam, and H. M. Onderdonk. 
North Carolina.I—Dr. Charles Harris, a native of North Carolina, 
served in the Revolutionary war before he had completed his medical 
education. He first practised with success at Salisbury, but removed 
to Eavonia, the name of his plantation in Cabaries County, where he 
remained actively engaged in practice to the close of his life. Ninety- 
three physicians studied with him, his reputation being such as to make 
him a desirable preceptor. Plis professional life extended over forty years, 
(b. 1763; d. Sept. 21, 1825.) Dr. James Norcom, a native of North 
Carolina, commenced practice at Edenton in 1799. He acquired a large 
but laborious business, often visiting patients at a distance of 100 miles, 
on horseback. His practice was chiefly that of a physician, although 
performing such surgical operations as usually fall to the lot of rural 
practitioners. His obstetrical practice was large. In 1812, he was com- 
missioned Assistant Surgeon in the IT. S. Array, but resigned in January, 
1813. Pie wrote a paper on the Winter Epidemic of 1816, and made a 
number of contributions to medical journals, (b, 1788 ; d. Nov. 9, 
1850.) Dr. James Dickson, a native of North Carolina, having prac- 
tised for a couple of years in South Washington, removed to Fayette- 
ville, where his practice became large. In 1835, he performed successfully 
the operation of transfusion of blood. In 1828, 1831, and 1833, he per- 
formed urethrotomy. In 1835, he divided the tendo Achillis, for the re- 
lief of club-foot. About this time he ligated the external iliac artery. 
He was everywhere recognized as a skilful and successful surgeon. Dr. 
Benjamin Robinson, a native of Vermont, commenced practice in his 
native place, but removed to North Carolina in 1804, and settled at Fay- 
etteville, where he spent the remainder of his life, laboriously engaged in 
1 North Carolina is one of the thirteen original States. Sir Walter Raleigh attempted 
to establish a colony in it in 1585, but failed. The earliest point successfully settled was 
on the Roanoke and Chowan Rivers, by emigrants from Virginia, in 1653. In 1693, North 
and South Carolina were separated. This State took an early and active part to secure 
American Independence. Ephraim Brevard, at a meeting of the citizens at Charlotte, on 
May 20, 1775, prepared what is known as the “ Mecklenburg Declaration of Independence.” 
This embodied many of the sentiments of the Declaration adopted more than a year later, 
at Philadelphia. The population of the State, as given by the census of 1870, was 1,071,362. 
There are no large cities or towns, and but about one in forty of the population live in 
towns of over five thousand inhabitants. There were, in 1870, 1143 physicians. A medical 
college has been projected, but is not yet organized. There is a State Medical Society, 
formed in 1850, which publishes Transactions. Institutions for the care of unfortunates, 
sufficient for the wants of the people, have been provided. 
The following medical journal has been published : Medical Journal of North Carolina, 
1858. ADDRESS ON MEDICAL BIOGRAPHY. 
121 
his profession. While a student of medicine, he performed an operation 
for the relief of strangulated hernia, with success. He was distinguished 
through life for his untiring assiduity and sound common sense. His 
memory is still cherished by the descendants ot the community in which 
he passed his useful life. (d. March 8, 1857, aged 82.) Dr Charles E. 
Johnson, a native of North Carolina, settled in practice at Menton, an 
thence removed to Raleigh in 1835. He was especially interested in net - 
vous diseases and physiological studies. He wrote a paper on the Medico- 
Regal Relations of Insanity, (b. March 15, 1812; d. April 1, 18 <6.) 11 • 
Arraand John He Rosset was a native of North Carolina, and a graduate 
of Princeton College. His immediate ancestors, father, grandfather, and 
great grandfather, were physicians. The duration of his practice ex- 
tended to 69 years. He was a good classical scholar, and a cultivator of 
the sciences, which he applied to the practical and every-day requiiements 
of his profession, (d. April 1, 1859, get. 92.) I will also mention Hrs. 
James J. Philips, of Edgecombe Co.; James Fergus Mcßee, of Wilming- 
ton; R. H. Shield, of Winton; Wm.H, McKee, ot Raleigh; Wm. Perry, 
of Franklin Co.; Elisha Battle, of Edgecombe Co.; Henry M. Shaw, of 
Karri tuck Co.; Joel B. Houston, of Columbia; Matthias E. Sayei, ot 
Edenton; Simon J. Baker, ot Raleigh; and Pinckney Caldwell.^ 
Ohio.I—Dr. Daniel Drake, a native ot New Jersey, but reared in Ken- 
tucky, began to practise in Cincinnati in 1804. He rapidly rose to be 
recognized as a leading physician, and as one of very extensive know- 
ledge and scientific attainments. In 1810 he published “ Notes con- 
cerning Cincinnati, and in 1815 a work entitled “ A Picture of Cincin- 
nati.” In 1817 he was elected a professor in the Transylvania Univer- 
sity, at Lexington, Ky. The following year he obtained a chattel and 
founded the Medical College of Ohio, at Cincinnati, and in 1819 he es- 
tablished the Commercial Hospital. From 1827 to 1839 he edited the 
u Western Journal of American Medical Sciences. Its publication was 
transferred to Louisville, Ky., and the name changed to “ Western Jour- 
nal of Medicine and Surgery.” He continued as one of the editors Dll 
1848. In 1882 he published an essay on Medical Education and Medical 
Men of the United States, and the same year a pamphlet on Cholera. 
His great work, which contained the observations of nearly halt a cen- 
tury) was published in 1850, entitled “ Diseases of the Interior Valley of 
r 1 No European settlement prior to the Revolution is known to have been made in Ohio, 
the first emigration to this State was in 1788, from New England to a point known as 
Marietta, on the Ohio River, it having been included in 1781 in the general territorial 
legislation pertaining to the territorynorthwest of that stream. The population in 1870, 
as given by the U. S. Census, was 2,605,2(!0, nearly one-tourth of the population living in 
towns of over five thousand inhabitants. There were at that time 4638 physicians. 1 opu- 
lation and wealth are still rapidly accumulating in this State. It has seven medical colleges, 
three at Cincinnati, two at Cleveland, and two at Columbus. A State Medical Society 
Was established in 1846. and publishes reports annually. Institutions for the care of 
unfortunates have been provided, sufficient for the wants of the people. _ 
the following medical journals have been published in Ohio ; Annals of Science, 1853 ; 
Cincinnati Journal of Health, 1844; Cincinnati Journal of Medicine, 1869; Cincinnati 
Lancet and Observer, 1858; Cincinnati Medical NewTs, 1858; Cincinnati Medical News, 
18j2; Cincinnati Medical Observer, 1856; Cincinnati Medical Repertory, 1868 ; Cincin- 
uati Medical and Surgical News, 1860; Cleveland Medical Gazette, 1859; Clinic. 1871; 
Oolumbus Review of Medicine and Surgery, 1860; Critic, 1853; Northern Ohio Medical 
uud Scientific Examiner, 1848; Ohio Medical Recorder, 1876; Ohio Medical Repository of 
uginal and Selected Essays and Intelligence, 1826; Ohio Medical and Surgical Journal, 
V4B; Ditto, 1876; Western Journal of Medical and Physical Sciences, 1828; Western 
Journal of Medicine, 1840; Western Lancet, 1842; Western Medical Gazette, 1832; 
VV estei'n Quarterly Reporter of Medical, Surgical, and Natural Science, 1822, 122 
TONER, 
North America.” A second volume of this series, in preparation at the 
time of his death, was published subsequently. This great work de- 
serves to he better known, (b. Oct. 20, 1785; d. Nov. 6, 1852.) Dr. 
Reuben D, Mussey, a native of New Hampshire, commenced practice in 
Essex Co., Massachusetts, in 1805, after having received the degree of 
Bachelor of Medicine from Dartmouth College. In 1807 he attended 
lectures at the University of Pennsylvania, and wrote a thesis on Cuta- 
neous Absorption, based upon original observations, his experiments 
proving certain facts, while an opposite doctrine was being taught in 
the colleges. He made many other experiments upon this subject,"which 
have not been published. Fresh from the college at Philadelphia, he 
settled at Salem, Mass., where he obtained a good practice, and where 
he resided for six years, devoting much time to the surgery of the eye. 
In 1814 he was elected to the chair of Theory and Practice in Dartmouth 
College, and in 1819 to the chair of Anatomy and Surgery in the same 
institution, holding the latter position till 1888. He also gave lectures 
on chemistry at Middlebury College, and at Fairfield College, New York. 
In 1829 the doctor visited Paris, to study medical institutions abroad. 
During the year 1837 he was tendered three professorships, at Nashville, 
New York, and Cincinnati, and accepted the latter. His fame as a sur- 
geon preceded him, and in a few years he was one of the best known sur- 
geons in the Valley of the Mississippi. He possessed much mechanical 
skill, and had a genius for original operations. He performed many capi- 
tal and heroic operations, tying on the same patient within twelve days 
both carotid arteries, and saving his patient’s life. His whole professional 
life was one of eminent success, and sheds lustre upon the profession. He 
was President of the American Medical Association in 1850. (b. 1780; 
d. 1866.) 
Dr. John Deleraater, a native of New York, commenced practice in 
1809, in the city of New York. He subsequently practised in Pittsfield, 
Mass., and was connected with the Medical College there. In 1848 he 
removed to Cleveland, Ohio, and was elected to the chair of General 
Pathology and Midwifery in the Western Reserve College at that place, 
(d, April, 1867, aged 80.) Dr. George Mendenhall, a native of Pennsyl- 
vania, commenced practice in Cleveland, but in 1843 removed to Cincin- 
nati, where by great devotion to bis profession he acquired a large 
business. In 1852 he was elected to the chair of Obstetrics in the Miami 
Medical College, and, on the consolidation of that college with the 
Medical College of Ohio, was re-elected and continued to serve till his 
death. He published a “ Vade Mecum,” which passed through several edi- 
tions. He was one of the editors of the “ Western Lancet,” and afterwards 
of the “Lancet and Observer.” The journals contained many articles 
from his pen. He was President of the American Medical Association in 
1870. (b. 1814; d. 1874.) Dr. Jesse P. Judkins, besides having a large 
practice, was Demonstrator of Anatomy in the Ohio Medical College, and 
Professor of Anatomy in Starling Medical College, at Columbus. After- 
wards he held the chair of Special Pathology in the Miami Medical 
College, filling the latter position with ability up to the time of his death. 
He wrote a number of excellent papers which were published in the 
Cincinnati Medical Journal, (d. Dec. 6, 1867, aged 52.) Dr. Horace 
Ackley settled in practice at Akron. He was elected professor in 
Willoughby College in 1837. In 1843 he was elected Professor of Surgery 
in the College then at Cleveland. He was an early and efficient member 
of the Ohio State Medical Society, and for some years its president. He ADDRESS ON MEDICAL BIOGRAPHY. 
123 
was physician to the Marine Hospital at Cleveland, and one of the 
trustees for the Central and Southern Lunatic Asylums. His surgical 
practice was for years quite large, and he was esteemed a safe and skilful 
operator, (d. April 22, 1859, set. 47.) 
Dr. Leonidas M. Lawson, a native of Kentucky, first practised in 
Madison, and started the “ Western Lancet;” and in 1844, commenced 
tlie reprint of Hooper’s Pathological Anatomy. The same year he was 
invited to a chair in the Transylvania University. In 1845 he visited 
England and France, to study medical institutions abroad. In 1847 he 
was offered the chair of Materia Medica and Special Pathology in the 
Medical College of Ohio. He also at this time held chairs in the 
Kentucky School of Medicine and in the University of Louisiana, (d. 
Jan. 21, 1864, set. 51.) Hr. John Hawson, a native of Virginia, after 
practising for some time in Green County, removed in 1851 to Columbus, 
and in 1853 was elected to the chair of Anatomy in the Starling Medical 
College, As a teacher he gave great satisfaction to his associates and 
to the students. About this time he became editor of the Ohio Medical 
and Surgical Journal. He was an original observer and forcible writer, 
((h Sept. 1866, get. 55.) Hr. G. W. Boerstler, a native of Maryland, settled 
111 practice in Lancaster, 1853. All the sympathies‘and all the energies 
°f his nature were directed to the discharge of his duties as a physician. 
His practice was very large, (d. Oct. 19, 1871, set. 78.) Hr, George C. 
D lack man, a native of Connecticut, commenced to practise in the State of 
Hew York, where he acquired reputation as a surgeon. In 1854 he was 
elected to the chair of Surgery in the Medical College of Ohio, He was 
surgeon to the Cincinnati Hospital, and also to the Good Samaritan 
Hospital. On the breaking out of the war he entered the medical service 
°1 the army as a Surgeon of Volunteers. He was a man of fine presence, 
apd had an air of resolution, (d. July 19, 1871.) I will name in addi- 
tion, Hrs. Edward Tiffin, John P. Harrison, John Butterfield, G. F. 
Mitchell, R. L. Howard, Haniel Tilden, Philip J. Buckner, John T. Shot- 
WeD, J. W. Russell, and S. M. Smith. 
Pennsylvania,l—Hr. Benjamin Rush commenced practice in Phila- 
delphia in 1769, and the same year was elected to the chair of Chemistry 
vtr. t>ennsylvania is one of the thirteen original States, and was settled by the benevolent 
J Penn in 1682. This State took an active part in the measures that ushered in the 
struggle for American Independence, and was. during the war, the chief seat of Congress. 
'> her territory were fought several of the important battles of the Revolution. The popu- 
■mon in 1870, according to the U. S. Census, was 3,522,050, nearly one-third living in towns 
0 over five thousand inhabitants. The number of physicians at the same time was 4843. 
mre are three medical colleges, all in Philadelphia. There is a State Medical Society, 
°nned in 1848, which publishes a volume annually. Institutions for the insane and other 
unfortunates have been provided in different parts of the State. Pennsylvania has Irom 
16 settlement of our country taken the lead in matters relating to medical publication 
and medical education, and, as a consequence, we find, as would be expected, a larger pro- 
P°inon than usual of eminent medical men resident within her borders. 
he following medical journals have been published : JEsculapian Register, 1824 ; Ame- 
ican Journal of the Medical Sciences, 1827; American Journal of Pharmacy, 1825 ; Ame- 
ican Library and Intelligencer, 1836 ; American Medical Intelligencer, 1837; American 
M r1; Reorder, 1818; Barrington & Haswell’s Medical Bulletin, 1849; Bulletin of 
rJ ieal Science, 1843; Cholera Gazette, 1832; Compendium of Medical Science, 1868; 
uspital Register, 1863; Journal of the Philadelphia College of Medicine, 1829; Medical 
annner, 1838; Medical Reporter. 1853; Medical Review and Analectic Journal, 1826; 
ami 1«a a.nc* SurfJcal Reporter, 1856; Medical Times, 1870; North American Medical 
18‘Ar TJ?-?11' J°u.rnab 1826; Philadelphia Journal of Medicine and Physical Sciences, 
18(U! 4.1 iDdelphia Medical Museum, 1805; Philadelphia Medical and Physical Journal, 
of J hiladelphia Medical and Surgical Journal, 1853; Philadelphia Monthly Journal 
01 Medicine and Surgery, 1828. 124 
TONER, 
in the Philadelphia College. In 1787 he was assigned to the chair of 
Theory and Practice. He possessed a remarkably ■well trained and observ- 
ing mind, and, in addition to his professional duties, took an active part in 
all public affairs. He was for many years physician to the Pennsylvania 
Hospital and other benevolent institutions. In the State convention he 
moved that the colony should express its sentiments on the subject of 
separation from the mother country. He was shortly afterwards elected 
to Congress, and signed the Declaration of Independence. His writings 
embrace many topics in medicine, and are everywhere characterized by 
originality and ability. His conduct through life as a citizen and phy- 
sician was such as to make him a marked man. (b. Dec. 24, 1745; d. 
April 19, 1813.) Dr. Philip Syng Physick, a native of Pennsylvania, 
commenced to practise in Philadelphia in 1793, after having spent a 
number of years in visiting the hospitals of Europe. This was the year 
of the great yellow fever epidemic in Philadelphia. Dr. Physick was 
placed in charge of Bush Hill Hospital, and discharged his duties with 
marked ability. In 1794 he was appointed one of the surgeons of the 
Pennsylvania Hospital, and from 1801 to 1816 he was one oflhe consult- 
ing surgeons of the Philadelphia Almshouse Infirmary. In 1815 he 
was appointed Professor of Surgery in the University of Pennsylvania, 
in which he afterwards filled the chair of Anatomy. In 1825 he was 
elected a member of the Royal Academy of Medicine of France, and in 
1836 a member of the Royal Medical and Chirurgieal Society of London, 
(b. 1768 ; d. Dec. 15,1837.) Dr. John Morgan, a native of Pennsylvania, 
after serving as surgeon to the Militia in the French war in 1759, resigned 
in 1760, and went to Europe to further perfect his knowledge of medical 
science. He returned to Philadelphia in 1765, and was then perhaps the 
most learned physician in America. The same year he delivered an 
address at the commencement of the Philadelphia College, and the open- 
ing of the first medical college in America, established through his own 
and Dr. William Shippen’s influence, and in which he was appointed 
Professor of Theory and Practice. In 1775 Dr. Morgan was appointed 
Director General and Physician in Chief of the Hospital Department 
of the American Army, but political cabals and the exigencies of the 
times caused his removal in 1777. A report by Congress shows him to 
have been an efficient officer. In his thesis he proposed the theory that 
pus was formed by a secretory process. He was one of the founders of 
the American Philosophical Society, and a member of the Royal Philo- 
sophical Society of London, (b. 1735 ; d. Oct. 15, 1789.) 
Dr. Benjamin Smith Barton, a native of Pennsylvania, settled in 
practice in Ihiladelphia in 1/89. He was the same year appointed 
Professor of Natural History and Botany, and in 1813 Professor of 
Materia Medica in the University of Pennsylvania. He contributed 
papers to the American Philosophical Society, and in 1804, started the 
“Medical and Physical Journal.” He was an indefatigable worker, 
and all his writings were practical contributions to medicine, (b. Feb. 
10, 1766; d. Dec. 19, 1815.) Dr. Caspar Wistar, a native of Penn- 
sylvania, commenced practice in Philadelphia in 1787. In 1789 he 
was elected Professor of Chemistry and Physiology in the University of 
Pennsylvania. In 1792 he was elected physician to the Philadelphia Dis- 
pensary, and to the Pennsylvania Hospital, and the same year was 
appointed Adjunct Professor of Anatomy, which position he filled until 
the time of his death. His abilities as a physician secured him a large 
practice, and assisted in popularizing the school. He was a member of ADDRESS ON MEDICAL BIOGRAPHY. 
125 
many learned societies, and President of the American Philosophical 
Society. His best known work is his “Anatomy,” in two volumes, the 
first of its kind contributed by an American, (b. Sept. 13,1761; d. July 
22, 1818.) Dr. Win. P. Dewees, a native of Pennsylvania, commenced 
practice in the interior of the State, but removed to Philadelphia in 1793, 
He devoted his time chiefly to Obstetrics, but, his health failing in 1812, 
he retired to his farm at Phillipsburg, where he remained for five years, 
when, having recovered, he returned and resumed practice, which he 
continued with increasing popularity. In 1825 he was chosen assistant 
professor of Midwifery in the University of Pennsylvania, and in 1834 
was elected to the full chair. But his health had gradually failed, and 
the following year he resigned and was elected emeritus professor, 
(b. May 5, 1768; d. May 20, 1841.) Dr. Nathaniel Chapman, a native 
of Virginia, commenced practice in Philadelphia in 1804. By his 
assiduity in professional duties, and by a fortunate marriage, he speedily 
acquired a large business. About this time he commenced a course of 
lectures on Obstetrics to medical students, and in 1808 associated himself 
with Professor James in a summer course of lectures. From 1813 to 
1816 he was Professor of Materia Medica in the University of Pennsyl- 
vania, and from 1816 to 1850, Professor of Theory and Practice and of 
Clinical Medicine. In 1817 he founded the Medical Institute, and 
lectured in it during every summer for twenty-five years. He was Pre- 
sident of the American Philosophical Society from 1846 to 1848, and 
President of the American Medical Association in 1847. (b. May 28, 
HBO ; d. Jan. 1,1853.) Dr. Wm. E. Horner, a native of Virginia, having 
resigned his commission in the U. S. Navy, commenced practice in the 
eity of Philadelphia. His abilities soon attracted the attention of the 
leading physicians, and he shortly after received the appointment of 
Demonstrator of Anatorn}r in the University of Pennsylvania. In 1819 
lie was made adjunct, and in 1831 full Professor of Anatomy. In 1824 
he discovered the “Musculus Horneri,” which had escaped the observa- 
tion of previous anatomists. His whole life was a continuous struggle 
°1 mind and duty over physical suffering. In 1847 he founded St. Joseph’s 
Hospital, to which he bequeathed his library and instruments. About 
this time he published a treatise on Pathological Anatomy, which was 
shortly afterwards followed by other important publications, (b. Jan. 3, 
1793; d. March 13, 1853.) 
Dr. John Iv. Mitchell, a native of Virginia, settled in practice in Phila- 
delphia in 1822, and soon acquired a large practice. After taking 
his medical degree he made three voyages to China as surgeon in a 
merchant ship. In 1824 he delivered a course of lectures on the Insti- 
tutes of Medicine and Pathology before the Philadelphia Institute, and 
m 1826 was appointed to the chair of Chemistry and Applied Arts in 
the I ranklin Institute. He was a ready writer, and frequently con- 
ributed to the medical journals. In 1841 he was elected to the chair 
0 . |heory and Practice in Jefferson Medical College, a position he filled 
with rare ability till the time of his death. He was a gifted lecturer, 
mid occasionally introduced experiments with good effect, as he was an 
expert manipulator. His writings wTere numerous, and always contained 
important additions to medical knowledge, (b. March 12,1796; d. April 
•>1858.) Dr. George McClellan, a native of Connecticut, shortly after 
graduation commenced practice in the city of Philadelphia. In 1825, 
|. a *ew able associates, he founded the Jefferson Medical College, in 
mih he was a professor till 1838. In 1839 he organized the Medical 126 
TONER, 
Department of Pennsylvania College, from which he retired in 1844, 
and devoted his time to private practice. He was a fluent and agree- 
able lecturer. For a time he edited a medical journal in connection 
with Dr, John Eberle, and was a frequent contributor to the columns of 
periodical medical literature, (b. Feb. 22, 1796; d. May 9, 1847.) Dr. 
Robley Dunglison, a native of Scotland, was invited to the United States 
in 1824, and elected Professor of Medicine in the University of Virginia, 
where he continued till 1833. From 1833 to 1836 he was Professor of 
Materia Medica and Therapeutics in the University of Maryland, and 
from 1836 to 1868 was Professor of the Institutes of Medicine and Medical 
Jurisprudence in the Jefferson Medical College. His Medical Dictionary 
is by far the most convenient work of the kind known to the profession, 
(b. June 4, 1798 ; d. April 1, 1869.) Dr. T. D. Miitter commenced prac- 
tice in Philadelphia about 1831, and shortly afterwards established a 
“ Quiz class,” and soon became a teacher of surgery in what was known 
as “Chapman’s Medical Institute.” He was made Adjunct Professor of 
Operative Surgery in Jefferson Medical College to assist Dr. Randolph, and 
on the resignation of the latter, was elected to the full chair of Surgery. 
It was in this field that he acquired his great reputation as a teacher and 
as an operator in rhinoplastic surgery. He has left an enduring monu- 
ment to his name in the establishment of the “Miitter lectureship” and 
the “ Miitter Museum” of the College of Physicians. Resides the names 
already given, I will mention Drs. William Shippen, Samuel Jackson, 
Franklin Bache, T. S. James, P. S. Dorsey, 11. L. Hodge, C. D. Meigs, J. 
1). God man, Adam Kuhn, J. Redman Coxe, Robert Hare, Samuel G. 
Morton, Rene La Roche, W. Darlington, John S. Parry, Samuel Jackson 
(of Northumberland), Peter Mowry, Nathaniel Bedford, James Agnew, 
Joseph Gazzam, B. R. Reese, W. W. Gerhard, Jacob Randolph, David 
Gilbert, G. W Norris, Thomas T. Harrison, Joseph Parrish, Thomas 
Harris, and P. B. Goddard. 
Rhode Island.I—Dr. Isaac Senter, a native of New Hampshire, served 
as a surgeon in the Revolutionary war, and in 1779 settled in practice in 
Pawtucket. In 1780 he was appointed Surgeon and Physician-General 
to the State troops, and removed to Newport, where he passed the re- 
mainder of his life actively engaged in the practice of his profession. 
He contributed articles on medical subjects to the journals, and was an 
honorary member of the Massachusetts Medical Society, of the Medical 
Society of London, and of the College of Physicians of Philadelphia. He 
was for some years President of the Rhode Island State Medical Society, 
(b. 1735 ;d. Dec. 20,1799.) Dr, Pardon Bowen, a native of Rhode Island, 
served during the Revolutionary war as a surgeon on a privateer, and in 
17<9 was taken prisoner, and after being exchanged re-entered the service. 
He settled in practice in his native town, and gradually acquired a large 
business. He was an active and efficient member of the Rhode Island 
State Medical Society, and for some years its president. He was also a 
member of the Board of Trustees of Brown University. His profes- 
1 Isla«d k one of the thirteen original States. Its first settlement was in 1636 by 
ogei Williams, at the present site of Providence. Other settlements were soon made at 
Newport and at Warwick. The population in 1870, according to the United States Census, 
was 817,353. Nearly one-half of the people live in cities and towns of over five thousand 
inhabitants. Jhe number of physicians in 1870 was 260. One medical college, a depart- 
ment of Browni University, is giving instruction. Rhode Island has a State Medical Society, 
toimec m iolw, which publishes Transactions annually, and a good system of registration 
of vital statistics. Institutions for the care of the insane and other unfortunates have 
been established, sufficient for the wants of the people. ADDRESS ON MEDICAL BIOGRAPHY. 
127 
sional life extended to nearly half a century, (b. 1757; d. Oct. 25,1826.) 
Dr. Usher Parsons, a native of Maine, became on graduating a surgeon 
in the navy during the war of 1812, and was in the battle of Lake Erie. 
After ten years’ service he resigned, and settled in practice in Providence. 
He held a professorship in Brown, Jefferson, and other medical colleges, 
and was President of the Rhode Island Medical Society, and Vice-Presi- 
dent of the American Medical Association. He wrote a number of 
medical works, and took four Boylston prizes. He was an influential 
promoter of the establishment of the Rhode Island Hospital, and a most 
agreeable and witty writer, (b. Aug. 18, 1788; d. Dec. 19, 1868.) 
Hr. Solomon Hrowne, a native of Rhode Island, served as a surgeon’s 
mate in the Revolutionary war, and on the restoration of peace settled 
jn Providence. In 1788 he joined a party going to the new settlement 
in the West, at Marietta, on the Ohio River. He attended, during his 
last illness, General Varnum, one of the Ohio Land Company, and, at the 
request of the community, pronounced his funeral eulogy. He resided 
f°r a time at Morgantown, Va., and for seven years at Uniontown, Fay- 
ette County, Pa. Here he delivered four orations commemorative of 
American independence, and a eulogy on General Washington. In 1801 
he returned to Providence and engaged in private practice. In 1811 he 
vras Professor of Materia Medica and Botany in Brown University. The 
Hhode Island Medical Society, in 1819, appointed him a delegate to the 
convention that formed the National Pharmacopoeia. He possessed a 
hue classical education, and was a beautiful writer and an interesting 
lecturer, (b. March 11,1753 ; d. Feb. 5,1834.) Hr. Wm. Bowen studied 
Medicine with his father, then a leading physician, and speedily acquired 
a large practice for himself. He avoided surgery, whenever practicable, 
and was deemed specially skilful in diseases of women and children. 
His instruction was much sought by pupils who were preparing to enter 
He medical profession. His reputation in the treatment of fevers was 
Unequalled by any physician in his section, (d. 1832, set. 86.) Hr. Caleb 
h iske, a native of Rhode Island, served as a surgeon in the Revolutionary 
then settled in practice in Scituate, and passed a long and successful 
Professional life, residing all the time in the house in which he had been 
corn. He was one of the original members of the Rhode Island Medical 
Society, and in 1823 its president. At one time lie was Judge of the 
Court of Common Pleas. He has perpetuated his name by endowing 
He Fiske fund for the promotion of medicine, (d. Sept. 1835, ret. 82.) 
1° the names already mentioned I will add those of Hrs. Levi Wheaton, 
Joseph Mauran, L. L. Miller, and Havid King—the first to introduce 
vaccination in Rhode Island. 
South Carolina.I—Hr. James Moultrie, a native of South Carolina, 
p ! Carolina was one of the thirteen original States. ■ The first settlement was at 
801B01 Royal by the English, in 1670. The government was a proprietary one till 1719, when 
;°« 1 became a colony under the crown. During the Revolution the State was 
61 y active, and suffered much from the depredations of the British troops. The popula- 
in°t' Ul A accor<3ing to the U. S. Census, was 705,606, with about one in thirteen living 
Th °WnS Cltles of over five thousand inhabitants. The number of physicians was 798. 
medical colleges, one at Charleston, and the other at Columbia. A State 
pul pi , ®ociety was formed in 1789, and a State Medical Association in 1848; the latter 
v,,,„ !Ues annually a volume of Transactions. Institutions for the care of unfortunates 
laPj been established. 
of m'G |'°l'owin? medical journals have been published in South Carolina: Carolina Journal 
1848 mre’ ®urSe,T> anc* Agriculture, 1825; Charleston Medical Journal and Review, 
pi. ’ harleston Medical Journal and Review, 1873; Southern Journal of Medicine and 
haimacy, 1846. 128 
TONER, 
commenced practice in Charleston in 1813, and was soon afterwards ap- 
pointed physician to the fort and jail. He took an active part in public 
health matters, and was soon recognized as the leading sanitarian of the 
city. In 1819 he was elected by the Medical Society of South Carolina 
a delegate to the first convention for forming the National Pharma- 
copoeia. In 1822, he, with other influential medical men, memorialized 
the Legislature for a charter to establish a medical college, which was 
granted in 1828. He was elected to a chair in the college, but declined. 
In 1832, however, he accepted the chair of Physiology, and here devel- 
oped the high powers of his well-stored and vigorous mind. He was 
President of the American Medical Association in 1851, and had pre- 
viously been President of the Medical Society of South Carolina, (b. 
1793; d. 1869.) Hr, Tucker Harris, a native of South Carolina, commenced 
practice in Charleston in 1771, in partnership with his preceptor Dr. Lionel 
Chalmers, and served as a hospital surgeon in the Revolution. Immedi- 
ately after the restoration of peace, he resumed his practice. From 1783 
to 1786 he had a business partnership with Dr. Oliphant. He was one of 
the earliest members, and an ardent friend, of the Medical Society of 
South Carolina, and from 1796 to 1799 was chosen its president, (b. 1747 ; 
d. July 6,1821, set. 74.) Dr. J. L. E. W. Shecut, a native of South Caro- 
lina, commenced practice in Charleston in 1791. He was attentive to 
business and a close student. In 1806 he exhibited an ingenious electrical 
machine of his own construction, and the same year published a work 
entitled “Flora Caroliniana.” His publications were quite numerous, 
(b. 1770; d. 1836.) Dr. Alexander Baron, a native of Scotland, settled in 
practice in the city of Charleston in 1769. His fund of general informa- 
tion was great, and his ability equal to any position in professional or 
civil life. He was one of the founders of the South Carolina Medical 
Society, and its vice-president in 1790. In 1770 he joined the St. An- 
drew’s Society, and was shortly after elected its president, an office 
which he held for twenty-eight years, (d. July 9,1819.) Dr. J. Edwards 
Holbrook, a native of South Carolina, established himself in Charleston 
in 1822. In 1824 he was elected Professor of Anatomy in the Medical 
College of South Carolina. He was universally recognized as a learned 
scientist, and as a popular and successful physician. He avoided sur- 
gery, and was particularly noted for his sympathy for suffering patients. 
He was a successful medical teacher, and particularly popular with his 
class. Although contributing valuable articles to medical journals, his 
greatest works, and those on which his reputation as an author will rest, 
are his “ American Herpetology” and “ The Fishes of South Carolina.” 
(b. Dec. 30, 1794; d. Sept. 8, 1871.) 
Dr. John Bellinger, a native of South Carolina, commenced practice 
in Charleston, where his eminent abilities soon carried him, through 
all difficulties, to a full recognition of his professional abilities. His 
high reputation pointed him out as a proper occupant for the chair of 
Surgery in the Charleston Medical College, to which he was elected. 
His skill in surgery was only equalled by his acuteness as a physician. 
He was a thorough pathologist, and, although a busy practitioner, kept 
pace with the progress of the profession, and with the latest and best 
literature, (d. Aug. 13, 1860, set. 56.) 
Dr. Samuel H, Dickson, the physician, author, and teacher, commenced 
practice in Charleston in 1820. In 1828 he delivered a course of lectures 
on Physiology and Pathology before a medical class. He was influential 
in the establishment of the medical college at Charleston, and, in 1824, ADDRESS ON MEDICAL BIOGRAPHY. 
129 
was called to the chair of Institutes and Practice of Medicine. He was 
Professor of the Practice of Medicine in the University of New York 
from 1847 to 1850, when he returned to Charleston ; but in 1858 was 
elected to the chair of Practice of Medicine in the Jefferson Medical 
College-at Philadelphia, which he held nearly to the time of his death. 
He contributed many able papers to medical journals, and wrote a work 
entitled “Manual of Pathology,” etc. (b. 1798; d. 18/2.) Dr. B. B. 
Simons was a native of South Carolina. In 1801 he commenced prac- 
tice in Charleston, and soon acquired business and reputation. His 
abilities were recognized by his appointment as Lecturer on Chemistry 
in the College of South Carolina. He was a thorough anatomist, and 
of rare skilllmd boldness in surgery, in which he acquired an extensive 
reputation and practice, (b. 1766; d. 1844.) Ur. Richard Evans Wylie, 
a native of Charleston, settled in 1882 in Lancaster Co., where he ac- 
quired distinction in his profession. He was a fine anatomist, and made 
many post-mortem examinations, and was a good pathologist. He was 
nf n pharitable and generous disposition, and was well versed in medical 
literature, (b. 1810; d. 1875.) Ur. Robert Wilson Gibbes was assistant 
and afterwards Professor of Chemistry, Geology, and Mineralogy in the 
South Carolina College, which position he filled with ability. He com- 
menced practice in Columbia, where he acquired a good professional 
business. He was for several years sent as a delegate to the American 
Medical Association, and was President of the Medical Society of South 
Carolina Uuring the late war he was Surgeon-General of the State 
troops, and was the originator of the “ wayside hospital system.” Ur 
Gibbes was an ardent student of the sciences, and the author of several 
valuable contributions to the Academy of Sciences'and to the Smithso- 
nian Institution. He was the author of Gibbes s History of South Caro- 
lina, and made a large collection of autographs, coins, and specimens in 
palaeontology, geology, etc., as also a collection of the fossils of South 
Carolina. ‘He was a member of the Royal Societies of England, Prance, 
Germany, and Uenmark. (b. 1809; d. 1866.) I will add the names of 
Ur. Uavid Ramsay, Ur. Geddings, and Ur. Peter Fayssoux. . . 
Tennessee.I—Ur.1—Ur. Win. H. Ueadrick, a native of Virginia, having 
acquired his professional education, settled in East Tennessee. His 
operation for the removal of the inferior maxillary bone, in 1816, and 
other capital operations performed at that early date, have won for nra 
an enduring name in the literature of the profession, (b. l/oo ; a. ro i.) 
1 Tennessee was the first State west of the Alleghany Mountains, settled y 
from the colonies, anterior to the Revolutionary war the settiers were chiefly N 
Carolina, to which State the territory belonged. Fort Loudon, in West lennessee & It 
as early as 1757. An attempt was made to found a State out of this Jemtoxy d the 
name of “ Franklin,” but after three or four years’ trial the effort was abandoned 
was admitted as a State in the Union in 1796. It has no very laige uti • . I p ’ 
according to the census in 1870, was 1,158,520, with about one in fif was 2220 One 
over five thousand inhabitants. The number of physicians at that tune was 2220.. One 
medical college, organized in 1850 at Nashville, is well supported, and there is another a 
department of Vanderbilt University. The profession of the State has a Medical Society, 
formed in 1830, which publishes Transactions annually. Institutions foi the care of un- 
fortunates have been organized in different parts of the State, snfiicien oi ic wants of the 
The following Medical Journals have been published in Tennessee: Memphis Journal ot 
Medicine 1853; Memphis Medical Journal of the Progressive Medical and Physical 
Sciences ' 1851 • Memphis Medical Recorder, 1852; Nashville Journal of Medicine and 
Surgery," 1851; Nashville Medical Recorder, 1860 ; Record of Medicine and Surgery, 1802 ; 
Southern Journal of Medical and Physical Sciences, 1853. TONER 
Dr. Felix Robertson, a native of Tennessee, wrote, for graduation in 1805 
a thesis entitled “ Chorea Sancti Viti,” giving in it a history of the dancino- 
“ann9la lch had exhibited itself in Tennessee, Kentucky, and Ohio about 
lie was well read in his profession, and possessed strong common 
sense and original powers of observation. He was twice Mayor of the city 
of Nashville, and a member of the Board of Trustees of the University • 
and through a long life maintained the dignity and charactei of an able 
physician, (b 1781; d. 1865.) Dr. Wilson Yandell, a native of North 
Carolina, settled in 1804 in Hartsville, Rutherford Co. He was a man 
ot mental vigor, untiring industry, and had a love for the acquisition of 
knowledge. His devotion to his profession rapidly advanced him to the 
trout rank of practitioners in the State. He received from the University 
of Maryland the honorary degree of M.D. in 1828. He was the imme- 
diate ancestor of the physicians of the same name in Kentuckv (b Dec 
17, 11 /4; d. Oct. 1, 1827.) Dr. A. H. Buchanan, a native of Viro-inia 
commenced practice in East Tennessee, then removed to Columbia, and’ 
finally to Nashville where he became a professor in the Medical School 
on its organization He was a man of learning and high character, (b. 
1808 ;d. June 20,1863.) Dr. John McClaran Watson, a native of North 
Carolina, settled in Murfreesboro, Tenn., but on the organization of the 
Medical Department of the University of Nashville, was induced to take 
the chair of Obstetrics and Diseases of Women and Children. He was a 
minister of the Gospel, as well as a successful practitioner, and a promoter 
of medical education (b. 1796; d. 1866.) Dr. A. P. Merrill, a native of 
Massachusetts served as a volunteer surgeon with General Jackson’s 
tlje ar. oi and 111 1819 was appointed surgeon in the 
U. b. Military service. In 1823 he resigned, and settled in practice at 
Natchez. In 1850 he removed to Memphis, Tenn., and assisted in organ- 
izing _ the Medical College at that place, taking the chair of Theory‘and 
I ractice. He originated and edited the Memphis Medical Recorder 
He was an able practitioner and an original writer,'his contributions to 
medical literature being varied and valuable, (b. April 1793- d. Nov 
1873.) In addition to these I will name Drs.T. R. Jennings James 
Roane, AY. Walker, R. Porter, J. L. Armstrong, and Samuel How 
lexas.I—-Dr. Benjamin Briggs Goodrich, a native of Virginia, practised 
for some time after graduating in Alabama and Mississippi, finally 
locating in Washington, Texas. He was a member of the State Legis- 
lature, and on Texas resolving upon independence, was one of the signers 
of its (b. 1800; d. 1860.) Dr. Anson Jones, a native of Mas- 
sachusetts a patriot of Texas, commenced his career as a practitioner of 
medicine at Brazoria. He entered the Texan army as a surgeon, and was 
1 exas until 1806 was a part of Mexico. In 1821, emigration to it from Hip llnitpd 
States became considerable. In 1830, it demanded admission to the Mexican confederation1 
as a separate State, but being refused, declared its independence and'conauered in a con! 
test of arms, in 1836, maintaining its independence as a republic till it was admitted as one 
of the Tinted States, in 1846. Its area is the largest of any of the States There are no 
hntVh ♦“« {Vi]i r1’ naviSable nvers, and rich minerals. The 
five bv r ordlug t?Ithe U-,S- VeuSUS’ WaS 818’899> with about one in twenty. 
ln pWnl°- °Ver five thousaijd “habitants. At the same time there were 1906 
located at P -Population increasing, and wealth accumulating. One medical college is 
and iton4,and 18 § instruction. A State Medical Society was formed in 
been estabfied168 Transactlons aunuallP Institutions for the care of unfortunates have 
lonrnllf°l18°rmingr medi.?lU'°Ura,S have beGn published in Texas : Galveston Medical 
Journal, 1866; lexas Medical Journal, 1873. cai ADDRESS ON MEDICAL BIOGRAPHY. 
131 
at the battle of San Jacinto. In 1837-8, he was a representative in the 
Texan Congress. In 1838, he was Minister to the United States, where 
he made an unsuccessful endeavor to secure the annexation of his country. 
On his return, he was made Senator from Brazoria to the Texan Congress. 
He was Secretary of State of Texas in 1841, and in September, 1844, was 
elected President of the Republic, and held this office up to the time of 
the annexation of Texas to the United States, (b. 1798; d. 1858.) Dr. 
Edward A. Pye, a native of Maryland, was a physician of eminence. He 
had a good practice at Hearne, in Robertson Co. When the yellow fever 
at Calvert had exhausted the medical men of that place, lie offered his 
services, which were gladly accepted by the authorities. But this heroic 
act cost him his life. He contracted the disease, and died. During the 
war, he served as surgeon at Beaumont, (b, July 9, 1818; d. Rov, 9, 
1873.) Dr. John A. Pettus, a native of Virginia, settled at Port Bend, 
Texas, where he acquired a large practice. During the late war, he was 
Medical Director of the Corps of Surgeons of U, S. Volunteers. After 
the war, he returned to practice, and was elected Professor of Physiology 
and Medical Jurisprudence in the Galveston Medical College, (d. Sept. 
26, 1870, aged 52.) Dr. E. L. Massie was a skilful and benevolent phy- 
sician of Houston. During the war, he served as a surgeon in the Con- 
federate army, and was afterwards Medical Purveyor of Texas. He was 
one of the leading physicians of Houston. I will name in addition, Drs. 
E. T. Bonney, Alva Connell, W. Riddell, George W. Peete, W. D. Rob- 
inson, Wm. Richardson, W. R. Smith, and Wm. McCraven. 
Vermont.I—Dr. Joseph Adams Gallup, a native of Connecticut, settled 
in practice at Woodstock, Vermont, in 1800. He possessed a vigorous 
niind, and was a close observer and correct reasoner. By skill in his pro- 
fession, and by force of character, he acquired a leading business. He 
was Professor in the Castleton Medical College, and in the Medical College 
of the University of Vermont. In 1827 lie founded the medical school 
of Woodstock. His best known writings are entitled “ Sketches on Epi- 
demic Diseases in Vermont,” published in 1815, and “Outlines of Insti- 
tutes of Medicine,” published subsequently, (b. Mar. 30, 1769; d. Oct. 
12,1849.) Dr. Noadiah Swift, a native of New York, commenced practice 
in Burlington about 1802, and enjoyed a large practice for nearly fifty 
years. He was a man of great energy of character, and of correct habits, 
and possessed rare skill in his profession. His reputation extended far 
beyond the community in which he resided. He was elected at differ- 
ent times to the State Senate, (b. Nov. 24, 1776; d. Mar. 21, 1860.) 
Dr. Benjamin R. Palmer commenced practice in Woodstock, Vermont, 
where he acquired much popularity, and a good professional business. 
He possessed decided talents as a teacher of anatomy and physiology. 
He was elected to the chair of Anatomy in the Vermont Medical College, 
where he taught for many years with success. He also held the same 
1 A ermont was settled by emigrants from Massachusetts, New Hampshire, and New 
York, each of which States claimed her territory. In 1791 Vermont was admitted as the 
first new member of the Union. The population in 1870, according to the United States 
Census, was 330,531. She has no large cities, and about one in twenty-three ot her popula- 
tion live in towns of over five thousand inhabitants. She had at the time mentioned 560 
physicians. Vermont has one medical college, a department of the University of Burling- 
lou. A State Medical Society was organized in 1814, and publishes Transactions annually, 
Y registration of vital statistics has also been established. Institutions for the care of 
unfortunates have been founded, sufficient for the wants of the people. 
The following Medical Journal has been published in Vermont: Vermont Medical 
Journal, 1874. TONER, 
chair in the Berkshire Medical College of Massachusetts. His reputation 
as a teacher gained him the election to the chair ot Anatomy in the Louis- 
ville Medical College, when he removed to Kentucky, where he enjoyed 
an extensive practice up to the time of his death. Dr. Benjamin Chandler, 
a native of Connecticut, commenced practice in 1792 in Rutland, Vermont, 
where he acquired reputation, and whence he removed to St. Albans in 
1807. As a successful operator in surgery, he had no equal in that section 
of the country. He was one of the founders of the Vermont State Medical 
Society, and of the Franklin County Medical Society, (b. 1772; d. 1818.) 
Dr. John Pomeroy, a native ot Massachusetts, was a physician of ability. 
He settled in Cambridge, Vermont, in 1787, and in 1792 removed to Bur- 
lington, where he remained actively engaged in practice for over torty 
years. He was a man of vigorous intellect, and was characterized by 
simplicity of manner, directness of purpose, and strong common sense. 
Although he could not claim superior education, he was an ardent 
supporter of it. He was a member of the Corporation of the University 
of Vermont, and a professor in the Medical Department, (b. April 9, 
1764 ; d. Feb. 19, 1844.) Dr. Jonathan Adams Allen, a native of Massa- 
chusetts, commenced practice at Windham, in 1814. In 1820 he com- 
menced to give lectures on Chemistry, at Middlebury College, and con- 
tinued till 1826. In 1822 he removed to Middlebury, where he became 
extensively engaged as a physician. He was an active member of the 
State and County Medical Societies, (b. Nov. 17, 1787 ;d. Feb. 2,1848.) 
Dr. Horace Eaton, a native of Vermont, commenced practice in Enosburgh 
about 1824, and soon became popular as a physician. He was a man of 
great energy, and fully qualified in the duties of physician and surgeon. 
He was elected to the Legislature of the State, and was six years in the 
State Senate. He was also Lieutenant Governor and Governor ot the 
State for two years. He was greatly interested in education, and was 
for years State Superintendent ot Schools. In 1848 he was elected Pro- 
fessor of Natural History and Chemistry in Middlebury College, a posi- 
tion which he tilled with credit to himself and the Institution till the 
time of his death, (b. June 22, 1804; d. July 4, 1855.) To these names 
may be added those of Dr. Theodore V oodward, ot Castleton ; Dr. David 
Palmer, of Woodstock; Dr. Ezekiel Porter, of Rutland; the Drs. Tudor, 
of Middlebury, and Dr. Danforth. 
Virginia.I—Dr. Wm. Baynham, a native of Virginia, studied medi- 
cine with his father, and then with the celebrated Hunters of London. 
He was an excellent anatomist, and was held in high esteem by his 
London preceptors, and by Mr. Cline and Mr. Else. He made some deli- 
i Virginia was, in 1607, the seat of the first permanent settlement by the English in Ame- 
rica at Jamestown. Her first charter was annulled in 1677, and a new one, less liberal, 
granted. She took an early and decided stand in favor of American Independence. Her 
territory at that time was very large, and in 1781 she ceded the whole northwestern part to 
the U S government. In 1861 the western part of the State was formed into a separate 
State under the name of West Virginia. Her geographical position gives her great commer- 
cial advantages. The population of Virginia, according to the U. S. Census in IB <O, was 
1,225 163 about one in ten living in cities of over five thousand inhabitants, ine number 
of physicians was 2226. There are two medical colleges, one at Richmond and the other 
at the University, at Charlottesville. The State Medical Society, formed in 1821, pub- 
lishes Transactions annually. Institutions sufficient for the care of unfortunates have been 
organized in different parts of the State. The first Insane Asylum in this country, under 
State authority, was established at Williamsburg in 1773. 
The following medical journals have been published in Virginia : Monthly Stethoscope 
and Medical Reporter, 1856; Richmond Medical Journal, 1866 ; Virginia Clinical Record, 
1871; Virginia Medical Monthly, 1874; Virginia Medical and Surgical Journal, 1856. ADDRESS ON MEDICAL BIOGRAPHY. 
cate dissections and minute injections, which are still on the list of 
preparations at St. Thomas’s Hospital. He practised for some years in 
London, hut returned to Virginia, and settled in Essex Co. He was, 
without question, the most celebrated anatomist and surgeon in his day 
in America. Although being in a sparsely settled region, he was con- 
sulted by many persons from a distance, and frequently made long visits 
to perform surgical operations, (h. Dec. 7, 1749 ; d. Dec. 8, 1814.) Dr, 
James McClurg, a native of Virginia, served during the Revolutionary 
war as a surgeon, and part of the time as Medical Director. He com- 
menced practice at Williamsburg in 1773, and soon won his way to 
recognition as a physician of high culture and skill. He had published 
in London, in 1772, a thesis on the Bile, which attracted the attention 
of the profession. On the removal of the State government from Wil- 
liamsburg to Richmond in 1793, the doctor took up his residence in the 
latter city. By virtue of his decided skill, he was for nearly fifty years 
at the head of the profession of Virginia, (b. 1746 ;d. July, 1823.) Dr. 
Wm. B. Selden, a native of Virginia, settled in practice in Vorfolk in 
1799, and was fully employed for half a century. He was an elegant 
scholar, retaining his love for the classics to the close of his life. He was 
a careful reader of the best medical literature, and a close observer of 
disease. In 1799 he obtained from Dr. Jenner some vaccine virus, with 
which he continued to vaccinate, and with which he- kept up a con- 
tinuous supply for fifty years. He declared that he could see no varia- 
tion in the appearance of the vesicle, nor any failure in its power of 
protection in all this time. (b. Aug. 31, 1773; d. 1849.) Dr. Beverly 
R. Welford, a native of Virginia, settled in practice in Fredericksburg 
in 1816, when he was scarce twenty-one years of age, and soon won the 
confidence and affection of a large circle of friends and patients. He 
was a man of liberal studies, and enthusiastically devoted to the 
ment of the medical profession. In 1854 he was elected to the chair ot 
Materia Medica and Therapeutics in the College of Virginia, and re- 
moved to Richmond, His courteous manners, ripe experience, and pro- 
fessional knowledge soon made him the popular physician of that city. 
In 1852 he was President of the American Medical Association, (b. July 
29,1797; d. Dec. 20,1870.) 
Dr. Hugh Holmes McG uire, a native of Virginia, commenced his career 
ns a medical man in Winchester, Ya., and soon developed a preference 
for surgery. His. first operation was for cataract, which he successfully 
performed with a needle made under his direction by a mechanic in W in- 
ehester. In 1827, with other physicians, he established the Winchester 
Medical School, in which he was Professor of Anatomy and Surgery. 
In 1847 this instituton obtained a charter, and continued in successful 
operation till the beginning of the war. In 1862 the buildings were 
burned by soldiers under Gen. Banks. In the same year the Doctor was 
commissioned as surgeon in the Confederate Army, and served till the 
close of the war. He was tendered a professorship in a medical school 
nt Philadelphia, and also at Vew Orleans. In 1850, he was elected one 
of the Vice-Presidents of the American Medical Association. He was a 
man of great industry, and had wonderful success as a surgeon. He 
performed lithotomy thirty times without losing a case. (b. 1801; d. 
1875.) Dr. James Craik, a native of Scotland, was a surgeon in Brad- 
dock’s expedition against Fort Duquesne, and also a surgeon in the Revo- 
lutionary Army. After peace was established, he settled in practice near 
Mt. Vernon, in Virginia. He was a warm personal friend of Gen. Wash- TONER, 
ington, who mentioned him in his will, as his “old and intimate friend.” 
The Doctor was one of the three physicians who attended Gen. Wash- 
ington in his last illness. He was a thoroughly educated physician and 
surgeon, and a man of great probity of character, (b. 1781; d. Feb. 6, 
1814.) Dr. George Cahell, a native of Virginia, practised for years with 
success and reputation at Lynchburg. He was a man of superior endow- 
ments and much culture. His practice extended for many miles along 
the valley of the James River, (d. 1823.) 
Dr. J. P. Mettauer, a native of Virginia, practised in Prince Edward 
County. He was in many respects one of the boldest and most successful 
surgeons in the State. He commenced practice in this sparsely settled 
region about 1809, and during a long life maintained the character of a 
learned and skilful physician and surgeon. Ho medical man in the South 
was better known for his success, and for his valuable and numerous 
contributions to medical literature. Even when past eighty years of age, 
he was active and energetic in practice, and performed important surgical 
operations with success, (d. Hov. 22,187b, aged 88.) Dr. Francis T. Strib- 
ling settled in Staunton, Va., where he soon acquired a large practice by 
devotion to professional duties. In 1836 he was elected physician to the 
Western Lunatic Asylum, and in 1840 was appointed Superintendent, 
which position he filled with great success to the time of his death. He 
possessed a strong intellect, and introduced many improvements in the 
management of the insane, (b. Jan. 20,1810 ;d. July 23, 1874.) In addi- 
tion I will mention Drs. Charles B. Gibson, James Henderson, John 
Minson Galt, Thomas Massey, Goodridge Wilson, Thomas Robinson, P. 
C. Spencer, Micajah Clark, James Bolton, John Cullen, James Currie, R. 
W. Haxall, B. H. May, A. L. Warner, H. Selden, G. H. Upsher, J. B. 
Strachan, J. S. Giliaira, J. B. McCaw, A. G. Strachan, John Field, John 
F. Peebles, T. R. Atkinson, D. J. Claiborn, R. B. Butt, besides the 
forty-five martyrs who died of yellow fever at Horfolk in 1855.1 
1 I believe that a complete record of the names of the physicians who died during the 
great epidemic of yellow fever in Norfolk, in 1855, has not found a place in medical litera- 
ture. The list given here is taken from the Virginia Medical and Surgical Journal for Oct. 
1855, p. 838, from the Portsmouth Relief Association’s report, from Forrest’s “Great Pes- 
tilence in Virginia,” and from other sources. It will be observed that in some cases no first 
names are given. In the midst of the terrible panic and distress that existed, these noble 
men wei'e buried without any special cei’emony, hut wei’e conveyed silently to their graves. 
We honor their courage and devotion to pi’ofessional duty, which was equal to that which, 
in the church, purchased the title of Saint. Over one hundred physicians volunteered their 
services, and actually went to Norfolk and Portsmouth during the epidemic. FoiJy-five 
medical men are known to have died of yellow fever in these cities, and, so malignant was 
the disease at one time, that seven physicians died upon one day, and five on another. A 
majority of the deaths of physicians took place among those who came from other places to 
render assistance to their medical bi’ethren and the citizens in their great distress. While 
it is probable that I have not obtained the names of all, it is possible that some in the list 
may have been druggists and not gx-aduates in medicine. The following are the names in 
alphabetical order, with the place of residence when known 
Bache. Berry, J. L. (Memphis, Term.), Berry, R. B. (Tenn.), Blow, Richard (Sussex, Va.), 
Booth, T. (Baltimore, Md.), Briggs, J. A. (Norfolk, Va.), Burns. Capri (a Hungarian), 
Cole, C. (Philada., Pa.), Collins, Win., Constable, T. F. (Norfolk, Va.), Craycroft, T. H. 
(Philada., Pa.), Crowe, N. J. (Richmond, Va.), Dabershe (Dist. of Columbia), I)e Beraixe, 
Dillard (Montgomery, Ala.), Fliess (Baltimore, Md.), Gilbardt, Leon (Richmond, Va.), 
Gooch. P. C. (Richmond, Va ), Raison, G. I. (Norfolk, Va.), Handy, T. W. (Philada., Pa.), 
Higgins, F. L. (Norfolk, Va.), Howe (Baltimore, Md.), Howie, Thos. P. (Richmond, Va.), 
Hunter, Edwin (Brooklyn, N. Y.), Jackson (Dist. of Col), Lovett, M. P. (Portsmouth, 
Va ), Marshall (Baltimore, Md.), Mierson, T. (Philada., Pa.), Moi-se, Nash, Thos. (Nor- 
folk. Va.), Nicholson, L. P. (Portsmouth, Va.). Obermuller (Georgia), Parker, R. H. 
(Portsmouth, Va.), Rizer (Penn.), Schell (N. Y.), Selden, Henry (Norfolk, Va.), Sil- ADDRESS ON MEDICAL BIOGRAPHY. 
West Virginia.I—Dr. James W. Clemens, a native of Pennsylvania, 
commenced practice in Wheeling in 1819. He was not only solicitous 
for business, but ambitious for knowledge, and a constant reader of the 
best medical literature. He had a private chemical and pathological 
laboratory attached to his office, in which he was constantly experiment- 
ing. He was a ready writer and a fluent speaker, and enjoyed through 
life the reputation of a successful physician, (b. May 26, 1795; d. Hov. 
21, 1841.) Dr. Martin L. Todd, a native of Hew York, commenced 
practice in Wheeling in 1810, and soon acquired reputation in the treat- 
ment of a then prevalent low grade of fever, popularly called the “Cold 
Plague.” He served as a surgeon with the State troops in the war of 
1812. He was remarkable for his acuteness in diagnosis, as well as for 
his choice of efficient remedies, (b. 1782; d. March 8, 1866.) Dr. S. P. 
Hullihen, a native of Pennsylvania, commenced practice as a surgeon 
and dentist in 1832, and the same year received the degree of Doctor of 
Medicine from Washington Medical College, Baltimore. He was a man 
of genius, gifted with original conceptions, and with ability to overcome 
difficulties in surgical operations, and to make efficient appliances. He 
never was a general practitioner. To him belongs the credit of originat- 
ing the movement for the establishment of the Wheeling Hospital. He 
contributed some valuable articles to Medical Journals, the result ot 
observation and experience. His death was regretted by all classes, and 
at a public meeting a spontaneous subscription was made to erect a 
monument to his memory, (b. Dec. 10, 1810; d. March 27, 1857.) Dr. 
P. H. Cummings, a native of Pennsylvania, commenced practice in 
Wheeling. His professional qualifications were of the first order. He 
was a ready writer, and a close observer ot all the conditions that aflect 
health. He occasionally contributed to medical literature, and was Pre- 
sident of the State Medical Society in 1872. (b. Feb. 17,1817; d. April 
12, 1873.) In addition to the foregoing, I will name Drs. Samuel Mc- 
Keehan, John AY. Moss, H. D. Chapman, and James Tanner. 
Wisconsin.2—Dr. Mason C. Darling, a native of Massachusetts, settled 
in 1830 in Fond-du-Lac, Wisconsin, the pioneer physician of that place. 
He had formerly practised for about thirteen years in Greenwich, Mass., 
where he had acquired experience and reputation. In addition to being 
a good physician, he was an energetic far-seeing business man. These 
qualities caused him to be put forward in politics, and he was elected to 
vester, Richard J., and Silvester, R. W. (Norfolk, Ya.), Smith, J. C. (Columbia, Pa.), 
Thompson, Robt. (Baltimore, Md.j, Trugien, J. W. H. (Portsmouth, Ya.), Tunstall, R. B. 
(Norfolk, Ya.), Upsher, (t. L. (Norfolk, Ya.), Walters, Charles (Baltimore, Md.). 
1 West Yirginia formed a part of Virginia until 1861, when a convention at Wheeling 
formed it into a new State; and it was admitted into the Union Dec. 31, 1862. The popu- 
lation in 1870, according to the U. S. Census, was 442,014, about one in twenty living in 
cities and towns of over five thousand inhabitants. The number of physicians was 612. 
A State Medical Society, organized in 1867, prints annually a volume ot Transactions. In- 
stitutions for the care of the insane and other unfortunates have been established. 
The following medical journal is published in West Yirginia: West Virginia Medical 
Student, 1875. 
2 Wisconsin was early visited by the French missionaries, and permanent settlements 
'were made in the latter part of the 17th century. It was erected into a territory in 1836, 
and admitted as a State in the Union in 1848. Population and wealth are rapidly moving 
to it. The U. S. Census of 1870, assigns to it a population of 1,064,985, with about one in 
oight living in towns of over five thousand inhabitants. The same authority gives 915 
physicians. The agricultural resources are of the first order. A State Medical Society 
and a State Board of Health have been organized; the first, formed in 1842, has for years 
published Transactions. 136 
TONER, 
the Legislature and also to the State Senate, where he took a prominent 
part in favor of educational projects. He was one of the originators and 
first President of the State Historical Society, (b. May 18,1801; d. March 
12, 1856.) Hr. John B. Honsman, a native of Michigan, commenced 
practice in 1826 with his preceptor Dr. Twitched, of Hew Hampshire. 
In 1840 he came to Wisconsin, and settled in Milwaukee, where he prac- 
tised with success up to the time of his death. He was a man of clear 
perceptions, great stability of character, and devotion to his profession. 
He was a member of the State Medical Society and of the American 
Medical Association, (b. 1807; d. 1868.) Dr. Clark G. Pease, a native 
of Hew Hampshire, commenced practice in Holyoke, Mass., in 1849, but 
in 1850 removed to Janesville, Wisconsin. His agreeable address and 
skill as a physician soon won him a numerous class of patrons. He was 
an influential member of, and one of the best workers in, the State Med- 
ical Association, acted on nearly every committee of importance, and 
was elected President in 1857. He contributed papers to the State 
Society, and also to the American Medical Association. He served as a 
surgeon in the late war, and lost his life from a dissection wound, 
(b. Dec. 31, 1821; d. June 27, 1864.) Dr. Alexander McDill, a native of 
Pennsylvania, after practising for fifteen years in his native State, 
removed in 1856 to Wisconsin, and settled in Plover, Portage Co., where 
he became fully employed. In 1862-3 he was sent to the Legislature, 
and the following year to the Senate. In 1868 he was chosen Super- 
intendent of the State Hospital for the Insane. In 1872 he was elected 
to Congress, but at the expiration of his term of office, resumed his 
place as Superintendent of the Asylum, (d. Hov. 12,1875.) In addition 
to the foregoing, I will name Drs. Henry M. Lilly, Moses Barrett, H. 0. 
Crone, A. Blanchard, B. F. White, and Corydon Farr. 
My task here ends, A century of American Medical Biography has 
been traversed. Of necessity, the memoirs are very brief. The claims of 
every part of our country have however been considered. The retrospect 
is finished: I would it were worthier of the occasion. And in conclu- 
sion I wish to bear testimony to the fact that the study of the lives of the 
physicians of America, for the Centennial period, has produced in me, 
as I trust it will in others, a profound conviction that eminence and hon- 
orable distinction in the profession, are the legitimate results of good 
education and professional knowledge, conjoined with high moral cha- 
racter and devotion to duty. These qualities, with a desire to do good 
and an active sympathy for our race, stand out so prominently in the 
lives of all truly eminent physicians, as to appear to be essential traits 
of professional character. So uniformly are love of man and devotion to 
duty characteristic of the true physician, that it is not arrogant to claim 
for him a higher approbation, as in the vision of Abou Ben Adhem, 
who saw that the name of him who loved his fellow men “ led all the 
rest,” on the roll “of those whom love of God had blest.” 
When in the course of time another century of American Independ- 
ence shall have been concluded, the professional men then occupying our 
places may perchance choose to meet as we have done, and, casting a retro- 
spective glance across the second century, contrast their position and the 
progress then attained with that which marks our era. And while 
1 trust that they may have abundant reason to congratulate themselves 
upon the advance which medicine shall have made, I doubt not they will 
have an honest pride in the monuments, legacies, and records left by ADDRESS ON MEDICAL BIOGRAPHY. 
the profession during the century just closed. These have in part been 
referred to in the addresses and papers read before this Congress. Per- 
mit me to indulge the hope that the biographer of the next Centennial 
may have as great pleasure and satisfaction in the study of the lives of 
the medical men of the second century of our country, as I have enjoyed 
in the preparation of this address. I am persuaded that the temple of 
fame holds no more honored tablets than those on which are inscribed 
the names and deeds of the worthy members of the Medical Profession. 
That the members of this Congress may deserve to have their names 
perpetuated to fame through all succeeding ages, is my earnest prayer. 
To have my own there enrolled, I may not hope, since this is granted to 
but the immortal few. 138 
ADDRESS ON OBSTETRICS. 
BY 
THEOPHILUS PARYIJST, M.D., 
PROFESSOR OF OBSTETRICS AND THE MEDICAL AND SURGICAL DISEASES OF WOMEN, COLLEGE 
OF PHYSICIANS AND SURGEONS OF INDIANA. 
“ There is no department of medicine or surgery, superior to midwifery in 
dignity and utility.”—Mauriceau. 
Of American Obstetrics, with its associate branches, Gynascology and 
Paediatrics, we commemorate the centennial. 
What have Americans done, in the century just closed, to advance 
these great departments of Medicine ? How easy the question and how 
difficult the answer! Contemporaneous discoveries and successes are 
found in these as well as in other fields of human effort, and who, then, 
shall be primus inter pares! Sometimes, too, that which is supposed to 
he new1 is really old, and the discoverer has unconsciously trodden in 
the footsteps of another. 
Beside this, much of medical knowledge is merely provisional, the 
best expression ot the truth for the time being, and serves only a present 
utility—a mere ladder by which we ascend to higher platforms and larger 
planes, and which is then cast aside. Ror does everything claimed as 
valuable by him who first points it out, prove to be such when thoroughly 
tested. Alas, for the many Ixions who mistake a cloud for a goddess ! 
Alas, for the fool’s gold that so often delights, so surely disappoints! 
Change is not synonymous with improvement; so far from change always 
being progress, it may be retrogression.2 
Aor are these the only difficulties. Add to them the limitation of 
individual knowledge, and the infirmities of human judgment, so liable 
to error in estimating the value of things present, no matter how deter- 
mined and desirous one may be suum cuique tribuere. And surmounting 
all these, there stands in bold relief the fact that the very work of this 
occasion has been largely anticipated by an able paper in the American 
Journal of the Medical Sciences,3 from the pen of one who has himself 
contributed so much to the glory of American Medicine. Confronted by 
such difficulties, and addressing such auditors, one even of ample qualifi- 
cations might well shrink from attempting the duty assigned me. 
However, strengthened by your recognition of these impediments, and 
1 Professor Blackie, Hover. Hellenicce, observes: “Even in the free exercise of poetical 
talent in the case of individual poets of highly potentiated imagination, we constantly 
stumble on comparisons which have been made independently by other poets at other times 
or in distant countries, and which superficial critics are sometimes eager to fasten on as 
plagiarism.” Quite similar facts are observed in the history of medicine. 
2 Baudelocque, Yol. 11, pp. 84, of Li Art des Accouchemens, Paris, 1781, in referring to 
the obstetrical forceps remarks: . car si plusieurs ont travailU dsa perfection, 
les autres ne I’on rendu que plus imparfait.” 
,/3 July, 1876. A Century of American Medicine. Ill—Obstetrics and Gynaecology. 
By T. Gaillard Thomas, xM.D. ADDRESS ON OBSTETRICS. 
139 
confiding in your earnest sympathies with this work, I address myself 
to it with zealous desire to honor justly both the dead and the living of 
our country, who have added useful knowledge in obstetrics, and in 
diseases of women or of children, and to help exalt their fame in all 
they have thus done to lift or lighten the cross of human suffering. 
In this proposed exposition, the subject of Obstetrics will, for obvious 
reasons, be presented first. After some brief allusions to the condition 
of obstetric art and science in the last century, and the sources from which 
the first American practitioners of this art derived their knowledge, 
suitable topics will be found in works on Obstetrics, and in special con- 
tributions to obstetric pathology and therapeutics. 
The eighteenth century was marked by great advances in obstetric 
knowledge and improvements in practice, though history has shown 
the mistake of a distinguished physician of South Carolina, Dr. David 
Ramsey, who, in an address before the Medical Society of his State, on 
the first day of the present century, asserted “that the art of obstetrics 
had been brought to such perfection, further improvements were scarcely 
to be expected.” 
-Standing at the commencement of the eighteenth century is the famous 
Hollander, Deventer, who declared theory as essential to practice as body 
to shadow—surely a very doubtful compliment to practice—who asserted 
that those1 ignorant of the obliquities of the uterus were equally blind 
with him that saw trees as men walking, but who, despite these and similar 
exaggerations, despite plain, palpable errors, advocated cephalic version, 
and taught the genu-pectoral position as part of the treatment in one 
variety of prolapse2 of the cord, and in some cases of transverse3 presen- 
tation. 
Kear its close we have the illustrious Baudelocque, to whom so many 
of our obstetric authors acknowledge their obligations, and whose fame, 
notwithstanding his twenty-three presentations and ninety-four positions, 
lias suffered only partial eclipse in the revolutions of more than four- 
score years. And interposed we have Chapman coming from the country 
to London once a year to give lectures on obstetrics, the first,4 and the 
first ever given in that city, being in 1730, and revealing the beneficent 
instrument which the Chamberlens had kept secret with cruel cupidity, 
the obstetric forceps; we have Sir Fielding Guide, the wit’s “ Lord deliver 
. 1 • . quicunque obliqui situs uteri sunt ignari, in artibus obstetricantiurn mque cecu- 
tiant, ac ille, qui homines instar arborura videbat ambulantes. Henrici a Deventer, Medi- 
cinae Doctoris, Operationes Ohirurgicse Novum Lumen exhibentes Obstetricantibus, etc., 
■Leyden, 1701. 
Similiter accidit sed rarius, ut funiculus i capite retrorsum vertebris vel ossi sacro 
Imprimatur : tunc caput alterutra raanu removendum, prout scilicet plus minus in alterutrura 
lalus vergit; parturienti (si vires suppetant) in genuaprovolutce k tergo manum sospitam 
admoveat obstetrix : aut, si infirmior fuerit, in alterutrum latus declinetur, uno pede ad 
yenfrem attracto, ut plus spatii suppetat, etc., Ibid., cap. xxxviii. De partu difficili, ab 
infante prmvia vena umbilical! prodeunte, 
.. • • • ideoque parturientem, tali situ disponat, quo uteri spatium suppetat, nec 
1 c cum infante in manum obstetricis delabatur; nirnirum utero propendido convenit 
parturientem procumbere genibus, aut in dexirum latus inchnare, posteriore corpore 
auquatenus elevato, et ut plurimum prono, etc., Ibid., cap. xl. De infantibus transversim 
positis. 
, 4 % authority is Dr. Thyme. Tide MSS. Lectures, 1794, Surgeon-General’s Library, 
ashmgton. Dr. T. remarks, “Chapman had no machines, nor were his students allowed 
o attend midwifery cases. To Smellie we owe those improvements.” Denman, however, 
audits Dr. Maubray, 1724, with the first lectures. 140 
PAR YIN, 
us,” giving a glimpse at the mechanism of labor, that mechanism soon to 
be much more fully and clearly expounded by Smellie and Solayres; we 
have Smellie and William Hunter, representing opposite but concordant 
elements of obstetrics, mechanism and physiology, the one writing a work 
upon obstetrics, the fruit of forty years’ study, which for nearly three- 
quarters of a century.was the best English text-book, and enduring the 
harmless criticism of Dr. Burton, who probably had his reward in being 
made the Dr. Slop of Tristram Shandy ; the other preparing those plates 
of the human gravid uterus, which can never become obsolete ; we have 
Levret, the geometric obstetrician, explaining the mechanism of labor 
before the Paris Academy of Surgery, using in his demonstrations the 
egg of an ostrich and a “ mattrice mechanique,” and dividing with 
Smellie1 the honor of an important improvement in the forceps. With 
these two men, using the words of Baudelocque, commenced the most 
brilliant epoch of obstetric art. 
But it is not my purpose to mention further the famous obstetricians 
of the eighteenth century, and allude to any of their special contribu- 
tions. Enough to add that the two first American obstetric practitioners 
had been instructed by two of the most eminent of London teachers, for 
Lloyd,2 in Boston, and Shippen,3 in Philadelphia, were pupils of Smellie 
and Wro. Hunter. Thus we see that the germ of American Obstetrics 
was British rather than French, in so far giving probable contradiction 
to the assertion of Dr. Tyler Smith when he states, “ notwithstanding 
the blood relation between the United States and this country, American 
Midwifery is far more the child of France than of England.” So, too, 
probable contradiction is given by these other facts, that Dr. Samuel Bard, 
the author of the first American work on obstetrics, had received his pro- 
fessional training largely in Edinburgh; and that there, too, after having 
previously been a house-pupil in London under Drs. Osborne and John 
Clarke, was instructed Dr. T. C. James, the first professor of obstetrics in 
the University of Pennsylvania. And the famous Dewees, who bears 
the same paternal relation to American Obstetrics that Physick does to 
American Surgery, or Rush to American Practice, and who u has the 
high honor of first attempting a full course of lectures on obstetrics in 
America,”4 was too independent a thinker and original investigator to 
be unduly swayed by the teachings of any man or of any school.5 And 
finally, the obstetric books of the American profession have been British 
or American much more than French. 
Seventy or eighty years ago, the practice of obstetrics was almost 
exclusively in the hands of women, even in the long settled parts of the 
United States, and, as the tide of population passed westward, the female 
midwife was still the trust of the matrons among the early settlers who 
1 Possibly, according to the recent researches of Dr. McOlintock, each of them was anti- 
cipated by Dr. Pugh (see Dublin Journal, June, 1876), so that there is an end to the con- 
test in this matter between France and England. 
2 Dr. Bartlett, of Massachusetts, states that Dr. James Lloyd, of Boston, was the first 
systematic practitioner of midwifery in that section of the country, 1754. 
3 In 1756 Dr. William Shippen engaged in the same practice at Philadelphia, and sub- 
sequently was Professor of Anatomy, Surgery, and Midwifery in the University of Penn- 
sylvania. 
4 Eulogium upon William P. Dewees, by Prof. Hugh L. Hodge. These lectures were 
first delivered in 1797. 
5 “ Drs. James and Dewees should be regarded as the fathers of obstetric science in 
America: the former, erudite and polished, gave currency to the teachings of the British 
schools ; the latter, more vigorous and energetic, exemplifying theoretically and practically 
the doctrines of the French obstetricians.”—Preface to Hodge’s Obstetrics. ADDRESS ON OBSTETRICS. 
141 
swept away the forests and founded an empire beyond the Alleghanies. 
Dr. J. G. F. Holston1 has given a most graphic description of early mid- 
wifery in Ohio; but the compensation of these practitioners, as stated 
by him, seems so meagre that none could have had a lucrative practice, 
no matter how large it was—one dollar, and in cities not more than 
three dollars, and in the country the midwife was also nurse the first 
week or until the ninth day. 
Nor had the American midwife any of the posthumous honors which 
were once the fortune of her sisters in France. That famous sage-femme, 
Louise Bourgeois—whose picture2 Dr. Goodell has with such perfect 
art recently exhibited to the profession—in her Instructions to her 
daughter, Paris, 1617, states, “ There are now very few women who have 
such an affectionate regard for their midwives as prevailed formerly, 
when it was the custom, if a midwife died, for her friends to put on deep 
mourning for her, and they prayed God not to send them any more 
children,”3 etc, . . , 
However the fact remains that the general practice of obstetrics in 
this country has been but for little more than half a century chiefly 
devolved upon medical men, and even to this day, in most of our large 
cities, a considerable portion of this practice, more especially among the 
foreign population, is attended to by females. _ 
The first American work on obstetrics was the Compendium of Mid- 
wifery, by Dr. Samuel Bard, of New York, the first edition being issued 
in 1808, the fourth and last in 1817. Using the phrase of the present 
day, this book is remarkable for its amount of padding, page after page 
being filled with extracts from Smellie, Perfect, Clarke, and various 
writers in the Medical and Physical Journal. But it also contains 
many judicious thoughts and directions well expressed by Dr. Bard, and 
from the very number and variety ot important cases quoted, is leally 
an excellent corapend of clinical obstetrics. In meeting that nodus obste- 
tricus—why labor occurs at nine months, Dr. Bard does not shelter him- 
self with Avicenna behind the grace of God, but assails the question 
with a brace of questions, Why do strawberries ripen in June and 
peaches in August ? . 
In reference to the delivery of the placenta, he certainly was greatly 
in advance of many obstetric authors of recent days, advising almost 
essentially Credo’s method before Credo was born, as the following passage 
clearly shows. “While this is about,” i. e. attention to the new-born 
child, “let an assistant or the woman herself, place her hand on the ab- 
domen, a little above the fundus uteri, so as in some measure to giasp it 
in the palm, and make a moderate pressure upon it. This can possibly 
do no harm; it has been my general practice; and I think I have found 
a manifest advantage from it in promoting the contraction of the uterus 
and in disengaging the placenta.” _ . 
And in the management of women after parturition the following 
instructions seem wise, though even at this day they are too generally 
neglected. “After one or tw7o days, women should rise from their beds, 
and sit up for a longer or shorter time every day, according to their 
1 Transactions of the Ohio State Medical Society, 1857. 
2 A Sketch of the Life and Writings of Louvse Bourgeois—The Annual Address of the 
Retiring President before the Philadelphia County Medical Society, by William Goodell, 
A.M., M.D. Delivered June sth, 1876. 
3 Dr. John Moultrie, for forty years at the head of the profession in Charleston, died 
about 1773; and several of the ladies of the city bedewed his grave with their tears, and 
went into mourning for him.—Thacher’s Medical Biography. 142 
PARTIN, 
strength and inclination.” “ The lochia require no other attention than 
sitting up a short time every day to promote their evacuation.” 
Of wider scope, of more originality, and destined to a much larger 
fame, was the Compendious System of Midwifery, by Dr. Dewees, first 
issued in 1826, of which no less than twelve1 editions have been pub- 
lished. Dewees himself had some years before, 1807, published an 
abridgment of Heath’s translation of Baudelocque, with annotations, 
and it passed through at least three editions. Burns’s Principles of Mid- 
wifery was republished in 1810, with notes by Dr. Chapman, and several 
subsequent editions edited by Dr. James ; in 1821, Denman’s Introduction 
to the Practice of Midwifery, with very valuable notes by Dr. John W. 
Francis, was issued in Hew York, But not Baudelocque, nor Burns, nor 
Denman was to be the first great obstetric teacher of the American pro- 
fession. He who was to have this honor was no favored child of fortune, 
but one early in youth left fatherless and poor, with no heritage but a 
good name, with few facilities for acquiring a complete literary education 
amid the desolations of the Devolution, yet bravely struggling up against 
rude adversities. His first professional labors were those of a country 
practitioner in one of the pleasantest2 of villages—once hidden away, 
surrounded by farms or forests—now almost lying within reach of the 
outstretched arms of this great city. There he acquired those habits of 
close observation and reflection which were the foundation of his future 
greatness and fame. Then, after four years’experience casting his lot in 
Philadelphia, and without fortune, without family influence, without 
professional friends save as they were attracted to him by the recognition 
of his abilities—no adventitious aids—he succeeded by his own inherent 
power and perseverance. The name of William Potts Dewees should 
live forever in the memory of the American profession. 
Dr. Hodge, in speaking of Dr. Dewees in 1842, observed: “He is our 
representative to other nations on the science of obstetrics, and as such 
is continually quoted by European authorities, as if he constituted one 
of their own number.3” As to the merits of Dewees’s Midwifery, let me 
again quote the opinions of Dr. Hodge. He considered it, twenty years 
after its publication, as “probably the best practical book in our pro- 
fession.” “It takes a stand decidedly in advance of Denman, Osborne, 
Burns, and other English authorities in general use in our country at 
that period, and even of Baudelocque himself,” etc. Without acceding 
to the truth of Pope’s couplet— 
“Authors, like coins, gi'ow dear as the}*" grow old ; 
It is the rust we value, not the gold,” 
1 “An honor rarely, if ever, bestowed on any similar work.”—History of American Medi- 
cal Literature. By Professor S. D. Gross. 
2 Abington, Penna. 
3 “ Dr. John Ramsbotham, of London, dedicated the second part of his ‘ Practical Obser- 
vations on Midwifery’ to Dr. Dewees, in connection with Sir C. Mansfield Clark. Dr. Edward 
Rigby, of London, and author of a most excellent work on Obstetrics, which has lately 
been republished in this country, writes to Dr. Dewees in August, 1834, in the following 
manner:—‘l trust you will pardon the liberty I have taken in writing to you, as well as 
the motives which have induced me to do so. I have been accustomed, for some years, to 
hold such frequent intercourse with you in reading your admirable system of Midwifery, 
and work on children, that I cannot refrain from requesting a more direct intercourse 
between us,’ etc. The July number of the British and Foreign Medical Review, for 1839, 
contains the following handsome compliment‘ The Philadelphia school of Midwifery has 
for many years been looked upon with great respect by the obstetricians on this side of the 
Atlantic. The high name and professional standing of Dr. Dewees, his great experience, 
and, above all, his inestimable, compendious system of Midwifery and other valuable pub- 
lications, have mainly contributed to this result.’ ” ADDRESS OX OBSTETRICS. 
143 
let me predict that as with pious care and grateful appreciation one of 
the most celebrated of the Dublin school is bringing the “ Treatise” of 
Smellie before this generation, so this or a succeeding generation will 
see the avatar of the “ Compendium” of Dewees in like modern form. 
To Dr. Dewees, probably, we are more indebted than to any one else, 
for the general preference on the part of the American profession for the 
long forceps.1 Dr. Dewees2 accomplished great good in exposing the 
errors of Denman in his aphorisms as to the use of this instrument, and 
the practice of the former is much more in accordance with that of 
to-day, than is that of the latter: an apparent timidity and conservatism 
ruled Denman’s teachings in this regard, which conduced to the interests 
of neither mother nor child—he was a representative of that physiological 
school of obstetrics, originating with William Hunter, in opposition to 
what Tyler Smith has termed the mechanical school of Smellie—but our 
American obstetrician represented both in harmonious union. 
To Dr. Dewees belongs the honor of pointing out the value of 
venesection not only in overcoming rigidity of the os uteri, but also 
in diminishing the resistance of vaginal cicatrices—the utility of his 
teaching and practice in this regard being recognized by foreign obste- 
tricians. 
It is sad to recall the fact that this famous man, with whom the history 
of American obstetrics really begins, should ever have been an unsuc- 
cessful candidate for the chair of midwifery in the University of Penn- 
sylvania ;3 sadder still to know that when, twenty-four years later, the 
honor came by unanimous voice of the trustees, failing health permitted 
him to hold it but a year—the infirmities of age are upon him, almost 
the shadow of the grave is in his path before he reaches the noble goal of 
his life, and grasps the coveted prize. How true it is that his 
Rustled most when the leaves turned brown.” 
—“ laurel crown 
The next American work on Obstetrics was “The Philadelphia Prac- 
tice of Midwifery,” by Dr. Charles D. Meigs,4 published in 1838 ; it was 
brief and elementary; a second edition was issued in 1842. Three 
years subsequently Dr. Meigs was elected a professor in Jefferson Medi- 
cal College, and became famous as one of the best of teachers and one 
of the most brilliant of lecturers, while his genial manners in social life 
won all hearts. Almost equally fascinating with his uttered are his 
printed words, so that one can now read page after page until hours 
pass away without weariness. Fluency and force, strength and beauty, 
characterized his literary composition in a remarkable degree; not only 
1 It is stated by Hutchinson (Biographia Medica, London, 1799), that Smellie for a time 
endeavored to substitute wooden for steel forceps. 
2ln referring to Dr. Denman, Dr. Dewees remarks : . . “there w7as a time in my life 
when I looked upon Dr. Denman to be the highest authority in midwifery.” 
3 The election of Dr. James seems really to have been effected by a combination between 
him and Dr. Chapman—there w7ere only three candidates—the latter to have half the emolu 
ments, and to succeed to the next vacant chair in the University (see Hodge’s eulogium 
upon Dewees)—a sort of bargain and sale which at this distance does not seem quite im- 
maculate. 
4 A very interesting memoir of Dr. Charles D. Meigs, by his son, Dr. J. Forsyth Meigs, 
has been published, but unfortunately did not come into the writer’s possession until he 
was correcting the proof-sheets of this Address. In the memoir the author states that his 
lather wished to call his home in the country “ Paraclete,” the Comforter. Was not this 
111 imitation of Abelard, who, when his admiring students, following him to his desert 
retreat, built him a new oratory, called it the Paraclete? 144 
PARTIN, 
the treasures of his favorite department were his, but he was at home 
in general literature and familiar with classic story, while a Gallic 
vivacity, if not a poetic genius, flashed out as he moved on his brilliant 
path, like the phosphorescent spray from a ship’s prow as she ploughs 
the tropic seas. 
In 1849, Dr. Meigs re-issued his work on obstetrics in a much en- 
larged and improved form; since that date four editions have been 
published, this fact indicating the great favor with which the Ame- 
rican profession regarded it. The most valuable discovery in obstetric 
pathology made by Dr. Meigs is the usual cause of sudden death after 
delivery, which he announced in 1849. Before and since, various other 
explanations of this terrible accident have been given, such as the entrance 
of air by the uterine veins, nervous exhaustion, shock, puerperal poison- 
ing, etc., but to-day the theory of Meigs has general professional accept- 
ance, even if the heart clot, or pulmonary thrombosis, the immediate 
cause of fatality, should be proved to be itself a result of myo-cardiac1 
degeneration. 
As we read how earnestly Dr. Meigs declares against Caesarean section, 
save in the interests of the mother, we shall find additional reasons for 
questioning Dr. Smith’s allegation as to American obstetrics being so 
much more nearly a product of French than of English teaching—the 
chief alleged characteristic of the French school being the proneness to 
sacrifice the mother’s rather than the infant’s life whenever the rights of 
the two are brought in conflict. 
Dr. Meigs’s views as to puerperal fever were boldly expressed, and no 
concealment of them is now required. The painter in the Sacrifice of 
Iphigenia simply drew a veil over the face of Agamemnon: Would that 
a veil had forever hidden, not the views of Dr. Meigs only,.but of other 
teachers of the Philadelphia school, and many sacrifices, blinder, more 
terrible, might have been averted 1 He who held the non-contagiousness 
of measles, of scarlet fever, even, might also hold to the non-communica- 
bility of puerperal fever under all circumstances. To-day, at least, the 
American profession are generally agreed that while the disease is fre- 
quently auto-genetic, it sometimes at least, and in its most terrible forms, 
is hetero-genetic, and it is the merest petitio principii to allege, as Dr. 
Meigs did, that, because he did not know of his having communicated it, 
either by conveyance of the poison from one patient to another, or from 
autopsies, therefore this never happened to others. 
In 1849, “A Theoretical and Practical Treatise on Human Parturition,” 
by Professor Henry Miller, of the University of Louisville, was published. 
In 1858, a republication of this work, much enlarged and improved, was 
made. From Dubois, Dr. Miller took his anatomy, and from Dugbs, his 
classification of presentations and positions, while his principles of practice 
were essentially the same as those of Burns and Hamilton. Dr. Miller’s 
views in reference to the importance of inflammation of the lining mem- 
brane of the uterus as a frequent cause of abortion, were certainly in 
advance of obstetric writers of his day. So, too, the higher honor must 
be given of being the first American obstetric author who advocated 
anaesthesia in labor. 
Dr. Miller was a man of vigorous mind; he was clear and original in 
thought, concise in expression, severe almost to bitterness in controversy. 
1 De la Myocardite Puerp6rale, comme cause la plus fr6quente des Morts Subites apres 
I’Accouchement. Par Maurice Ooste. Paris, 1876. ADDRESS ON OBSTETRICS. 
145 
Like Dr. Dewees, he had few early advantages in education, but he 
learned to use his pen with more ease and force than the latter, and pro- 
bably was a man of better original endowments. His work on obstet- 
rics was declared by the late Dr. Condie1 to be a most able one, confer- 
ring the utmost credit upon the author. 
The Principles and Practice of Obstetrics, by Gunning S. Bedford, 
M.D., Professor of Obstetrics in the University of Hew York, was pub- 
lished in 1861; and five subsequent editions have been issued. Dr. 
Bedford’s volume, which is probably the most learned of American 
works on obstetrics, is in the form of lectures, and with here and there 
some extravagances in rhetoric, is written clearly, plainly, indeed some- 
times assuming a colloquial style. It is evidently “ the result of much 
labor and research.”2 From its long list of authors quoted, and from its 
full and carefully prepared index, it is admirable as a book of reference. 
We find this author arraying himself on the side of the contagionists 
as to puerperal fever, but a rejector of anaesthesia in normal labor. His 
teaching as to the choice between craniotomy and the Caesarean section 
is almost directly the opposite of that of Dr. Meigs and most other 
American obstetricians, and while he protests against craniotomyhe 
does not fully recognize that podalic version may be the true alternative, 
and not the Caesarean operation. 
In 1864, the most original and elaborate of American Obstetrical 
works was issued in Philadelphia, the admirable treatise of the late Dr. 
Hugh L. Hodge, the honored successor of Dewees in the University of 
Pennsylvania. After thirty-one years of obstetric teaching, he prepared 
this rich legacy for the profession.3 
Dr. Hodge was the first to illustrate the of the female 
pelvis, its axes and its planes, by taking a plaster cast ot it, and making 
sections of the cast. He was the first to use photography,4 to exhibit 
with perfect accuracy the relations of the toetal head to the mother’s 
pelvis, in the various presentations and positions, and in the different 
stages of simple and of complicated labor, and also the applications oi 
the forceps in different positions. He contributed materially to restore 
the vectis to use in the remedying of malpositions. The application 
°f the obstetrical forceps to steady and isolate the head, in craniotomy, 
then after the operation the use of the instrument for compression 
End extraction, must be regarded as a most valuable improvement, for 
which the profession is indebted to Dr. Hodge. He also improved the 
operation of cephalotripsy by devising a simple and efficient instrument 
his compressor cranii. He taught the doctrine of synclitism, or 
parallelism of the plane of the child’s head, in cases of natural presenta- 
tion, to the planes of the pelvis and vagina, as early as the year 1832r 
and from that time until his death presented this doctrine with more- 
precision and detail than has any other author. He was among the first 
to recommend the induction of premature labor, in cases where labor had 
previously terminated fatally to the child in consequence of its great size 
and the complete ossification of its head. His obstetric forceps is the one 
2 American Journal of the Medical Sciences, Jan. 1857. 
s British and Foreign Medico-Ohirurgical Review, July, 1862. 
“ Dr. Hodge’s treatise is, nevertheless, full of much valuable information, and although 
ns price alone will prevent its ever becoming popular amongst students in this country, 
still we strongly recommend that it should have a place in the library of every obstetric 
Physician.”—British and Foreign Medico-Ohirurgical Review, October, 1865. 
this was done at the suggestion of his son, Dr. H. Lenox Hodge. 
10 146 
PARTIN, 
held in most favor by the American profession. Few men have studied 
the mechanism of labor more thoroughly, none have expounded it more 
clearly. Generations may come and depart, until another century pours 
its treasures upon the race, but it is doubtful if among these will be found 
another work on obstetrics of greater relative merit an’d of more enduring 
value than the treatise of Dr. Hodge. 
In the year 1870, a Treatise on the Theory and Practice of Obstetrics, 
by Dr. W. H. Byford, was published, a second edition appearing in 
1873. The design of Dr. Byford was to furnish the student and busy 
practitioner with a more concise work than any in general use, and 
yet embodying all the necessary practical information. Ho one can 
question how well its able and industrious author has succeeded in this 
design. 
A work entitled Elements of the Principles and Practice of Midwifery, 
by Dr. David H. Tucker, was issued in 1848. The Obstetric Catechism 
of Dr. Warrington was, in Philadelphia, held in high esteem twenty or 
more years ago, especially by those who were fortunate enough to avail 
themselves of the practical instructions of this excellent teacher. Dr. 
Cock’s Manual of Obstetrics, 1853, was held in like favor in Hew York. 
Having devoted so much space to the consideration of treatises upon 
obstetrics, the topics of obstetric pathology1 and therapeutics must neces- 
sarily be briefly considered. 
The present century has been marked by some of the most important 
advances in obstetrics ; and “it is not going too far to assert that, not- 
withstanding the brilliant improvements in surgery, and the solid and 
wise modifications in medicine, the changes in our art have preserved 
more lives, and relieved more human suffering and misery.”2 In pro- 
moting these advances, and in effecting these changes, our country has 
borne her part. Few obstetricians of the present day would accept the 
statement of William Hunter, that upon the whole the forceps had “ done 
more harm than good,” or participate in the “doubt of Denman 
“ whether it would not have been happy for the world if no instrument 
of any kind had ever been contrived for, or recommended in, the practice 
of midwifery,” or believe—and we quote again from Denman3—that 
■“ the doctrine of applying forceps before the bulk of the head has passed 
the superior aperture of the pelvis, carries great danger and insurmount- 
able difficulties with itnor again, does the obstetrician now wait until 
he can “ feel an ear,” or until “"the head has rested six hours upon the 
perineum,” before resorting to an instrument that is at once for the good 
of both child and mother. 
Anaesthesia in obstetricy must be counted one of the greatest glories 
of the century—nay, the brightest, broadest beam of perennial light that 
has ever fallen upon woman’s pathway, darkened by the primeval curse. 
In 1846, the great discovery of anaesthesia by inhalation of ether vapor, 
with which the names of Wells and Morton are so inextricably inter- 
1 The topics of obstetric anatomy and physiology would be appropriate could their history 
be made really complete. Under the former head would be mentioned in detail Dr. Hodge’s 
studies as to the female pelvis, already referred to; Dr. John Neill’s, as to the shape of the 
thyroid foramen, and numerous similar investigations; and under the latter, studies such 
as Dr. Dalton’s, of the corpus luteum; Dr. Geo. J. Englemann’s recent, patient, thorough, 
and interesting researches as to the mucous membrane of the uterus ; Dr. Isaac E. Taylor’s 
demonstration of the non-shortening of the cervix in the latter months of pregnancy; and 
Dr. J. R. Beck’s observations upon the entrance of the spermatozoa into the uterus. 
2 Dr. Thomas Edward Beatty’s address before the Dublin Obstetrical Society, 1862. 
3 Criticism of Leake. ADDRESS ON OBSTETRICS. 
147 
woven, was made; in January, 1847, the illustrious Simpson, of Edin- 
burgh, proved the value of ether in child-birth. The discovery found 
'"'Walter Channing, the first professor of obstetrics1 in Harvard, past his 
three-score years ; but he entered heartily into the study of this question, 
and the next year he presented a volume upon Etherization in Child-bed, 
in which the records of nearly six hundred cases were given, and which 
greatly contributed to the frequent—l wish at this day one could say 
general—use of anaesthetics in labor. Other names deserving of recogni- 
tion in this connection are those of Hrs. F. Barker, of Hew York ; H. R. 
Storer, of Boston ; J, C. Reeve, of Dayton, Ohio ; and H. Miller and L. 
P. Yandell, of Louisville, Kentucky. 
The administration of chloral is another of the beneficent means of 
recent times for the relief of the sufferings of parturition, which has had 
many advocates in this country. 
The opium treatment of peritonitis is one of the most important ad 
vances in therapeutics. It may be now true, as asserted by Dr. Spender,2 
that “ the bare mention of that terrible disease, peritonitis, is suggestive 
of the siren lullabies of opium.” But this treatment was the suggestion 
and practice of Dr. Alonzo Clark, as early as 1841,3 though it was not 
until 1848 that he had an opportunity of demonstrating its value in the 
puerperal form of peritoneal inflammation. Opium alone, is the treat- 
ment of 'phlegmasia dolens advocated by Dr. Clark,4 of Oswego, and he 
claims that the remedy is as efficient as quinia in ague. 
A marked advance has been made in the more liberal diet and rational 
hygiene of women after labor. That former horror of the lying-in room, 
1 This position Dr. Channing held for nearly forty years, and only a few weeks since 
passed away from earth, having lived to be upwards of ninety years of age. 
2 Therapeutic Means for the Relief of Pain. London, 1874. 
3 The following recent note from Dr. Clark will be read with interest:— 
Ukar Doctor : I continue to use opium in the treatment of simple peritonitis and puer- 
peral peritonitis, and peritonitis after perforation, with the fullest confidence that it will 
cure a much larger proportion of cases than any other treatment yet proposed. It is ac- 
cepted by all the physicians of this city and State, I think ; at least I hear of no other, not 
°nly for peritonitis in its different forms, but in all operations, injuries, and wounds that 
ai-e likely to be followed by this inflammation. I do not know how far it is approved 
abroad, but infer that it has received little attention in England, from the fact that Dr. 
Darker, of this city, made it the topic of an address at a meeting of English physicians a 
5 car or so ago. 
4>r. Graves, it is said, used opium in large doses for the cure of peritonitis after perfora- 
'on of the intestine. When he began that treatment I do not know; but Ido not find 
any reference to it in his lectures published in 1843. Watson’s Lectures, one of the later 
editions, refers to a Mr. Bates, who treated peritonitis with opium; but when he began, 
oes not appear. Still the English physicians generally seem to know little of the power 
0 opium in the different forms of peritonitis. In the Am. Journ. of Med. Sci., July, 1876, 
fo fob you may find a statement of the origin of this treatment in my own mind, in 1841; 
and before 1843 cases of intestinal perforation had been successfully treated on this plan, 
t ifar(^in£ le rules, I begin with two grains of opium, or its equivalent opiate, and in 
vo hours give the same, or more, or less, according to the effects produced. Patients re- 
CTIS ,or yield to the narcotic effects of the drug very differently. In some cases, twenty-four 
plains of opium a day is all that is required ; in a few, twelve or sixteen grains is sufficient, 
u most, two to four grains at a dose are needed ; in a few, more than this. The aim is to 
j a. ..maintain the symptoms of safe narcotism, or, as I sometimes call it, semi-narcot- 
m, indicated by subsidence of the pain; contracted pupils; itching of nose and skin; a 
}nu?us sleep, from which, however, the patient is easily aroused; reduced frequency of 
piration, followed by reduced frequency of pulse ; and absolute quiet of the bowels, 
ami n£ the respiration, the aim is to reduce its frequency to twelve in the minute, 
ln the attempt to do this it is often found to fall as low as seven, without danger, if 
to 1°blllra 48 then withheld for a few hours, till it rises to ten, when a smaller dose is given, 
4 ® lncreased or not afterwards. Yours truly, A. Clark. 
-New York Medical Record, June, 1870. 148 
PARTIN', 
the very existence of which is cast in doubt—milk fever—which was to 
be averted by a liberal use of the canonical caudles of Smellie’s day, and 
the prophylactic panadas of more modern times, and by poisoned air, no 
longer governs practice; and the recent parturient is given cold water 
as she desires, inhales pure air, and is fed with wholesome food, that is, 
such as will best repair her exhausted powers and furnish suitable mate- 
rial for making good milk. How early any publications were made 
advocating this course, I cannot ascertain, but certainly it has been pur- 
sued for some years, and possibly it may not have been at the instance 
of any professional leader, but simply a general tendency of physicians 
themselves. The names of Hrs. F. Barker, William Gfoodell, and Wil- 
liam B. Atkinson, are among the more prominent of those who have ad- 
vocated it. 
During the present year a most able volume on Extra-uterine Preg- 
nancy, by the late Dr. John S, Parry, has been published. In it the 
talented author, removed too early for the honors that surely awaited 
him, and for a career of great usefulness not half accomplished, has col- 
lected live hundred cases of this accident, and from a careful study of 
them has deduced most important practical rules. Such works are at 
once permanent contributions to medicine, and indices of its higher de- 
velopment and more scientific character. 
Some of the most remarkable cases of operation for extra-uterine preg- 
nancy are those by Dr. William Baynham,1 of Virginia, who operated 
twice, 1791 and 1799, successfully by abdominal incision; one by Dr. 
John King, of South Carolina, 1813, who incised the vagina at full term, 
saving both mother and child, and one by Dr. T. G-. Thomas, the preg- 
nancy having advanced to three months, who also incised the vagina, 
but with the galvano-caustic knife. So, too, the case reported by Clarke, 
in 1806, where he passed his hand into the bowel, and with his finger in 
the child’s mouth exerted such traction that he withdrew the head per 
anum, should not be forgotten among the extraordinary cases, especially 
as he thus showed the feasibility of the method of abdominal explora- 
tion recently proposed by Simon. Dr. Easley,2 of Little Dock, Ark., has 
quite recently reported an interesting and successful case of abdominal 
section for the removal of a dead foetus. 
The Induction of Premature Labor was first resorted to in this coun- 
try, in 1810, by Dr. Thomas C. James3—the cause, contracted pelvis, and 
the result fortunate to both mother and child. Since that time a much 
larger range has been given this operation. We have already stated Dr. 
Llodge’s views as to its being indicated in cases where the head is large 
and completely ossified at full term. Dr.Thomas4 has enumerated ten 
other conditions indicating it, the most important being placenta prsevia 
and aggravated uraemia. The teaching and experience of Dr. Thomas have 
contributed much towards the recognition of the propriety of inducing 
premature labor, in the interest of both the mother and the child, in 
cases where the placenta is prsevia. A distinguished British obstetrician5 
observes: “We have arrived at a very generally admitted conclusion as to 
1 Dr. William Baynham was long considered the most eminent surgeon in the Southern 
States, and was particularly distinguished for his accurate knowledge of anatomy.— 
Thacher’s Medical Biography. 
2 American Practitioner, September, 1876. 
3 Memoir of Dr. Thomas C. James. By Professor Hugh L. Hodge, Philadelphia, 1853. 
4 New York Medical Journal, February, 1870. 
5 Dr. Playfair. British Medical Journal, May 4th, 1872. ADDRESS ON OBSTETRICS. 
149 
the danger of temporizing, and as to the advisability of artificially in- 
ducing labor as soon as the existence of placenta prsevia has been fully 
determined.” It is true Dr. Thomas’s publication was in some measure 
anticipated some six years by a paper from Dr. Gfreenhalgh,1 advocating 
this practice; but he himself was partially anticipated by Dr. A. S. 
Donkin,3 who proposed to expedite labor and check the flooding in pla- 
centa pme via by inserting into the os uteri a sponge-tent prepared for the 
purpose. Dr. S. C. Busey,3 of Washington, has presented an able argu- 
ment for the induction of labor in uraemia. 
Placenta Praevia has been the subject of special study by Dr. J. D, 
Trask,4 and by Dr. Wm, Bead.5 Dr. Read was regarded by the highest6 
critical authority in Great Britain as having rendered valuable service 
to his profession, and considerably enlarged and strengthened the founda- 
tions of obstetric science; and it is declared that the impartial and philo- 
sophic manner in which he has used statistics for the purpose of deciding 
grave practical problems is worthy of all praise and imitation. 
Dr. Trask, whose prize essay on placenta prsevia has been alluded to, 
has also laid the profession under obligations by quite a thorough study 
of rupture7 of the uterus; four hundred and seventeen cases of this 
accident are tabulated, and important lessons deduced. This mono- 
graph ranks by the side of the one by Crosse on uterine inversion. 
Dr. John Stearns,8 of New York, in a letter to Dr. Akerly, published 
in the Medical Repository, 1807, announced that ergot9 was capable of 
exerting a specific action upon the uterus; that it greatly augmented 
the power of that organ during the efforts of parturition ; and that, in 
lingering and protracted cases, it speedily induced forcible pains, and 
greatly expedited delivery. And in June, 1813, Dr. Oliver Prescott, in a 
communication made to the Massachusetts Medical Society, pointed out 
the value of this agent in post-partum hemorrhage. Thus the two most 
important obstetric uses of ergot were first made known by American 
physicians. An able paper, by Dr. William Goodell, on Concealed Acci- 
dental Hemorrhage,10 was published in 1869. This paper contained an 
analysis of one hundred and six cases, and presented the symptomatology 
more clearly and definitely than had been done before. Diphtheria of 
Puerperal Wounds has been made the subject of important contributions 
hy Drs. Lusk and Parry. 
We now make some brief references to operative obstetrics, including 
both manual and instrumental. 
One of the most valuable contributions to obstetric art ever made was 
1 Transactions of the London Obstetrical Society, vol. vi. 
2 Edinburgh Medical Journal, 1859. 
3 American Journal of Obstetrics. 
Prize Essay. Transactions American Medical Association, vol. viii- 
J Library of Practical Medicine. Published by order of the Massachusetts Medical So- 
Clet7- Pol. xxii. Philadelphia, 1861. 
British and Foreign Medico-Chirurgical Review, 1862. 
g American Journal of the Medical Sciences, 1848 and 1856. 
9 Mnerican Dispensatory. By Dr. James Thacher. Boston, 1817. 
Pulvis ad partum was the name soon appropriated to the powdered ergot. Hosack, 
however, shortly substituted for it, Pulvis ad mortem. This is suggestive of Guy Putin’s 
remark in regard to an antimonial preparation which was in great favor in his day, known 
as the Vinum vitae. In one of those letters, first published at Geneva, 1683, of which 
oltaire has observed, “ they were read with eagerness, because they contained anecdotes 
o such things as every body loves, and satires, which are liked still more,” Putin writes 
that the Vinum vitce should be called Vinum mortis. 
American Journal of Obstetrics, August 1869. 150 
PAEVIN, 
that of Dr. M. D. Wright,1 of Cincinnati, in the year 1854. To him is 
justly due the credit of originality in the method of such bimanual 
operation as will in shoulder-presentation succeed in converting it into 
a presentation of the head. Even if the method of Wright were pre- 
cisely the same as that of Hicks,2 still it was published six years before. 
But the essential of each is in the use of both hands—the external hand, 
not as by former operators merely to steady the uterus, but to assist the 
action of the other. True, Dr. Wright applied the method only to what 
is called cephalic version; Dr. Hicks gave greater prominence to the 
accomplishment of podalic version. 
Hext among important manual operations must be placed the postural 
treatment of prolapsed cord and of shoulder presentations, known in its 
first application as the method of Thomas, in its second as that of Maxon. 
In foot-notes I have given extracts from the original work of Deventer, 
conclusively showing that this treatment was advised by him, though it 
was pressed with no urgency, and seems to have been theoretical rather 
than supported by clinical facts. Dr. Bard, in considering podalic ver- 
sion in presentations of the breast, belly, and back, says expressly; “And 
in all cases of particular difficulty, we may facilitate the operation by a 
judicious choice of the posture of the woman ; or by changing it from the 
side to the back, or from the back to the knees and elbows, Deventer par- 
ticularly recommends this position.” Ho one in the face of these testi- 
monies can doubt the priority of the Hollander in the suggestion of 
postural treatment in these labor-complications. So, too, in Dr. Wright’s 
essay, already referred to, the suggestion of the knee-elbow position is 
made, nevertheless, to Dr. Thomas, of Hew York, and to Dr. Maxon, 
of Syracuse, is due the credit of having demonstrated by abundant 
clinical facts the great value of this method in prolapse3 of the cord, 
and in transverse presentation, and of establishing it in professional 
confidence. 
A passing notice is due Dr. Goodell’s “ Management of Head-Last 
Labors,”4 in which constant supra-pubic pressure conjoined with con- 
tinuous traction may so expedite delivery as to greatly diminish foetal 
mortality; and Dr. Parry’s5 method of correcting with the hand faulty 
presentations and positions. 
In obstetric surgery no country can claim more brilliant operations 
than those of the late Dr. William Gibson, Caesarean section twice suc- 
cessfully performed upon the same subject, the children also saved, and 
the gastro-elytrotomies of Thomas and Skene. 
Of course it is impossible to refer to even a tithe of all the valuable 
American contributions to obstetrics and puerperal diseases in the limits 
of this Address—a simple bibliography would consume more than the 
time allotted it; and a dictionary of dates, with a catalogue of cases, 
would illy meet the requirements of the occasion, nevertheless, three 
contributions in this department demand special notice. 
In the year 1843, Dr. Oliver AY. Holmes published, in the Hew England 
1 Prize Essay. Ohio State Medical Society. “ Difficult Labors and their Treatment.” 
2 Dr. Hicks published his method in the Lancet in 1860, giving five cases of placenta 
prtevia in which he had resorted to bimanual version, and in 1863 (London Obstetrical 
Society’s Transactions, vol. v.), presented a fuller account of it. 
3 Prolapse of the cord has been made the subject of an elaborate monograph by Dr. 
George J. Englemann, American Journal of Obstetrics, 1873-4. 
4 Philadelphia Medical Times, March 20, 1875. 
5 American Journal of Obstetrics, vol. viii. p. 138. ADDRESS ON OBSTETRICS. 
151 
Quarterly Journal of Medicine and Surgery, a paper afterwards issued in 
book form, in reference to the contagiousness of puerperal fever. Emped- 
ocles combined in one, poet, priest, politician, and physician ; and history 
records that he rescued a city from desolation by blocking up a mountain 
gorge through which pestilential winds were sweeping. In like manner 
an American, whom the world so knows as poet, essayist, and philosopher, 
that, arrayed in these glories, crowned with these honors, we almost for- 
get that he is a physician and medical teacher, once by his bold, decisive 
utterances, his startling array of facts, his invincible logic, greatly con- 
tributed to destroy a pernicious doctrine taught by some of our leading 
obstetric authors—a doctrine which was more certainly laden with death 
than the foul wind that was destroying the citizens of Agrigentum. 
In 1868, the Obstetric Clinic, a Practical Contribution to the Study of 
Obstetrics and the Diseases of Women, by Dr. George T, Elliot, was pub- 
lished. Its author, whose talents and culture were admirable, and who, 
alas, was taken away in the prime of life and power, utters these noble 
and just words explaining his motives in writing this book, words which 
ought to be well pondered by all who have similar opportunities. “The 
work is presented as a partial discharge of the debt due to the profession 
by all who enjoy hospital advantages; and in grateful recognition of the 
benefits which the author has derived from the experience of others.” 
Elliot’s Obstetric Clinic has taken its place among the classics of our 
profession, and cannot fail to be of value to any one who consults its 
pages. 
lir 1874, the first edition of Dr. E. Barker’s Lectures on the Puerperal 
Diseases was issued, and the second edition the present year. _ This, too, 
is a clinical work, and eminently practical. It filled a gap in medical 
literature, met an urgent need of the practitioner, and was received 
with great favor, both at home and abroad. 
In considering the second division of the subject, an order similar to 
that observed in the first will be pursued, and accordingly American 
treatises on Diseases of Women will first be referred to. These works 
have had the following authors: Dewees, Meigs, Hodge, Byford, Chap- 
man, and Thomas. The first edition of Dewees’s work was issued in 
1826, the ninth and last in 1847 ; this contains the revisions and addi- 
tions made by the author a short time before his death, and may be 
regarded, therefore, as embracing Dr. Dewees’s best utterances upon the 
subjects discussed in it. To say that the book is badly written, would 
be a mild way of stating that there are therein frequent instances of 
violations of the simplest rules of grammar and the plainest laws of 
rhetoric. But what of the matter? More than one-third of the five 
hundred and odd pages are occupied with the disorders of pregnancy, 
puerperal fever, phlegmasia dolens, milk abscess, and hysteria; diseases 
of the ovaries are discussed in a little more than a page, and the moder- 
ately well-behaved irritable uterus of Gooch, becomes a monster ot 
inflammation for the conquering of which general depletion is some- 
times, and local depletion is always, necessary. On pages 256 and 257, 
there is given the history of one of the most strangely managed cases, as 
seen by the light of to-day, that ever was recorded. In brief, nature 
tried to extrude from the vagina a uterine fibrous polypus as large as a 
child’s head, and the doctorwith might and main resisted, but vainly, 
the extrusion; and then, instead of dividing the short, thick pedicle, he 
tried to push the tumor back because the womb was inverted; but the 152 
PARVIN, 
tenderness of the parts prevented, the tumor became black and offensive, 
and the next day the patient died. 
However, Hr. Hewees did advance the knowledge of the profession in 
regard to the symptoms of uterine displacements, and the means for 
relieving them ; he taught when and how to use tincture of cantharides 
in amenorrhoea, and his name will not be forgotten as long as dysmenor- 
rhoea ever suggests the aramoniated tincture of guaiacum. But Dr. 
Dewces’s great fame is that of an obstetrician, not a" gynecologist. 
Woman, Her Diseases and Remedies—the of Dr. Charles D. 
Meigs—was issued in 1847, and the fourth edition in 1859. The volume 
is in the form of letters, and, of course, less dignity of style and greater 
freedom of expression are permitted than in a purely didactic treatise. 
Here are not only sketches of disease, but also lessons of high morality, 
of professional honor, and of tender sympathy; here are odd words and 
odd forms of expression ; sometimes ludicrous dialogues, in which refine- 
ment and dignity are thrust in the background'by realism; a fluent 
stream, apparently wandering at its own sweet will—now rippling with 
music and sparkling with sunshine, here narrow and strong, there diffuse 
and almost wearisome in its slow progress—but still always advancing, 
and strengthening in the advance; or a picture-gallery (and the esthetic 
element in his nature was so strong that, possibly, Dr. Meigs might have 
been a great poet, or a great painter, had he not been a great physician), 
in which various representations, persons and scenes are collected, some 
altogether mean, and given with painful minuteness of sketch and color, 
others noble in conception and expression, but each filling a destined 
place, all real, vivid, and combining in a common design and purpose— 
such are these Letters that never lose their charm. Dr. Condie, who 
had no patience with anything but the plainest English, severely criti- 
cized in the American Journal of the Medical Sciences the style of these 
letters. But the style was the man; the letters are not less his teach- 
ings than they are Dr. Meigs himself. 
Undoubtedly the instructions of Meigs were very much in advance of 
those of Dewees. Was he not, too, the first American at least to describe 
vaginismus under his horrible designation of sphincterismus ? He hated 
abdominal surgery, and so rejected ovariotomy ; cervical surgery, too, 
and so in stenosis adhered to Mackintosh rather than to Simpson ; he 
clung with devout faith to Gooch’s canula in the removal of uterine 
polypi, and regarded complete perineal ruptures as incurable. 
Clinical Lectures on the Diseases of Women and Children, by Dr. 
Gunning S. Bedford, were published in 1855, the seventh edition in 1862. 
To this work was paid the high compliment of translation into French 
and German. With much that is valuable even to-day, and impressively 
given, there are some things that would be utterly rejected as rules of 
practice. For example, who would now think of salivating a patient 
because she had ovarian dropsy, or expect such dropsy to disappear under 
the magnetic influence of “patting the tumour with the ends of the 
fingers several times during the day, together with pressure, and the in- 
ternal administration of muriate of lime.” The author’s utterances, too, 
as far as manner is concerned, are at times either simply grandiloquent, 
or degenerate into tedious and undignified dialogues, or trite common- 
places. 
A far better book than any of those yet referred to is the Practice of 
Medicine and Surgery applied to the Diseases and Accidents incident to 
Women, by Dr. William H. Byford, published in 1865. Its great merit ADDRESS ON OBSTETRICS. 
153 
is its evidence of faithful observation and reflection; it was the work of 
a painstaking, conscientious man with large experience, and it has con- 
tributed much to the promotion of a knowledge of diseases of women 
among the American profession. Dr. By ford (p. 348) has proposed and 
practised an original method of treating uterine fibroids, which is pro- 
bably deserving of more professional attention than it has received, and 
he also first made use of tents of slippery elm. Dr. Byford speaks of the 
“ philosophy” of uterine displacements, and in the misuse of this term1 
has been imitated by some others; would it not be quite as correct to speak 
of the philosophy of boot-blacking or of coat-cutting? 
Diseases Peculiar to Women, by Dr. Hugh L. Hodge, the first edition 
in 1860, the second edition revised and enlarged in 1868, and Hysterology, 
by Dr. E. H. Chapman, Hew York, 1872, are two works diametrically 
opposed to each other, or at least presenting entirely different theories of 
uterine disease. Dr. Chapman’s pathology is congestion, and his local 
therapeutics are chiefly scarification and nitrate of silver; where pessa- 
ries are required, preference is given for those that are globular, and appro- 
priate constitutional treatment is directed. His work is largely clinical, 
though unfortunately most of his reports of cases are too brief to he of 
great utility. Dr. Hodge, on the other hand, taught that the condition 
of uterus characterized by tenderness, congestion, increase of secretion and 
of size, was not inflammation, and should not be so treated. Here was 
the irritable uterus rescued from the inflammation of Dewees which was 
devouring it, and restored to the position which Gooch and Addison meant 
to assign it; nay, given an importance and extent in uterine pathology 
which they could hardly have anticipated. According to Dr. Hodge, 
“ displacements of the uterus are the most frequent cause, original or 
secondary, of irritable uterus;” and “the mechanical treatment of ute- 
rine displacements by intra-vaginal supports is essential, a sine qua non 
tor their perfect relief.” 
Whether accepting in full, or only in part, the viewrs of Dr. Hodge upon 
uterine pathology, no one can deny the great service that he rendered 
uterine therapeutics in the device of his lever pessary, an instrument in 
such common use in all lands where diseases of women are studied. His 
pessary was no happy accident, but the result of much thought and of 
many experiments; as he himself once expressed it, he had hundreds of 
abortions before producing it. “Great poetry, great philosophy, great 
scientific discovery, every intellectual production which has genius, work, 
and permanence in it, is the fruit of long thought, and patient and pain- 
ful elaboration.”2 Hot only with the form of the pessary, but with the 
material, is Dr. Hodge to be credited. Ho man ever accomplished as much 
with these instruments, or explained their modes of application and their 
utilities more clearly and completely. He showed their value not only in 
relieving the ordinary results of uterine displacement, but also in curing 
sterility, and in the prevention of abortions when these, too, were conse- 
quences ot such mal-positions. So, too, he demonstrated their value as 
mpositors, gradually replacing the uterus when in mal-position. He 
v lr Hamilton, Discussions on Philosophy and Literature, remarks upon the 
pY'f universality which is given to the terms philosophy and philosophical in common 
riirf T ! an hidefinitude” limited especially to Great Britain : “ Mathematics and physics 
ca^ed. philosophical sciences; whereas, on the Continent, they are excluded 
Pglosophy, philosophy being there applied emphatically to those sciences which are 
immediately or mediately mental.” 
h roude’s Address to the Students of St. Andrews, March 19, 1869. 154 
PAR YIN, 
showed how useful they were, too, in relieving some of the urgent 
symptoms of uterine fibroids. 
But the American work on diseases of women most widely known is 
the Practical Treatise of Dr. T. G-. Thomas, published in 1868, and pass- 
ing to its fourth edition in 1874, As a clear, concise, and practical expo- 
sition of gynaecology, it has no superior. At home, its merits have been 
so fully appreciated by the profession that nearly twenty-five thousand 
copies are now in their hands, helping them in their daily work—a suc- 
cess which, when we compare it with that of even popular1 literary pro- 
ductions, is simply astonishing. Abroad, its great merits have been fully 
acknowledged by the leading journals of the profession, and it has been 
translated into French, German, Spanish, and Italian. Some of Dr. 
Thomas’s views as to uterine diseases, and some of his special contribu- 
tions to gynaecology, will be referred to in the next topics presented. 
Laying aside the briefer mongraphs, whether appearing in the form of 
reports in the Transactions of Medical Societies, lectures, addresses, etc., 
the libelli of our literature, and contributions to our medical journals—all 
these numbering not merely hundreds but thousands, and of course an 
analysis of which, even if it might be instructive, would be impossible 
—four works relating to diseases of women, demand especial attention. 
These are Clinical Lotes on Uterine Surgery, by Dr. Sims (Hew York, 
1869); Yesico-Yaginal Fistula, by Dr. Emmet (Hew York, 1868); Gene- 
ral and Differential Diagnosis of Ovarian Tumors, by Dr, Washington 
L. Atlee (Philadelphia, 1873); and Ovarian Tumors, their Pathology, 
Diagnosis and Treatment, especially by Ovariotomy, by Dr. E. Eandolph 
Peaslee (Hew York, 1872). F 
The Uterine Surgery was published not only in Hew York, but also 
in London, and a French translation appeared in Paris. It met, as it 
deserved, with much favor at the hands of the profession, although some 
parts of it did not escape2 severe criticism. One of the leading British 
journals3 spoke in these terms of the book: “ It is a collection of bedside 
studies of the uterine diseases of which it treats, notable for their accu- 
racy, and continually challenging our admiration for the sagacity and 
originality of their author, the fertility of resource, the unfailing patience, 
the successful adaptation to new purposes of simple means, the exact 
perception and clear statement of the vital points of every case.” “ For 
the first time in the history of medicine, the sterile condition is here 
subjected to a full and philosophical analysis, complete as far as the 
advanced knowledge of our time permits.” 
Dr. Emmet’s work on Yesico-Yaginal Fistula was essentially clinical 
in character, the history and treatment of the seventy-five cases given, 
representing the author’s own invaluable experience. “ The results of 
the numerous cases related are in the highest degree honorable to Dr. 
Emmet’s skill as an operator, and also to American surgery.”4 
Of the two admirable volumes upon Ovarian Tumors referred to, one 
embodies the thirty years’ experience of a surgeon who ranks as one of 
the world’s most celebrated ovariotomists, and is a treatise upon the 
general and differential diagnosis of these tumors. The other is more 
ambitious in design, and wider in scope. More largely a work of com- 
1 Mark Twain’s Innocents Abroad, for example, has reached a sale of two hundred 
thousand. 
2 London Medical Times and Gazette, 1866. British and Foreign Medico-Chirurgical 
Review, January, 1867. 
3 Lancet, February 3, 1866. 4 Lancet, February 20, 1869. ADDRESS ON OBSTETRICS. 
155 
pilation and of analysis, than a record of personal experience, it exhibits 
the indefatigable research, the patient investigation, and the accurate 
judgment of its scholarly and erudite author. Without being encum- 
bered, or possibly for some enriched, with so many details, it has much 
of the encyclopedic character of Grallez’s volume,1 and not only is a most 
useful guide in the diagnosis and treatment of ovarian tumors, but is 
valuable for reference. 
Special contributions to gynaecology, other than those just referred to, 
can be better considered under the heads of particular disorders. But 
before entering upon this division of our subject, two or three prelimi- 
nary observations may be permitted. 
The first is, that while in this country specialism in other departments 
°f medicine has made rapid progress, in gynaecology few, and until quite 
recently only two, specialties are found. And this arises from the fact 
that the diseases of women must, in the nature of things, be chiefly 
under the charge of the general practitioner. What is the numerical 
relation, between those diseases that are constitutional in their origin 
and amenable to general treatment, and those that are local and re- 
quire local treatment, is a question that would have different answers, 
according as addressed to the general or the special practitioners. That 
there were extreme surgical tendencies of uterine pathologists, was the 
complaint a few years since of one2 of the most eminent of British 
gynaecologists; and that this is true to-day, in this country, will be very 
generally admitted. There is something so fascinating in surgery, so 
demonstrative and demonstrable—that which the eye can see and the 
fingers touch—as to inspire the operator with ambition and the patient 
with hope. 
Undoubtedly the danger of specialism is an undue exaltation of local 
disease and of local therapeutics. The general practitioner, on the other 
bund, is liable to depreciate the former, and then of course the latter. He 
does not extend himself, as Mill said of Jeremy Bentham, infinitely in 
°ue direction, but must be many-sided, undergoing a more general and 
complete development. Thus, other things being equal, he will be better 
. le to detect the relations between local and general disorder, what in a 
gJven case is the antecedent and what the consequent, what may be cause 
ci’ effect, unless indeed the specialist, as I believe is true of all who are 
uevoted to gynaecology in this country, has chosen his department after 
targe experience in general practice. The pine in our Southern forests 
grows stately and tall, lifting its tufted head far up to the clouds, but it 
is almost bare of boughs, and barren of foliage and fruit. “The un- 
wedgeable and gnarled oak” is knit together with a stronger fibre, 
'fore firmly rooted, it spreads broadly on every side great branches, with 
omße0mBe foliage, ample shade, and abounding fruit, 
i fee American development of gynaecology has been largely due to the 
abors of men engaged in general practice. Considering now that devel- 
opment, brief reference will be made first to the treatment of some of the 
positional disorders of the uterus. 
I he pessary of Hodge has already been spoken of; an instrument 
-,JICIb both as to form and material, has received the general and grate- 
u acceptance of the profession everywhere. Modifications or additions, 
uoie or less valuable, of the lever pessary have been made by Drs. Albert 
1 Histoire des Kystes de I’Ovaire, etc. Brussels, 1872. 
2 Dr. E. J. Tilt. Transactions of the London Obstetrical Society. 156 
PARYIJST, 
H. Smith, Cutter, Thomas, and others. Nor must we omit, in this con- 
nection, a passing reference to the very interesting observations of Dr. H. 
F. Campbell, of Georgia, upon pneumatic pressure in the treatment of 
uterine displacement. 
Turning to the greatest of all the positional disorders of the uterus— 
inversion—we will find that American operators may challenge com- 
parison with those of any country in regard to ingenuity, skill, and 
success in its cure. 
Inversion of the uterus,1 an accident first noticed by Celsus,2 was, until 
quite recently, an opprobrium of the profession, since replacement of 
the organ, unless efforts were made almost immediately after the acci- 
dent, was regarded as impossible. The few instances where a chronic in- 
version was reduced, were regarded as happy accidents rather than as 
indicating a rule of practice. On April 13, 1858, Dr. Tyler Smith ob- 
served, in reporting to the Medico-Chirurgical Society3 a case of uterine 
inversion of nearly twelve years, which he had reduced; “ Hitherto 
inversion of the uterus has been treated either with styptics and astrin- 
gents, or the inverted organ has been removed by ligature or excision. 
The instances in which reinversion has been accomplished have been few 
in number, and chiefly limited to cases of recent origin.” On the 12th 
of March of the same year, Dr. J, P. White,4 of Buffalo, reduced an in- 
version of nearly six months’ duration. The one used elastic pressure 
and taxis ; the other taxis and pressure5 with a bougie. These success- 
ful cases were the heralds and guides of numerous similar successes at 
home6 and abroad. 
In this country the most important new methods of accomplishing 
reduction were that of Noeggerath, indenting one or other or both of the 
cornua, and thus starting the movement of restoration ; that of Emmet, 
using silver sutures to hold in place a partial reduction; and those of 
Thomas, consisting, the one of mediate dilatation with a boxwood cone 
pressed down from the abdomen into the constriction, the other of abdo- 
minal section, and then immediate dilatation ; and the repositor of Dr. 
White. Abdominal section, with immediate dilatation, has been twice 
performed—once with complete success, and once with a fatal result— 
but fails of professional endorsement. The repositor of Dr. White is 
an admirable instrument, as any one who has ever used it faithfully will 
testify : no one comparing it with the “ drum-stick” repositor of Depaul 
1 Dr. Isaac E. Taylor has proposed and ably sustained the view that spontaneous inver- 
sion of the uterus sometimes commences at the os; a view which is strengthened by the 
cases of spontaneous reduction, the most extraordinary of which has recently been reported 
(American Practitioner) by Dr. Chesnut, of Lafayette, lud. In Dr. Chesnut’s case the 
restoration was twelve years after the accident. 
2 I am indebted to Dr. J. S. Billings for the following reference : Celsus, A. Cor., Medi- 
ciii£e Libri Octo; Ed. by A. Lee, London, 1831. Lib. I. Prsefatio, p. 15. “Cum aetate 
nostra quaedam, ex naturalibus partibus came prolapsa et arente, intra paucas horas exspi- 
raverit; sic ut nobilissimi inedici neque genus rnali, neque remedium invenerint. Quos ego 
nihil tentasse judico, quia nemo in splendida persona periclitari conjectura sua voluerit; ne 
occidisse, nisi servasset, videretur,” etc. I find that several have commented on this pass- 
age, and especially Morgagni, who decides it to be a case of inversion of the uterus. Re- 
spectfully and truly yours, J. S. Billings. 
3 Medico-Chirurgical Transactions, vol. xli. 
4 American Journal of the Medical Sciences, July, 1858. 
5 Dr. Thomas is in error when he states (Diseases of Women) that taxis alone was used 
by Dr. White, as can be seen by reference to the original account of the operation. 
6 Dr. White has been successful in twelve cases, and in one of the twelve the inversion 
had existed for twenty-two years. ADDRESS OX OBSTETRICS. 
157 
would hesitate to give a decided preference to the former. Its value 
will become more and more appreciated as its use becomes more general. 
Two of the most useful therapeutic agents in uterine disease, the one 
suggested by Dr. Sims, the other by Dr. Emmet, are among the simplest, 
viz.: glycerine1 and hot water.2 Dr. Emmet began the use of hot water 
injections in 1859, and observes, “I have been so thoroughly identified 
with this mode of practice, that it seems scarcely necessary to claim the 
priority. Certainly, no one in this country is on record as an advocate 
for the practice previous to myself; and so far as I have been able to 
ascertain, the same is true in regard to the practice of gynaecologists 
abroad.” Confirmatory of Dr. Emmet’s views as to the action of hot 
water injections in producing contraction of bloodvessels, and therefore 
useful not only in uterine, hut also in pelvic, congestion, and in threatened 
cellulitis, was the practice of Trousseau3 in menorrhagia—frequently 
directing two or three very hot injections daily. If Dr. Emmet had done 
nothing beside this, his name would deserve to be one of the most hon- 
ored of the century in medicine. 
Since the invention of the hysterotome by the illustrious Sir James 
Y. Simpson, and of its many modifications or substitutes by others, the 
cervix uteri, relieved from the potash-persecutions which, carried on by 
the ultra followers of Dr. Henry Bennet, a few years ago, threatened its 
integrity, has been made the subject of numerous cutting operations for 
the relief of dysmenorrboea, or of sterility. Those who have contributed 
most to the practical study of these operations are Drs. Sims, Emmet, 
Tallen, Peaslee, and Worster, of Hew York, and Rearay of Cincinnati. 
There is something wonderfully fascinating both for surgeon and patient, 
when the former can carry salvation from dysmenorrboea, and also a 
baby, upon the sharp edge of a bistoury, or between the blades of scis- 
sors! Unfortunately a conflict exists, both in theories and in experi- 
ences, as to the utility, the modes of, and the cases for, operation. It is 
to be hoped that since the recent publication of Dr. Peaslee, so conserva- 
tive in its character, there will be elicited such discussion as will fully 
present the truth in this matter, and firmly establish practical rules for 
general professional guidance. 
In amputation of the cervix uteri the flap method of Dr. Sims, and 
the use of the galvano-cautery of Dr. Byrne, are .worthy of remembrance. 
I mid applications to the lining membrane of the uterus are regarded by 
the profession everywhere as of great utility; and the safest and most 
common way of making such applications is simply one in close imita- 
tion of that originally devised and practised by the late Dr. Henry Mil- 
mr,4 of Louisville, Ky., more than a score of years ago. 
Uterine fibroids in their frequency, in their exacting symptoms, in 
their sometimes apparently capricious history, and in the utter uncer- 
tainty ot therapeutic means pursued for their relief, have long presented 
to the gynaecologist a field at once inviting and repellant. Electrolysis, 
studied in this relation by Heftel, Sims, Cutter, Kimball, and some others, 
cannot yet be said to have been admitted to professional confidence. Dr. 
Byford has ably collected most of the experience of the profession of this 
2 Tlras's Uterine Surgery, pp. 21, 72. 
3 ew York Medical Journal, June, 1874. 
4 Dictionnaire de Medecine et de Obirurgie Pratiques, vol. xxii. p. 452. 
C thers whose names might be mentioned in connection with the study of means for 
naking such applications are Emmet, Lente, Nott, and Reamy. 158 
PARTIN', 
country in the hypodermic use of ergot of Hildebrandt. But this treat- 
ment frequently fails, and the knife is occasionally required. 
Those whose names ,in this country are especially identified with ope- 
rations for the removal of these tumors, are I)r. Atlee,1 Dr. Sims, and 
Dr. Emmet. The most valuable original observation belonging to the 
last is the pedunculization of a fibroid which can be effected by traction. 
The important operations performed by the others, and the ingenious in- 
struments devised for this by Dr. Sims, almost as prolific of instruments 
as Hudibras2 of tropes, we pass by with this brief reference. 
Removal of the uterus by abdominal section has been performed seve- 
ral times in this country, but most of these operations have not been suc- 
cessful. Probably the first case in this country, certainly one of the first, 
was that of Dr. Thomas G. Prioleau,3 of Charleston, S. C., in the year 
1819. The tumor, prior to the operation regarded as malignant, was 
very large, its removal with the uterus attended with much hemorrhage, 
and thepatient died in twenty-four hours. On the 16th of April, 1850, 
Dr. Paul F. Eve removed the uterus for malignant disease, and the pa- 
tient lived for between three and four months. The operation has, how- 
ever, been done on account of fibroid disease, with permanent recovery, 
by the Atlees, Burnham, Kimball, EL. R. Storer, Thomas Wood,4 and 
some others. 
Removal of the prolapsed uterus—the vaginal operation—has several 
times been successfully performed. One of the most interesting of these 
cases is that of Dr. S. Choppin, of Kew Orleans. The doctor, in 1861, 
removed not only the uterus, but with it the left ovary and Fallopian 
tube, which were also prolapsed, and the patient rapidly recovered. 
Many other topics in this division are suggested, but only two can be 
considered as the greatest glories of American gynaecology, the operation 
for genitourinary fistula, and that for the removal ot ovarian tumors. 
Holding up these to the world, she may, with just pride, exclaim; These 
are my offerings to Humanity and to Medicine! Tea, these are my 
offerings! 
But Is not the operation for genito-urinary fistula a triumph of Ameri- 
can surgery ? Dp to less than a quarter of a century ago, how deplorable 
the condition of the unfortunate woman suffering from such a lesion ! 
She had entered upon all the remaining sad and weary years of her life, 
through a portal over which surgeon and obstetrician alike had, time 
and again, witten : Let her who enters here dismiss hope. If here and 
there, now and then, a case was cured, the result was the exception, 
failure the rule. If Jobert, for example, cured some, his operation always 
failed in the hands of others. Row, how changed! An operation, known 
abroad as the American method, rescues these unfortunates from their 
infirmity, and restores them to society. Failure is now as rare as success 
was formerly. 
Of course surgeons had come to apprehend the principles, before they 
had attained the method of cure. 
His mouth, but out there flew a trope.” 
3 Dr. Prioleau graduated in Philadelphia in 1808. Drs. Samuel Jackson and W. P. 0. 
Barton were classmates. At the organization of the Medical College of the State of South 
Carolina, in 1824, he became Professor of Obstetrics, and filled the chair for many years. 
I am indebted to Prof. J. Ford Prioleau, the present occupant of the chair, for the state- 
ments given. 
4 Dr. Wood’s cases are seven, with three recoveries. 
1 Transactions of the American Medical Association, 1853. 
2 “ pior rhetoric, he could not ope ADDRESS ON OBSTETRICS. 
159 
For the closure of these fistulous openings two things were necessary. 
First, their margins must be thoroughly and uniformly freshened. 
Second, this vivification accomplished, the freshened surfaces must be 
brought and retained in accurate apposition until union took place. But 
how should these edges be pared so completely and accurately? The 
first step for the accomplishment of this end was their thorough expo- 
sure. This step was taken in the position and speculum of Marion Sims. 
Here we have the very foundation of the operation. This fixed, knives 
of various angles, forms, and sizes, or curiously curved scissors, became 
mere minor matters, resting with the individual operator, or determined 
by the exigencies of each individual case. 
But how are the prepared fistulous margins to be brought and kept in 
contact until nature binds them fast? Here again we hear, in 1852, the 
voice of Marion Sims crying, and crying aloud and on, until the whole 
world has heard Silver Sutures. Am I told that a British surgeon, in 
1834, using silver gilt sutures, cured a case of vesico-vaginal fistula? He 
did not follow up this one success, and confirm it by others. He estab- 
lished no rules of practice, he instituted no method, and his report was 
unnoticed, it was as the voice of one crying in the wilderness. That 
one- success, too, was it any more than an American, Mettauer, of 
Virginia, had gained in 1830, with lead sutures? Was it as much as 
Hayward, of Boston, accomplished with silk sutures? But are the 
brilliant results which Simon obtains, adduced to disparage the Ameri- 
can method ? Simon’s operation has become the property and the prac- 
tice of the profession scarcely more than Jobert’s. We gratefully record 
the statement of one of the most eminent of French gynaecologists, 
County,1 that the American school has no higher claims to future cele- 
brity than the operation for vesico-vaginal fistula. 
. H is needless to mention the various modifications made by Hr. Sims 
in his original operation, or the valuable improvements introduced by 
Hr. Emmet, or the peculiarities of the method of Hr. Bozeman, who has 
labored with such signal zeal and ability, both at home and abroad, in 
this department of surgery, or the additions made by Hr. Mastin, of 
Alabama; or by Hr. Schuppert, of Hew Orleans; or by Hr. Battey, of 
Heorgia; for the American method remains essentially that of Hr, Sims. 
Aor is it necessary to speak of Hr. Sims’s early trials, patient persever- 
ajice, and triumphant success in working out the great problem to which, 
rnore than thirty years ago, he devoted himself with all that he had. 
he world knows them, and he has received honors such as have been 
accorded to few representatives of American Medicine. 
. beautiful fable of the old Greeks made Apollo, the god of healing, 
pve to the laurel tree its evergreen leaves, and consecrate them as crowns 
V‘e brows of victors. And surely who so worthy of the present of 
<rse crowns as a son of Apollo, who, after years of bitter struggles, has 
gained a victory which has brought blessings to thousands, and will 
ring them to tens of thousands more ? 
W]8 n OVari°tomy one of the rightful glories of American gynaecology ? 
iat are the facts ? In the year 1809 a village doctor of Kentucky suc- 
-1830 7 rern°ved an ovarian tumor, and from that time until his death in 
0, operated in all thirteen times with eight recoveries2—a success, by 
t Jrai*f Pl,atique des Maladies de I’Uterus. 
Grvoss°l tlB co^ectloa °t Dr. McDowell’s cases, the profession is indebted to Prof. S. D. 160 
PARVIN, 
the way, which, compared with the first thirteen cases of Baker Brown, 
or Spencer Wells, is most extraordinary. Spencer Wells, whose opera- 
tions began in 1857, lost four out of the first thirteen, and Baker Brown 
lost eight out of his first thirteen. 
Is the priority of Ephraim McDowell as the first surgeon to remove 
the diseased ovary invalidated by the case of Houston, of Glasgow, in 
1701 ? All other claims to priority have been swept away as blunders or 
shams, and this, too, would need no notice, had not Dr. Washington L. 
Atlee republished it as a proof that ovariotomy “ originated with Eng- 
lish surgery,” and had not Spencer Wells asserted that it “ undoubtedly 
strengthens the claims of British surgery to the honor of originally piac- 
tising ovariotomy.”1 It is strange that this case, rejected by Boinet and 
Clay,2 should be now adduced. The operator simply incised a cyst and 
evacuated its contents. He no more performed ovariotomy than he who 
lances a suppurating parotid has extirpated the gland. The claim of 
British surgery to the honor of originating ovariotomy is weak beyond 
expression if it rests upon this case. 
Again we are told, “But the operation was suggested by William 
Hunter ; its practicability and the mode of performing it were taught by 
John Bell.” William Hunter said ; “lam of opinion that excision can 
hardly he attempted.” He adds, however; “If we could beforehand know 
that the circumstances would admit of such treatment, the incision should 
admit of only two or three fingers, and the cyst be tapped and drawn 
out, that the surgeon may cut the pedicle without introducing his hand.” 
But Tozzetti,3 in 1752, Yanderhaar and Delaporte, in 1752, and Morgagni, 
in 1761, gave more encouragement to ovariotomy than did William Hun- 
ter; some of them as much, indeed, as John Hunter did, in 1786. Ihe sug- 
gestions of Hunter and the instructions of Bell doubtless had an import- 
ant influence upon McDowell’s mind, but this detracts nothing from the 
glory of his achievement. The fame of Columbus is not dimmed by the 
fact that others before him, others in his time, believed with him that by 
sailing westward a sea-way to the,lndies would be found. Ko matter 
what surgeons may have believed and suggested as to removal of diseased 
ovaries, no matter though John Bell taught the mode ot operating, their 
faith without works was utterly dead, and the new Columbus started 
upon his exploration without pilot or chart. 
But then, declares Eelaton, McDowell’s first patients were negresses, 
and Gallez follows him, adding that his effort was to save the lives ot 
slaves, who at that time commanded a high price, so that surgery owes 
this brilliant conquest to the cupidity of planters. How strange that 
historical facts of the present century can be so misrepresented. The 
truth is, that Dr. McDowell’s first patient4 was not a colored woman, but 
one of his own race and social position. 
1 Diseases of the Ovaries. ..... 
2 Oomme le fait judicieusement remarquer Boinet, aprks J. Clay, il y a eu simple incision 
du kyste, qui n’a e'tb lie, ni excis6 : on ne pent done voir la une operation d’ovariotoniie 
proprement dite. Gallez, op. cit. 
3 Gallez, op. cit. p. 404. ... 
4 This was Mrs. Crawford, who, after the operation, resided for a time at Madison, Ind. 
From the late Dr. Speer, of Hanover, Ind., who, when a young man, was for a time a 
member of her family, I received some years since a statement as to the efforts made by Dr. 
Ephraim McDowell’s nephew to wrest the honors of the operation from the uncle. A law- 
yer from Lexington, Ky., visited Mrs. C., urging her to sign a paper stating that the 
nephew was the operator. Her reply was that she was blindfolded, and could not posi- 
tively assert that Dr. Ephraim McDowell was the operator, but that she never would have 
consented to the young man’s operating. ADDRESS ON OBSTETRICS. 
161 
Surely British surgery has glory enough in the splendid successes of 
Spencer AVells and Keith, and the French in those of Bean, without either 
abating one jot or tittle of the fame of Ephraim McDowell. 
Only sixty-five years since the performance of his first ovariotomy, 
only fifty-eight since its publication, and then many years before general 
professional recognition of the operation as legitimate, and probably it is 
Dot extravagant to assert that more than two thousand women have been 
by it rescued from Impending death! Dr. Peaslee, writing in 1872, 
concluded, from a careful calculation, that ovariotomy had, in the 
United States and Great Britain, within the last thirty years, added 
piore than thirty thousand years to the active life of woman. We may, 
indeed, assert most unequivocally that the name of the father of ovari- 
otomy is worthy of being recorded with those of the best benefactors of 
the race. 
Dr. McDowell’s third ovariotomy was in 1816. In that year, or in the 
one preceding, Dr. Thomas G. Prioleau, whose extirpation of the uterus 
has already been referred to, assisted by his nephew, Dr. Philip Prioleau, 
and Dr, Frost, attempted ovariotomy, but was compelled by extensive 
adhesions to abandon the attempt ; he therefore simply evacuated the 
cyst, and excised a portion of it. The patient died. Dr. Kathaii Smith, of 
Connecticut, Dr. Alban G. Smith, of Kentucky, Dr. David L. Rogers, of 
hlew York, and Dr. Billinger, of South Carolina, are among the early 
American oyariotomists. To give a list of those who have operated 
since, including as it w-ould numbers of the profession in almost every 
felate in the Union, and in some more than a score of them, is impossible, 
-those who have operated most frequently are Atlee, Kimball, Dunlap, 
-Unrnham, Peaslee, Thomas, White, Sims, and Bradford. The last named, 
he late Dr. J, T. Bradford, of Augusta, Ky., had a higher percentage, no 
G:SS than ninety per cent., of recoveries than any other operator in the 
world. Those who have contributed most, by the publication of statistics 
c the operation, or arguments in its behalf, to its proper appreciation, are 
ie late Dr. Pope, of St. Louis, Dr. Lyman, of Boston, Dr. Atlee, the late 
f'1 ni-'^er’ Louisville, Ky., Dr. Peaslee, and Drs. Hamilton and Reeve, 
3 yb.io* In regard to the diagnosis of cystic diseases of the ovary, no 
Aoie important addition lias been made than the examination with the 
ncroseope 0f the contained fluid by Dr. Drysdale.1 Dr. Atlee has estab- 
important rules of diagnosis from the coagulability of the fluids 
Ained from uterine or ovarian cysts, or from the abdominal cavity.2 
found E-ARnSIR- Since.readin£ the PaPer at St. Louis, in 1873, “On the Granular Cell 
fluids U1 , |Vaidan Fluid,” I have continued the investigation of these and other dropsical 
enableaUC* laVe now. examined over a thousand specimens of them. These examinations 
is m tli1116 to etllPflasize the opinion which I then expressed, that the ovarian granular cell 
(l )() uu0111]00'0 cWic disease of the ovary. Yours, very truly, T. M. Drysdale. 
Flo not Ui ’ drawn fr°m the peritoneal cavity, or from ovarian or broad ligament cysts, 
luulati Coapu a^e 011 mere exposure to air. (2) Fluids, drawn from non-inflammatory accu- 
a|l(|‘ ni.nS 111 .I6 peritoneal cavity, will coagulate more or less under the influence of heat 
heat nn iIC-f ■ ‘ -bb Fluids, drawn from inflammatory accumulations, will coagulate by 
titles witl*11 ’ aild Yll also, by standing, produce a fibrinoid deposit in small quan-. 
greater a? 1 ni,tric acid- Fluids of ovarian cysts proper, will coagulate to a 
Parenchv . t exteilt by heat and nitric acid. Certain fluids, however, may collect in the 
IJitric ifirilatoUS StlUcture an oval’ian tumor, which will neither coagulate by heat or 
coaauhtp w°1' 011 rnere exPOSure to air. (5) Fluids of cysts of the broad ligament will not 
tfl'guish-iblp f Fluids, drawn from fibro-cystic tumors of the uterus, are dis- 
posure to ah- a'others taken from the abdominal cavity by coagulating rapidlv on ex- 
stained with V !!k atter.standing, by separating into clot and serum. This fluid, when not 
liquor samrnin; b °°d’ « veiT transparent and of a yellowish color, and is really blood, or 
sanguinis mmus the red corpuscles. Washington l! Atlee. 162 
PAEVIN, 
In the operation itself the most important advance is the enucleation 
of the cyst according to the method of Dr. Miner, of Buffalo. This 
method is not of general, but of particular, application, and permits the safe 
removal of tumors that otherwise could not be dealt with in consequence 
of adhesions. Clamps, instruments used probably by only a minority of 
American operators, have been devised by Atlee, Storer, Dawson of Kew 
York, and Mears of Philadelphia. Peritoneal drainage after operation 
has been practically studied by Kimball, Atlee, Sims, and Thomas. Dr. 
Peaslee has shown the utility of intra-peritoneal injections in septi- 
caemia, regarding them as more valuable than any other and all other 
means. 
Vaginal ovariotomy originated with Dr. Thomas, in 1870. The same 
operation has since also been successfully performed by Dr. Davis, of 
Pennsylvania, Dr. Gilmore, of Alabama, and Dr. Battey, of Georgia. 
Ovariocentesis Vaginalis has been greatly improved by Koeggerath, 
and the results he has had are remarkably favorable. 
Removal of the ovaries in order to determine the menopause in certain 
cases where menstruation is attended with great suffering, and otherwise 
incurable disease, was the proposition of Dr. Battey. The operation lias 
been performed sixteen times,1 with three deaths, the operators being Dr. 
Battey, Dr. Sims, and Dr. Thomas. Its propriety is hardly established 
in the face of such statistics. 
Did time permit, many other contributions to operative gynecology 
might be alluded to, such as that of JSTott,2 extirpation of the coccyx tor 
coccygeal neuralgia, in 1844; Schuppert’s3 operation for obliteration of 
the vagina, in 1858, “ the first case of vulvar occlusion by elytro- 
episiorraphy without ulterior accidents ;”4 and Emmet’s method of securing 
the restoration of the anal sphincter in operation for ruptured perineum, 
a method which has recently been successfully followed by a surgeon of 
Rouen.5 So, too, we might mention the peculiarities of Dr. Bozeman’s 
operation for vesico-vaginal fistula his knee-chest support, his self- 
retaining speculum, his button sutures, his method of auto-plasty by 
gradual approaches,6 and, above all, his past successes at home, his present 
abroad, might be mentioned. The merit of a method will be at once 
conceded when it has won the approval of such men as Simon, Braun, 
and Dolbeau. 
One of the minor, but by no means insignificant advantages of the 
establishment of a method of cure for vesico-vaginal fistula, that must 
not be omitted, is that in consequence thereof the operation of vaginal 
lithotomy is relieved of its most serious objection—the resulting fistula. 
Row surgeons, following the example of Dr. Sims, in 1850, remove the 
calculus by vagino-vesical incision, and immediately close the opening 
with silver sutures. This operation is growing in favor; in this country 
forty-one cases have been collected by Dr. Mastin: “the operation,”7 says 
Dr. Warren, “seems to have been done more frequently in this country 
1 Dr. Trenholme, of Montreal, and Dr. Peaslee, have reported cases of the operation since 
the delivery of this address. 
2 American Journal of the Medical Sciences, October, 1844. 
3 A Treatise on Vesico-Yaginal Fistula, New Orleans, 1866. 
4 Le Double, Du Kleisis Genital, et principalement de I’Occlusiou Vaginale et Vulvaire 
dans les Fistules Uro-G6nitales. Paris, 1876. 
5 Annales de Gynecologic, »July, 1876. 
6 New York Medical Record, August 26, 1876. 
7 Boston Medical and Surgical Journal, July 20, 1876. ADDRESS ON OBSTETRICS. 
163 
than in any other.” Hybord,1 in considering the relative advantages of 
lithotrity, dilatation and lithotomy, observes that the latter, especially 
vesico-vaginal, with immediate suture, is preferable if the calculus is hard, 
large, or encysted. 
But turning from these and many other topics, and concluding this 
division of the subject, we cannot retrain from a remark or two concern- 
ing the surgical development of American Gynaecology. Of course in 
this country, as in others, the advance has been much greater in the 
surgical than in the medical department of so-called uterine therapeutics. 
In explanation ot this fact, as it is observed here, two peculiar causes 
have been in operation, in addition to those which are common. One of 
these is in the characteristics of the American mind—its tendency is to 
action rather than to reflection; quick and fertile in expedients, it seeks 
immediate results, rather than exercises the patience for recondite inves- 
tigation. And again, most of those who have made themselves espe- 
cially famous, and therefore have become leaders of sentiment and of 
action, have acquired their celebrity and influence by brilliant operations. 
An inspiration comes from the graves of the dead and from the deeds of 
the living, kindling hope and ambition, to emulate their fame, and to do 
their works, or even greater works. American Gynaecology has proved 
its power, and recorded triumphs that cannot perish. The”past is secure. 
The future is the child of the past, and its glories may be more numerous 
and grander. 
“Men, my brothers, men the workers, ever reaping something new; 
That which they have done but earnest of the things that they shall do.” 
Let us hope that, as Uterine Surgery has in this country made such 
gi'eat progress, and accomplished so much, the future historian will 
I’ccord similar progress and a corresponding development of Uterine 
Medicine. 
The first American work on Diseases of Children, entitled, “A Treatise 
cn the Physical and Medical Management of Children,” was by Dr. 
ewees, and published in 1825. Up to 1842 no less than seven editions 
iad been issued, “To Dr. Dewees we are greatly indebted,” said Dr. 
edge, “simply for fixing attention on the physical management of 
c iildren, independently of the high value of his directions; for, prior to 
ns period, the profession in this country left the details almost exclu- 
sively in the hands of nurses and midwives, with all their tormenting 
ignorance and offlciousness.” Dr. John Eberle, one of the first professors 
ii _ efterson Medical College, then a professor in the Medical College of 
no, and finally in the Transylvania School at Lexington, Ky., where 
IU. Clod *u 1838, was author of a Treatise on the Diseases and Physical 
a anagernent °* Children, which was published in 1837. A third edition 
appeared in 1845. Dr. Eberle was a compiler, but was always judicious 
m his compilations. 
n 1841, the Practical Treatise on Diseases of Children of Dr. James 
was published. This was, according to Dr. Condie, “ certainly 
penor in many points of view, to those heretofore accessible to the 
factmi °( ,y ouf pnifcssiori in this country.” The author refers to the 
hi • lat opium is of admirable benefit in many of the inflammatory com- 
ok! aC* Children, especially after bleeding, and was much in use by the 
ei Anencan practitioners. The practitioner of to-day would use the 
Tes Calcules de la ~V essie chez la Femme et les Petites Filles. Paris 1872. 164 
PARTIN', 
opium much oftener than he would the bleeding. The year 1844 brought 
another Practical Treatise on Diseases of Children, the well-known vol- 
ume of Dr. D. Francis Condie. The sixth edition of it was issued in 
1868. 
Dr. Condie was, according to Prof. Stilffi, by long and extensive ex- 
perience, accurate observation and diligent study, not only ot English 
writers, but also of the Continental, and especially of the German, well 
qualified to prepare such a work. The volume grew with each new edi- 
tion, especially in accretions from foreign sources, and one who reads it 
now will, without the greatest care, occasionally get lost in conflicting 
pathological opinions and theories. But no one can mistake the two 
important characteristics of the therapeutics—great caution in the use of 
opium, great faith in the power of mercurials. Few American physicians 
have equalled Condie in medical learning, and the hundreds, possibly I 
might say thousands, of pages of. criticism he has contributed to the 
American Journal of the Medical Sciences, constitute an important feature 
of our national medical literature. He was remarkably fluent in compo- 
sition, yet no one could say— 
“ His talk was like a stream which runs 
With rapid course from rocks to roses.” 
Rocks, big, solid rocks, enough there were in his writing, but roses 
fared as ill at his hands, as the poppy-heads that fell before Tarquin’s 
angry cane. 
In 1848, A Practical Treatise on Diseases of Children, by Dr. J. Forsyth 
Meigs, was issued by Lindsay and Blakiston. This was the third of the 
series of manuals which this well-known firm engaged in publishing, the 
first being the work on Obstetrics, by Dr. Tucker, to which reference 
was made"in a former part of this address. Meigs on Diseases of Child- 
ren has been and still is held in much esteem by the American profession. 
It has passed to the fifth edition, and in the preparation of the two last 
editions Dr. ¥m. Pepper has been associated with Dr. Meigs. 
A Treatise on the Diseases of Infancy and Childhood, by Dr. J. Lewis 
Smith, was issued in 1869; the third and latest edition appeared in 1876. 
“Smith” is a book of fewer pages than “Meigs and Pepper,” but clearly 
and concisely written. As a guide for the practitioner, and as a text- 
book for students, it hardly has a superior. 
In 1849, Dr. John B. Beck, one of the first professors in the College of 
Physicians and Surgeons, Hew York, published his work on Infant 
Therapeutics, which Dr. Gross1 recently pronounced “a perfect gqm in its 
way.” The late Dr. C, R, Gilman2 states that “it wras received with the 
greatest favor, both at home and abroad. Few medical books of its size 
contain an equal amount of sound learning and practical good sense.” 
Observations on certain of the Diseases of Young Children, by Dr. 
Charles D. Meigs, wras issued in 1850. Here wre have, in the midst of 
excellent and most useful instruction as to the management of several of 
the diseases of children, some of the author’s peculiar pathological views, 
views which were always ingenious, and, it not always true, never failed 
of the semblance of truth. Here we are taught the efficacy of a wool- 
len cap in coryza, the “right-side treatment” of cyanosis,and are brought 
face to face with that “endangium” which played so important a part in 
bis theories of disease. 
1 History of American Medical Literature. 
® American Medical Biography. ADDRESS ON OBSTETRICS. 
165 
In Dr. Bedford’s valuable Clinical Lectures, already referred to, some 
of the diseases of children are treated ot plainly, practically, and wisely, 
but there is by no means a complete course given. Indeed, in reading 
this volume, and finding here and there these diseases considered, while 
the great body of the work is occupied with diseases of women, one is 
reminded of a street-car or omnibus crowded with adults, and then here 
and there a child interposed or superposed. 
Having thus briefly noticed these different volumes, we shall next refer 
to a few special American contributions to Paediatrics, Among the 
earlier, must be placed the letters on Angina Trachealis, by Dr. Richard 
Bayley, of New York, 1781, to Dr. William Hunter. Dr. John W. 
I rancis1 speaks highly of these letters, and states, “we are justified in 
giving to Dr. Bayley the merit of being the first writer who understood 
the nature and treatment ot croup.” In a letter written to Dr. Fother- 
gdl by Cadwallader Golden, New York, October 1, 1753, the writer 
describes diphtheria and its treatment, chiefly as observed by Dr. Doug- 
lass, of Boston. In 1736, Dr. Douglass published a pamphlet2 entitled, 
Ihe Practical History of a new Epidemical Eruptive Miliary Fever, with 
an Angina Ulcusculosa which prevailed in New England in the years 
7,. 5 and 1736. “The first full description of this affection published in 
tins country,” says Dr. J. F. Meigs, “ was by Dr. Bard, and based on an 
epidemic which occurred in 1771. The views advanced in his paper have 
been universally recognized, even to the present day, as most clear and 
Dr. Bard’s account of the disease has been recently very favorably 
referred to and quoted by Loraine & Lepine.3 
Shall we mention one of the first applications of electricity as a thera- 
peutic agent, in this country; its successful use in 1752 by the illustrious 
in a case of convulsions, in a patient of Dr. Cadwallader Evans, 
°f Philadelphia, a girl of fourteen, who had been afflicted for ten years? 
In regard to the treatment of croup, four important therapeutic agents 
. ave been introduced by American physicians. The mercurial treatment 
is attributed to Dr. George Monroe, of Delaware, who graduated at the 
piversity of Edinburgh in 1786. Dr. Hubbard, of Maine, is to be credited 
With first using and advising the yellow sulphate of mercury, a remedy 
neb has received from Dr. Fordyce Barker, after using it twenty-eight 
pfi’ tllG h^l]est Possible praise. The late Dr. Charles D. Meigs was 
ie fust to advise the common alum as an emetic, while more recently 
o treatment by cold has been ably advocated by Dr. Jacobi. 
1 0 most valuable contributions to the subject of umbilical hemorrhage 
nave been by th ree American physicians, Drs. Minot, Stephen Smith, and 
Foster Jenkins. 
Ie subjects of masturbation and hysteria in young children have been 
toairately Presented by Jacobi, whose many and valuable contributions 
abroad la^r*CS are 8° known to the profession, not only at home but 
oA- T' Taylor4 has produced a monograph upon Syphilitic Lesions 
tr. 10 Csseous System in Infants and Young Children, which has at- 
D ecLmu°b attention, both in this country and in Europe, 
i. Jiusey5 has given a faithful study of the action of certain drugs in 
2 i”ni'elsary Discourse before the New York Academy of Medicine, 1847. 
3 Nontostlarw tlllS- PaPer will be found in the Medical Recorder, Philadelphia, 1825. 
4 Am aU Dictionnaire de Medecine et de Chirurgie Pratiques, vol. xi. 
* American Journal of Obstetrics. 
Columbia Hospital Report. 166 
PARTIN', ADDRESS 0NT OBSTETRICS. 
bronchitis. And thus, name after name might he mentioned, paper after 
paper referred to, showing how active the American profession has been 
in the department of diseases of children. But this address has already 
transcended the time assigned it, and I must conclude. 
Bid time permit, I might mention the organization of societies devoted 
to the especial study of obstetrics, and of diseases of women and of child- 
ren, in Louisville, Boston, Yew York, and Philadelphia, as at once the 
signs and means of advance. So too, the American Gynaecological So- 
ciety, born this Centennial year, gives promise of high honor and great 
usefulness. The establishment of hospitals devoted to diseases of women, 
is another evidence of progress. The Woman’s Hospital of Yew York, 
founded and built chiefly by the labors of Sims and Emmet, and which 
has been of such incalculable benefit to thousands of suffering women, 
and to the profession, has been the noble pioneer. May the day speedily 
come when every State shall have a similar institution 1 
The American Journal ot Obstetrics, founded by Dr. Dawson, and 
conducted with such signal ability, the demand for the reprint of the 
Obstetrical Journal of Great Britain and Ireland, and the valuable addi- 
tions made to it by American writers, are evidences of progress. 
And now, in conclusion, have we brought the names of those who, in 
this country, have been prominent in advancing the knowledge of Obstet- 
rics, Gynaecology, and Paediatrics, for apotheosis in some new Olympus? 
Yay, rather, for inscription in our memorial window of the Temple of 
Medicine. There let them be written, Samuel Bard, William P. Dewees, 
Thomas 0. James, Ephraim McDowell, Charles D. Meigs,_ Gunning S. 
Bedford, Hugh L. Hodge, D. Francis Condie, Henry Miller, Walter 
dimming—but X cannot repeat the long list.1 There let them all be 
and there forever abide. It is Lo! the Orient sun of 
the Bepublic’s second century is pouring its light upon them, is kin- 
dling in our hearts gratitude and joy, and evoking more than Mbmnonian 
music, Te Deums and Jubilates, from a multitude whom no man can 
number, who lived because they lived, who suffered and who were saved 
from their sufferings and from the sorrow’s of death by the interposition 
of their Divine Art. When that sun is sinking behind the flood of years, 
may its departing rays gild those names with a new glory, shining too 
on others still more illustrious. 
1 Is it presumptive to interpret the presence with us to-day of two eminent obstetric 
teachers from abroad, as a cheerful tribute to the value of American work in this depart- 
ment of Medicine ? To those teachers, one of them the honored occupant of a chair made 
illustrious by the names of the Hamiltons and of Sir James Y. Simpson, and the other 
whose fame has gone out into all the earth, and whose imperial authority the professional 
world acknowledges, every American physician gives hearty thanks. 167 
ADDRESS ON MEDICAL JURISPRUDENCE. 
WITH 
NOTES AND A BIBLIOGRAPHICAL APPENDIX. 
BY 
STANFORD E. CHAILLfi, A.M., M.D., 
PROFESSOR OF PHYSIOLOGY AND PATHOLOGICAL ANATOMY IN THE MEDICAL DEPARTMENT 
OF THE UNIVERSITY OF LOUISIANA. 
Medical Jurisprudence owes its power to knowledge derived from 
every branch of medicine, but the law determines how far this power 
shall be utilized in the administration of justice. Hence, the develop- 
ment of Medical Jurisprudence has varied in different nations with the 
progress of medical science, and with the extent of its application to the 
protection of property, reputation, and life. Efficiency in this legal 
application varies with the appreciation of medical knowledge by the 
Talers of a nation ; and (since an adequate appreciation is limited to the 
educated few, and is not yet disseminated among the mass of any people), 
R results, that laws more favorable to the culture of legal medicine are 
to be found in nations ruled by the educated few, than in those governed 
!>y the people. The unequal development of Medical Jurisprudence in 
different nations finds in these facts an explanation, in large part at least, 
and recalls the political axiom that “ arbitrary powers well executed, are 
the most convenient,” while “ delays and inconveniences in the forms of 
justice are the price that all free nations must pay for their liberty in 
more substantial matters.”1 
. The papal canon-laws,2 originating many medico-legal questions, sowed 
m 1620 by the hand of Zacchias,3 a pope’s physician, the first sound seed 
ot Medical Jurisprudence in the land of Columbus, then the home of 
Science and the Arts.4 
Blackstone, iv. p. 350. Blackstone’s “Commentaries on the Laws of England” (four 
refe ere Polished a century ago, viz. 1765 to 1769, and, hence, are frequently 
3 '* Corpus Juris Canonici,” a compend of the canon-laws, is dated 1580. 
B. 2. This and all succeeding references to “ B,” refer to the Bibliography, with the 
numbers therein 
4 p , 
r rom many facts which might be cited to prove this statement, as also that the 
n°\e. oPmeft of medical jurisprudence in different nations has varied with their culture of 
tucal science» the following quotation is selected from p. 142 of Russell’s “ History and 
fr ef°e? Medicine,” London, 1861 ; “ If we survey the social and political state of Europe 
art'11 116 CV(dfth to the sixteenth century, in its relation to the development of medical 
r ’ olpl is at once arrested by Italy, which at this period was far ahead of the 
tint *! r 6 Woldd- Taking the number of Universities as an index of civilization, we find 
in C °re Ie year 1500, there were sixteen in Italy, while in France there were but six; 
the ermany • • • were eight; and in Great Britain two; making sixteen in all—’ 
1„ „exact P»mber which existed in Italy alone. The Italian Universities were likewise no 
rioi-uU*>UI(F in famet^an in number to thosp of the North.” Italy maintained this supe- 
y during, and even after, the sixteenth century. 168 
CHAILLE, 
The new-born shoot, languishing in Italy, was transplanted in German 
soil, where it received such culture as nourished its growth, developed its 
fruit, and reproduced seed to germinate in other lands. To favoring 
legislation from 1532’ to the present day, the fatherland owes its pre- 
eminence in Medical Jurisprudence. Germany, for two centuries, has 
had an organization of medico-legal officials, to whom alone it intrusts 
the duty, both to procure the medical facts needed by the courts, and to 
estimate the weight due such facts from whatever source obtained; it 
alone requires that these experts shall be especially educated, and 
provides medico-legal clinics2 for their practical instruction. In 1650, 
Michiaelis3 delivered the very first lectures on Legal Medicine, and as early 
as 1720 professorships of the same were founded by the state. By 1725, the 
celebrated works of Valentini, Teichrneyer, and Albertus,4 had supplanted 
that of Zacchias; and since then a medico-legal literature more abundant 
than in all other languages has nourished the science of Medical Juris- 
prudence both at home and abroad. In fine, Germany, specially excelling 
in the Art, has consequently excelled in the culture of the Science. 
France, from 1570 to 1692, enacted laws which, like those of Germany, 
favored the culture of Legal Medicine; but in 1692, medico-legal offices 
became hereditary and venal, and Legal Medicine languished until after 
the French Revolution. Since 1790, no nation has surpassed France in 
the culture of medical science; in addition, the judges appoint medical 
experts, who, since 1803, must be graduates in medicine, and must have 
attended one course of lectures, and have passed an examination on Legal 
Medicine, professional chairs of which were established by the state in 
1794.5 However, French authorities denounce their didactic instruction 
as insufficient for the education of experts, and declare the appointment 
of these by the judges, and the lack of skilled medico-legal officials to 
procure medical evidence, to be most unsatisfactory, and their whole 
system to be much inferior to the German. Still, France has at least a 
system, and meanly as this does apply the art, it has served to greatly 
stimulate the culture of the science, as has been notably illustrated since 
17966 by French medico-legal literature. A critical appreciation of how 
much of this literature has been derived from Germany, and how much 
of medico-legal science without the .art has been transported from Ger- 
many and France to Great Britain, and the United States, would, I fear, 
prove offensive to Gallic, and still more to Anglo American, vanity. 
Great Britain transmitted to this nation laws, barbarously conspicuous 
for the absence of provisions to apply medical knowledge to the admi- 
nistration of justice, and Anglo-American law continues to be, in large 
measure, hostile to Medical Jurisprudence. However, British laws have 
done something for the science, and a little for the art. For Great 
Britain has fostered medical education ; did in 1803 found a chair of 
1 The Constitutio Criminalis of Charles Y, 1532, (published in 1553) rendered it 
obligatory on the Courts to take the evidence of medical men in medico-legal cases. 
2 The first one established was at Vienna, about 1830; a second at Berlin, 1833; 
a third at Munich, 1865; and probably a fourth since 1870 at Strasbourg, where France 
had its only medico-legal clinic, 1840 to 1870. In France, Great Britain, and the United 
States, Medical Jurisprudence cannot be said to be practically taught, except as to 
Toxicology. 
3 University of Leipzig; Michiaelis was succeeded by Bohn. 
4 B. 29, 30, 31. 
5 Chaussier, in 1790, was the first lecturer, and Mahon, in 1795, (B. 115) the first 
professor. Fodere says the state enacted the first laws favorable to Legal Medicine in 1792. 
6 The date of the first French general treatise (B. 114). ADDRESS ON MEDICAL JURISPRUDENCE. 
169 
Forensic Medicine in one University,1 and now has such chairs in all its 
medical colleges (some of these conferring a special degree in State 
Medicine);2 has by the Registration Act and other laws3 greatly 
strengthened the medical profession ; and has compelled its courts to 
accept expert evidence only from registered, and therefore educated, 
medical men. Still, “ the crowned republic” remains destitute, as does 
its democratic American offspring, of popular, and hence of governmental, 
appreciation of the legal importance of medical knowledge, as is proved 
by the same lack of any system to secure the medical evidence of com- 
petent experts that characterized its laws when surgeons were barbers,4 
and when physicians were astrologers, sorcerers, and interpreters of 
dreams. What wonder that Germany and France began the study 
earlier, and have prosecuted it more successfully? 
The States of this Union have, for the most part, left the culture of 
medical science to individual enterprise which supplies solely that which 
the private citizen demands—practitioners of medicine to heal the sick. 
The States have as yet made no demand for competent medical experts 
to aid the administration of justice, and have done nothing designedly 
for the culture of Medical Jurisprudence. What growth can this branch 
of State Medicine have as long as a State does not recognize even its 
existence? Before attempting to answer this question, it will be well—• 
having now briefly examined the causes—to present as briefly some illus- 
trations of the extent of the general progress of Legal Medicine. 
To appreciate progress during any period, it is necessary to keep in 
mind the empire of the dead over the living; to recall some of the victo- 
ries gained over superstition and ignorance during the preceding century, 
as well as during that now closing. 
From 1620 to 1722, the authority of the father5 of medico-legal science 
was supreme. He devoted chapters to Torture, Sorcery, Prophecy, Mir- 
acle, and Immaculate Conception. Admitting one hundred and fifty 
births at a labor, he skeptically doubted the three hundred and sixty- 
five brought forth by the prolific Countess of Henneberg! During this 
period doctors gravely discussed whether a woman could be got with 
pbild by the devil, or by a dream; and French judges legitimized an 
mfant in a case where the husband had been separated four years from 
the mother, on the ground that the child owed its paternity to a dream. 
. Doctors taught that grossly deformed infants had a bestial parentage; 
judges, even in 1769, declared that they had “no inheritable blood” for 
University of Edinburgh: Dr. Duncan, Sr., in 1801, was the first English speaking 
ecturer on Forensic Medicine, and his son the first professor, in 1803. In this same 
University (chartered in 1582) was established, in 1726, the first English-speaking Medical 
acuity, which conferred degrees on less than 300 graduates from 1726 to 17; 6. From 
0) to 1726 twenty-one medical degrees, which would now be deemed irregular, perhaps 
onorary, were conferred. Institutions for medical education were established in Italy, 
ennany, and France, long prior to 1705 or 1726. 
Each of the twenty-three medical colleges reported in England and Scotland in 1875, 
nad a regular teacher devoted to Forensic Medicine; and some of these, at least those at 
Unbridge, Oxford, Edinburgh, and Dublin, confer a special degree in State Medicine on 
1) >s® applicants only who have already graduated in medicine, and have thereafter 
Verily pursued this special study. 
M q- e frustration Act was passed in 1858. “Glenn’s Manual of the Laws affecting 
eiieal Men,” London, 1871, gives a list of 36 such laws from 1800 to 1870, and of these 
r°m 1850 to 1870. 
Surgeons were barbers in England until 1745. 5 B. 2. 170 
CHAILLE, 
a “ reason too obvious and too shocking to bear a minute discussion,”1 
and the priest, encouraging doctor and judge, cried “Si tu es homo, te 
baptizo.” 
Until 1726 (Albertus), it was taught that, in presence of the murderer, 
his victim’s wounds did “open their congeal’d mouths and bleed afresh,” 
and courts accepted the testimony of medical experts to this miraculous 
bleeding of the corpse.2 The effect upon a suspected homicide of touching 
the dead body of his supposed victim, continued to be a legal expedient 
within the nineteenth century.3 
Unearthed bones served to convict men of murder, and yet these 
accusing bones, since not even human, were not those of missing men. 
A cranial foramen devised by nature, yet perverted by ignorance into 
an assassinating awl-hole, would have hung Thomas Bowman, but for 
accident. 
Superstition, denouncing raedicodegal autopsies even more fiercely 
than it now does cremation, did not permit these to become frequent 
until about 1750 ; and the work of the father of morbid anatomy,4 a 
foundation stone of Legal Medicine, was not published until 1761. By 
superstition, and by ignorance of normal and morbid anatomy, of the 
causes of sudden death, of diagnostics, and of chemistry, Legal Medicine 
was powerless, when compared with its present state. So great was 
its helplessness, that a horrible atmosphere of suspicion encompassed 
the fear of death by poison. On those even suspected, the grossest legal 
abuses were everywhere inflicted ; while those convicted were long boiled 
alive by English law, and burned (as late as 1780) by the French 
“ Cbambre Ardente,”5 which was not abolished until 1791. 
The highest medico-legal authorities6 taught belief in ghosts, witches, 
and possession by the devil; and united with the clergy until 1752 in 
denouncing all disbelievers thereof as heretics and atheists. They found 
demoniacs for the jailor and the stake, where we find patients for the 
doctor and the asylum. The distinguished medico-legist, Hoffman, com- 
mended to the barbarity of the law those who “ vomited nails, hair, wax, 
glass, or leather,” as indisputable witches.7 The “great and good” Lord 
Chief Justice Hale, prompted by the medico-legal testimony of the learned 
physician Sir Thos. Browne,8 illuminated the stake with witches—exem- 
plifying in 1664 the practice of Anglo-American witch-laws till 1727, laws 
not repealed until 1736.9 Thus did the legal medicine of our ancestors, 
only five generations removed, persecute, drown, and burn thousands of 
the insane, as “fire-brands of hell,” who were “moved and seduced by 
instigation of the devil.” 
1 Blackstone, ll.pp. 246-7. 
2 See plea of the great scholar and lawyer, Sir George McKenzie, in the “ State Trial,” 
1688, of Sir Philip Stansfield, executed for the murder of his father. 
3 The latest American case was in New York in 1824. (See B. 349, I. p. 807.) 
4 Morgagni, B. 18. 
5 Instituted at the close of 17th century as a special remedy for poisoning, which had 
become a very frequent crime in Paris. 
6 Pare, Zacchias, Hoffman, Storck, Boerner, &c., (B. 100, 2, 34, 39). 
7 “Be diaboli potentia in corpora.” Hoffman died in 1742. 
8 Author of “Religio Medici,” and also of “ Pseudoxia Epidemica,” or Vulgar Errors. 
9 The “witch-mania” originated with a papal edict in 1484. The last judicial execu- 
tions for witchcraft were in England, in 1716; Scotland, 1722; Wurzburg (Germany), 
1749; Glarus (Switzerland), 1780. The witch-mania prevailed in New England, 1692 to 
1727. Although the witch-laws were repealed in Great Britain in 1736, yet as late as 
1760 supposed witches were murdered by mobs, and there were “witch-doctors” in 1838. 
In France there was a legal trial for witchcraft as late as 1818. ADDRESS ON MEDICAL JURISPRUDENCE. 
171 
These few examples must suffice to recall the parentage of the Medical 
Jurisprudence of our century, and the facts that, with the impotence of 
science to aid the law, it adopted miracles as explanations, suspicion as 
proof, confession as evidence of guilt, and 41 torture as the chief witness,”1 
summoning the medical expert to sustain the accused until the rack 
forced confession.2 
During the hundred years now closing, the progress of medicine has 
been greater than in all preceding time. To detail the means acquired 
to aid the law, would require the record of every medical discovery; for 
what one of these may not contribute to the administration of justice? 
This occasion precludes more than bare suggestions illustrative of the 
general progress of medico-legal science. 
(1) Innumerable precious facts have been contributed by every branch 
of Anatomy, and especiall}’ by Pathological Anatomy. The study of 
putrefaction, fractures, burns, scars, marks, stains—in fine of every 
change and injury to be found on the living or dead body—has given 
the skilled expert a power (miraculous to the ignorant) to identify the 
body, to distinguish real from apparent death, to approximate the date 
of death, to decide whether it be due to morbid, accidental, or criminal 
causes, and often to point unerringly to the criminal.3 So great_ is this 
power that medico-legal autopsies have become indispensable to justice ; 
and, since 1837,4 the Microscope, strengthening notably Anatomy as also 
Toxicology, has repeatedly released the innocent from the jailor’s clutch, 
and delivered the culprit to the hangman. 
(2) Diagnostics, aided by stethoscope, thermometer, and many other 
instruments5 invented or newly applied since 1776, have stripped the 
malingerer of power to feign disease, become the corner-stone of Life 
Insurance, and aided the law in many other particulars. 
1 Montesquieu, 1748. 
2 It is true that in our motherland, England, torture was abolished in 1640 (a century 
and a half earlier than in continental Europe); but, to such extent did suspicion replace 
Proof, and the single penalty of death overtake every species and grade of crime, that the 
law had much less need than now of medical experts. Prisoners accused of a capital crime 
yere not permitted any witnesses until 1702 (Blackstone, IY, p. 360); an accusation of 
infanticide sufficed for conviction, unless there was one eye-witness to the birth, until 1802 
(B. 153, p 3Q<p . an(j u prisoners were first allowed the assistance of counsel” about 1830 
( “ Science of Law ”by S. Amos, p. 312). Even in 1769 there was “ a dreadful list of 160 
capital offences,” and, not content with this liberal supply of the halter, English laws 
Provided for criminals horrible mutilations, as branding, castration, slitting the nostrils, 
cropping the ears, and cutting off the hand, with a medical expert to sear the stump; 
death by exposure and starvation (“Peine fort et dure”), till 1772, by beheading, by 
drawing and quartering, and by burning alive; and brutal persecution of widow and 
orphan by corruption of blood and confiscation. Yet Blackstone asserts (1769), with 
evident pride, that this “ disgusting catalogue ” when compared with the criminal codes of 
other European nations did “honor to the English law.” It is calculated to soften 
impatient indignation to remember that “it cannot be justly regarded as a fault in 
(legislators] courts or juries not to be in advance of the age in which they live ”; and it is 
encouraging to recall that many of these barbarous laws were repealed because courts and 
juries did get so much in advance of them, that they could not be executed. 
Among errors credited by the profession and corrected within the 19th century may 
Mentioned here ; the beliefs that the human hair could grow after death; that the wind 
9 a canon-ball could destroy life ; and that violent and fatal injuries, which at times do 
tail to leave any visible signs externally, might also fail to present any lesions internally. 
Schwann and Schleiden. 
J Spirometer, Pneumatometer, Galvanic and Electric Batteries, Ophthalmoscope, 
laryngoscope, Endoscope, Spectroscope, Sphygmograph, Cardiograph, Dynamometer, 
-rLsthesiometer, etc. 172 
CHAILLE, 
(3) Obstetrics, until 1750 in the hands of ignorant midwives,1 conse- 
quently remained a special nursery of mystery and credulity. During 
the present century, Obstetrical Jurisprudence has rescued from igno- 
rant superstition monsters, retarded births, superfoetation, and hermaph- 
rodism; has discovered new signs of pregnancy, and the significance of 
uterine moles2 and hydatids; has appreciated the evidences of impotence, 
sterility, and “live-birth,” and has discarded the hydrostatic test3 as con- 
clusive proof of the latter. In vindication of chastity, the signs of 
virginity4 have been duly estimated, false have been distinguished from 
true corpora lutea,5 and it has been proved that sexual connection “with- 
out consent” may be fruitful. Finally, the “jury of matrons” has been 
slowly despoiled of its authority to decide a question of pregnancy. It 
is mortifying to record that, in criminal cases, the laws of some of our 
States continue to regard “ quickening” as proof of the very dawn of 
life; and yet add to this barbarism the inconsistency of admitting, in 
civil cases, the vitality of the embryo from the date of conception. More 
than a century ago, medico-legists,6 abandoning a belief long universal, 
taught that life began months prior to, and was as sacred before as after, 
maternal sensation ; but, to the encouragement of foeticide, this ancestral 
superstition7 still prevails among a free people, and lingers in their laws. 
(4) Chemistry, since 1789, when Lavoisier gave it a firm foundation, 
has enriched every science, bestowing such services on State Medicine as 
to necessitate the distinct department of Legal Chemistry. Two of 
many services may be mentioned: the murderer has been deprived of 
one refuge, which even professional credulity supplied—Spontaneous 
CombustionB—a mode of death yet to be witnessed by a skilled expert; 
but this interesting service is insignificant when compared with that 
rendered toxicology. Though poisons have become much more procur- 
able and numerous, yet the skill of the medical chemist has so increased, 
that criminal poisoning has become, largely through this power, one of 
the most certainly detected, relatively infrequent, and least dreaded 
modes of death. 
(5) By the knowledge acquired of the nervous system, medical science 
has influenced society and law to an extent difficult to over-estimate. 
1 A man-midwife was first employed with the greatest secrecy, in 1663. In England, 
men-midwives did not secure respectable professional position until 1783. Prof. T. G-. 
Thomas writes that in the United States the subject of obstetrics has “been recognized as 
one of paramount importance and dignity ” since 1767. 
2 The French Parliament decided in 1781 that virgins and nuns discharged moles {i. e. 
“ blighted ova ” ) without having had sexual connection. (B. 114, 2d Ed. I. p. 477.) 
3 The hydrostatic test was first practically used in legal medicine by Jan Schreyer in 
1682, and was long accepted as conclusive proof of live-birth. 
4 Buffon, as also Fodere (B. 114, in the Ist Ed. of 1796, not in the 2d Ed. of 1813), 
Mahon (B. 115) and many others taught that there was no such thing as the Hymen. 
5 In the trial of Chas. Angus (Lancaster, England), for the murder of Miss Burns, in 
1808, all the medical witnesses testified (to her dishonor) that all corpora lutea without 
distinction proved previous conception. 
6 Faselius, 1767 ; Haller, 1782 ; Farr, 1788, etc. 
7 “ Absurd ecclesiastical canons handed this error down from one criminal code to an- 
other.” B. 349, 11. pp. 9 and 1076; Fodere, etc. 
8 This debt is due chiefly to Liebig and Bischoff (Case of the Countess of Goerlitz, 1850). 
Casper wrote : “It is afflicting to be obliged in a serious scientific work in 1861 to still 
speak of the fable, spontaneous combustion.” A human body reduced in a few moments 
to a cup of ashes! To the credulous in this matter, one is prompted to recall Velpeau’s 
attitude in reference to the “ vagitus uterinus,” or capacity of the foetus (inclosed in its 
membranes) to cry in utero—a belief long firmly attested and universally credited. Said 
Velpeau : “ Since learned and credible men have heard it, I will believe it; but I should 
not believe it if I had heard it myself!” ADDRESS ON MEDICAL JURISPRUDENCE. 
173 
In 1774, England enacted the first law evincing one touch of pity for the 
insane; in 1792, Pinel1 adopted the first humane treatment of their dis- 
ease. Since then, civilization has been slowly taught that those upon 
whom our grandfathers inflicted “the pains of Hell” in order to thus 
drive the devil out of bodies “ accursed by God,” are the most pitiably 
diseased of all our fellow creatures, and we are enabled to point with 
pride to the palatial asylums with which our laws have replaced the 
garrets, cellars, stables, and dungeons, where starved and tortured insanity 
once writhed in filth and chains.2 The history of the Medical Jurispru- 
dence of Insanity is eloquent with the increasing number and efficiency 
of the laws designed to protect both society and the sufferer ; and with 
assurances of the extension of these laws from insanity to habitual 
intemperance. 
Is it too much to claim that the progress of Psychological Medicine 
has strengthened the conviction that not only mental disease, hut also 
hereditary organization, defective education, and circumstances for which 
society is more accountable than any of its units, do modify criminal 
responsibility in fact, and therefore should do so in law ? Has not this 
special knowledge broadened man’s charity, encouraged society’s efforts 
to redeem its outcasts, and influenced the law’s amelioration of its 
criminal code? Is it not forcing to the front that most important social 
question, the problem of heredity; thus disclosing an immeasurable 
field for the medical research and legislative labor of our descendants ? 
In fine, is it not true that science, stripping nature of providential 
caprice and disheartening chance, divinely adorning her with eternal order 
and omnipotent law, has gradually established that the diseases and de- 
formities of the mind are as much as those of the body subject to nature’s 
laws; and that the lunatic, the drunkard, the criminal, the sage, and the 
fool are not the products of chance, but of laws as comprehensible, 
though not yet as well comprehended, as those governing that thunderbolt 
which, once in the hand of Jove, now traverses even the depths of the 
sea at man’s command ? 
The part this nation has taken in the general progress of Medical 
Jurisprudence must now be considered, and to test our progress five 
inquiries will he instituted. 
_ I. What have our Laws done to apply medical knowledge to the Administra- 
hon of Justice?—In the United States there are probably forty-five 
thousand autopsies made annually. The service of a skilled 
expert at these “ coroner’s inquests,” which have exceptional opportunity 
and power to detect crime, is of inestimable importance; the opportuni- 
ties there presented, if once lost, can never be regained. Further, our 
courts have annually from twenty-five hundred to treble this number of 
criminal trials necessitating medical testimony; and of these a large 
part originate from the coroner’s inquests. If to these criminal be added 
a" the medico-legal civil trials, it would be found, I doubt not, that our 
courts require medical evidence in not less than twenty thousand cases 
annually.3 Whatever the number may be, it would indicate inade- 
’ B. 129. 
i. New England, say “ Wharton and Stille,” the insane were sold out to the lowest 
idder, who starved them, and when violent chained them in stables. 
t have sought in vain for full and reliable statistics to illustrate numerically the im- 
P°nance 0f ]egaj medicine. The numbers given are only approximative estimates based 
1 ai’tly bn some meagre British statistics cited by Guy and by Taylor, and partly on the 174 
CHAILLE, 
quately the number of citizens whose welfare is involved, and the extent 
to which society is interested in the efficient application of medical 
knowledge to the administration of justice. 
ISTow, what are the methods which Anglo-American law adopts to 
secure in practice that “ best attainable evidence” which in theory it 
demands ? It entrusts medico-legal autopsies, which require special 
medical and some legal knowledge,"to those having neither the one nor 
the other, except by accident; for, these coroners (whose inexperience 
our law insures by constant “ rotation in office”) owe their position 
wholly to political popularity, a qualification which a competent expert 
is most unlikely to possess. Are these unqualified officials supplied with 
efficient aid? If so, again by accident, since the law leaves it to chance, 
or the coroner, or to his still less qualified jury, to provide a medical 
expert; and, as is usual, accident and ignorance provide inexperience and 
incompetence. Could ingenuity devise for medico-legal autopsies any 
methods more inefficient than these, which Anglo-American laws, 
framed before the birth of Medical Jurisprudence, have barbarously per- 
petuated ?l 
On this Pelion of inefficiency our legislative giants have piled an Ossa 
of absurdity; for, besides these fatal defects in the primary legal pro- 
ceedings, Anglo-American law, in order to secure “ the best attainable 
evidence” for its courts, where poverty and dishonor as well as the halter 
are administered to the free citizen, clings to a method as sadly ludicrous 
as it is antiquated. To plaintiff and defendant the law gives full license 
to summon such medical witnesses as each has already found reason to 
following facts as to New Orleans, La., for the year 1875. The total number of coroner’s 
views and inquests was 1026 ; of these there were 268 inquests, and out of these grew 47 
trials. Giving New Orleans 210,000 and the United States 40,000,000 population, the 
New Orleans statistics would indicate for the United States annually 8952 medico-legal 
criminal trials, growing out of 51,047 medico-legal autopsies, or coroner s inquests. 
1 Convincing reasons could be given in proof that the duties of coroners are discharged 
even worse in the United States than in England. The following facts indicate how the 
Anglo-American method works in the latter country. An Englishman writes (1876): 
“ The coroner is elected for life by the rate-payers of his district [a superiority over the 
American method], and he is paid a good salary out of the county rates. In most cases he 
is a medical man who has studied the arts of popularity with more success than those of 
medicine, or he is a small country attorney who has failed in the higher paths of his profes- 
sion.” Dr. Wm. Farr officially reported as to England in 1868 : When all the verdicts of 
coroners “ for the first time came under review [another great superiority over the American 
lack of any such system], they were not at all creditable to the intelligence of the country. 
They conveyed the least possible information in the vaguest possible words.” Prof. A. S. 
Taylor wrote in 1873: “ The coroner’s inquest affords no certainty for the detection of 
crime. It, in some instances, tends to screen a criminal.” “In the course of thirty years’ 
practice, at least fifteen cases of the exhumation of dead bodies were referred to me. On 
some of these inquests had been held, but no inspections were made. Verdicts of death 
from cholera or natural causes had been returned, and at intervals of from one to twenty- 
two months the bodies have been disinterred, and it was then proved that the deceased per- 
sons had died from poison.” (See B. 358, I. p. 12.) The British Medical Journal (Jan. 
1876) reports a glaring case of poisoning, undetected by the incompetent coroner. National 
attention was recently attracted to the same monstrous evil in the inquest of a Mr. Bravo. 
An English writer asserts that “ almost every day, from all parts of England tales come up 
of the Inadequacy and absurdity of the institution. Notice has been given to-day [May 
23d, 1876] in the House of Commons, by an independent member on the ministerial side, 
that he will call attention to the office of coroner at an early day.” Other facts indicate 
that England recognizes this evil better than does the United States, and therefore will 
probably correct it sooner. July. 1876, it was reported that “ the practice of electing coro- 
ners has been condemned in the House of Commons by a unanimous vote. A bill for the 
reform of the office of coroner is soon to be brought in.” See also B. 259, 274, and 330. ADDRESS ON MEDICAL JURISPRUDENCE. 
175 
believe entertain opinions the most contradictory.1 Who are these partisan 
witnesses thus summoned by the law to apply the power of medical 
knowledge to the administration of justice ? Surely these legal represen- 
tatives of science must be competent experts? Ho.—Well, experienced 
and educated physicians of repute? Ho.—Then, of course graduates, at 
least some fledgling hatched in nine months, and fully feathered with 
the plumes of every branch of medicine, Medical Jurisprudence included ? 
Ho, not indispensable, since “ as a general rule” it has been adjudged 
that any practitioner of medicine (that is, any man who dubs himself 
Doctor) has sufiicient knowledge of medical science to furnish justice 
with its “ best attainable evidence.”2 “0, [this] offence is rank, it smells 
to Heaven 1” 
Common sense would presume that laws, so prodigal to ignorance and 
pretension, would provide means to test the value of scientific opinions 
by eliciting the facts upon which, if valid, they must be founded. Hot 
so ; since these opinions are replies to questions, which often by their 
very structure comically prove entire ignorance of the facts involved ; 
tor they are propounded by lawyers to whom these facts are unknown. 
Dinally, it would be presumed that the decision as to the weight due 
such opinions would be left to a judge or jury specially chosen. Ho, 
even this last poor boon is denied by the law ! 
With the power of medical science thus crippled at the coroner’s 
Diquest, then prostituted by the partisan opinions of incompetent experts, 
then perverted by advocates, and at last when emasculated of all vigor 
submitted for decision to those unable to estimate its weight; what 
wonder that such gross misapplication of medical knowledge brings 
upon it that public contempt which belongs justly to methods so mon- 
strous, and to which true medical knowledge is a helpless, pitiable, and 
disgusted victim! 
But these legal defects, so paralyzing to the past, so discouraging to 
1 Reference is often made to the well-known facts that the sound expert-evidence of the 
illustrious John Hunter was in 1781 overborne by the evidence of three ignoramuses, and 
that the testimony of the famous Denman was in 1806 set aside by the Court in favor of 
°ue male and two female quacks. The same system is continued, and therefore the same 
evils persist. Prof. A. S. 'Taylor reports now, as to England, that a good search and good 
pay can always find, in abundance, the witnesses needed on either side of any medico-legal 
issue. This is certainly true as to the United States. Some facts may be cited in illus- 
tration. I have personal experience in a suit (unsoundness of a slave) in which the medical 
experts were selected by one side because of their well-known ignorance of the special 
knowledge (auscultation) which the issue involved ; and the judge decided that the whole 
Medical testimony must be set aside, because the negative evidence of the incompetent suf- 
ficed to counterbalance the very positive affirmative testimony of the competent experts. 
Death, with a post-mortem examination, soon after the decision, conclusively proved that 
the ignoramuses deserved no consideration in justice, though they did receive equiponderant 
consideration in law. Whenever a notorious trial attracts public attention, the results of 
Mir defective laws become disgracefully apparent, as has been illustrated in recent years by 
[he Steinecke-Schoeppe (1868), the Wbarton-Ketchum (1872), and the Stokes-Fisk (1874) 
]ials (B. 363, 344, 370). If the medico-legal proceedings are so discreditable in cases like 
hese, exciting great public interest and engaging the best legal and medical talent, what 
probably are they in ordinary trials lacking these advantages ? 
9 He text will be found fully sustained by reference to B. 317, pp. 131-2, B. 349, I. pp. 
-y 3-5, and B. 363, p. 406. However, Elwell (B. 330, p. 589) refers to eight decisions to 
. effect that “ special knowledge must be fully established before a witness can be ex- 
?Mmed as an expert;” but had he stated by what slight proofs, and by what incompetent 
.judges, this “ special knowledge must be fully established,” the apparent discrepancy would 
lave practically disappeared. An eminent lawyer assures me that in the courts of my 
Motive State (Mississippi) the competency of a medical expert rests solely on his own oath ; 
anci Diat, when his own interests and reputation prompt such an oath! 176 
CHAILLE, 
the future of Anglo-American Medical Jurisprudence, are not the only 
disadvantages against which this nation has had to contend. It in- 
herited from Great Britain not even a page of the literature, in fact 
nothing of Medical Jurisprudence except laws hostile to it. So desti- 
tute was it of those indispensable promoters of science, well endowed 
institutions, with libraries, laboratories, and museums ; so exhausted by 
the war for independence; so closely occupied by the pressing demands 
of daily life; and so profitably absorbed by glorious efforts to present to 
civilization a savage continent, that every science seems to have required 
half our century to secure the conditions necessary to fairly begin its 
culture.1 Another potent, yet ill-appreciated friend to science, pressure 
of population, now wanting in many, was long wanting in every State. 
Finally, while a European nation requires but one legislative body to 
reform its laws, our political system now necessitates the action of thirty- 
eight State legislatures to embrace the entire nation. 
°Just consideration of all these impediments should incline other 
nations not to condemn, if we have done little for Medical Jurisprudence, 
but rather to wonder that we have done anything at all; and to con- 
gratulate us that, so great has been the diffusion of knowledge, so ardent 
the love of justice, we have in the main kept pace with, and in some 
particulars have even outstripped, our mother-land. Fairly we can claim 
no more; reasonably no more should be expected. 
11. What have our Medical Colleges done to cultivate and to disseminate a 
knowledge of Medical Jurisprudence?— The first chair of Medical Juris- 
prudence was established by the “College of Physicians and Surgeons” 
of Hew York City, and filled by Prof. Stringham,2 in 1818. In 1815 
two other Colleges3 had chairs devoted to the usual branches with 
Medical Jurisprudence attached to some one of these. In 1825 there 
were about twenty-two medical colleges; of these only one had a full 
chair, and only five others had even the fraction of a chair devoted 
to the subject.4 At present (1875-6) there are sixty-four regular 
medical colleges (four of these for women). A report5 as to forty-six of 
1 To illustrate this as to medicine, and also the practical difficulty encountered by the 
courts in securing, under our laws, the evidence of competent experts, the following facts 
are stated : Prof. S. 1). Gross reports that in 1776 the United States had about 3000 prac- 
tising physicians, of whom the great majority had never received a medical education, and 
those who had, were educated abroad. Prof. Austin Flint, Sr., reports that in 1776 our 
two medical colleges (one founded in Philadelphia in 1768, the other in New York City in 
1770) had not graduated even fifty doctors of medicine, and that up to 1800 the five colleges 
then existing had graduated only about two hundred. Thacher’s “ History of Medical 
Science in the United States” reports that it was computed that in 1826 the United States 
had 10,000 “ very easily graduated” doctors of medicine, and more than 15,000 practitioners 
without diplomas. Prof John B. Beck wrote that, “at no period in the history of this 
country, it may safely be asserted, has empiricism flourished to the same fearful extent as 
at the present time [1845], notwithstanding our boasted improvements in other respects.” 
In 1870, the United States had 62,383 practitioners of medicine ; of these there were per- 
haps 47,000 “ very easily graduated” doctors, and at least 15,000 quacks outside of profes- 
sional ranks. . 
2 Dr. Stringham was also the first lecturer on Medical Jurisprudence in the united 
States, viz., in New York City in 1804. 
3 In 1815, “The College of Physicians and Surgeons of the Western District of New 
York” appointed Dr. T. If Beck “ Professor of the Institutes of Medicine, and Lecturer on 
Medical Jurisprudence and the Medical Department of Harvard University (Cambridge, 
Mass.) appointed Dr. Walter Ohanning “ Professor of Midwifery and of Medical Juris- 
prudence.” 
* See “ Thacher’s History of Medical Science in the United States, 1828.” 
5 Due to the courtesy of (my colleague on this occasion) Prof N. S. Davis, M.D., of 
Chicago, HI. The forty-six graduate more than nine-tenths of all our annual graduates. 
The twenty-five graduate fully one-half of the whole number. ADDRESS ON MEDICAL JURISPRUDENCE. 
177 
the most noted, shows that twenty-one do not profess to teach the subject; 
of the remaining twenty-five, only fourteen (and these not the best known 
and attended) have professorships devoted exclusively to Medical Juris- 
prudence, and, by five of these fourteen, students are taught to become 
medical experts by lawyers ;l while the other eleven have Medical Juris- 
prudence “tacked on as a caudal appendage” to some one of the usual 
branches. In fine, only about one-half of even our best colleges profess 
to pay any special attention to the subject; and many facts could be 
cited to prove that the true significance of the whole matter, from 1818 
to the present day, is.correctly represented by the following quotations 
from one of the most prominent of our living medico-legists2 
“ There are very few of the medical colleges in which it is taught, and 
still fewer in which it takes rank as a distinct and independent branch 
along with the other departments. Usually when it professedly receives 
any attention at all, it is tacked on, as a sort of appendix, to some other 
branch with which it has no natural affinity whatever, as, e.g., Obstetrics 
or Materia Medica. This is of course done to make a show on the pro- 
gramme, while the subject itself is not taught systematically to the 
student, if taught at all.” “I very much doubt whether Medical Juris- 
prudence is ever made a qualification for graduation, even in those 
colleges wdiere it is professedly taught as one of the regular branches.”3 
From these facts it is manifest that, since 1813, our colleges (the off- 
spring of the enterprise of individuals, and not of the State) have made 
ineffectual efforts to cultivate that special knowledge which, while 
highly beneficial to the State, would not benefit the individual members 
of our profession any more directly than any other citizens. In fact, the 
States through these citizens have failed to provide honorable and prolif- 
ic employment for medico-legal experts, and, therefore, the profession 
has not furnished them ; and, however enlightened the colleges, however 
praiseworthy their efforts, they will continue to contend in vain against 
fhe obstinate “ demand and supply law” of political economy. 
The profession recognizes the absurdity of the popular and legal pre- 
sumption that every practitioner is a medical expert; but the profession 
does not yet recognize sufficiently that even the most skilful healers of 
disease are neither necessarily nor generally medico-legists ; and that the 
experience of other nations has fully proved that merely didactic lectures 
can never render medical graduates competent experts. Were this feasi- 
ble, any such ideal education is now impracticable; for who will deny 
y) that our two short courses of lectures are insufficient for proper 
instruction even in the fundamental facts indispensable to the education 
M practitioners of medicine ; (2) that the fundamental facts for the prac- 
titioner are the same as for the medical expert; and (8) that society 
i enumerates the one, while the State finds no use for the other ? Finally, 
here is reason to fear that, until the State demands medical experts, the 
colleges, dependent on the student and not on the State for their exist- 
ence, will be forced by these practical students to realize continually the 
and 9asPer insists, with good reason, that the medico-legist should remain a physician; 
doe ecome neither a lawyer, jurisconsult, nor judge, but simply an expert witness, who 
2S need from the law thorough instruction in the “ rules of evidence.” 
o»i,' .n F Reese, M.D., Professor of Medical Jurisprudence in the University of Penn- 
syUama. (See B. 247 and 362.) 
is <r °iUe our Law Schools have professorships of Medical Jurisprudence ; and there 
the°r°C Tason i° believe that the general facts as to the Medical are fully applicable to 
aw Schools, as far as instruction in Legal Medicine is concerned. 
12 178 
CHAILLE, 
force of the homely adage, “ you may take a horse to the water, but you 
cannot force him to drink.” 
HI. What new Facts hove Americans added, hy original research, to the com- 
mon stock of Medicodegal Science?— Restricting the list to researches design- 
edly and specially medico-legal, it must be borne in mind that the sum 
total of these in all nations has not been very large, and that few should be 
expected in this country for reasons already stated. Prof. John C. Dalton 
(though to some extent anticipated by Coste (1849) whose researches were 
unknown to Dalton) was the first (1851) to make a rigid comparison 
between the corpus luteura of menstruation and that of pregnancy ; and 
to distinctly indicate the differences which, during a certain period, 
enable the expert to determine from an inspection of the ovaries whether 
pregnancy has or has not existed.1 Dr. Joseph G. Richardson announced 
in 1869 the important medico-legal discovery that, by the proper appli- 
cation of high powers of the microscope, human blood-corpuscles could 
with certainty be discriminated from those of certain animals ;2 thereby 
enabling the expert to refute such statements as criminals have often 
offered to explain the presence of condemnatory stains of blood. Though 
the justice of this claim has been questioned, yet some of the highest 
authorities emphatically sustain it; and this discovery has been usefully 
applied in several criminal trials.3 Dr. Richardson deserves the additional 
credit of having called attention in 18754 to a simple method of so treat- 
ing a blood-stain, of even microscopic size, that it can be successfully 
examined by the spectroscope and guaiacurn test,5 as well as by the 
microscope. 
Researches by which error is exposed, or truth more firmly established, 
are often as important to science as those which discover new facts. 
Among such researches may be mentioned those of John D. Deck, on 
Ploucquet’s 6 and on the hydrostatic test,7 in 1817 and subsequently ; of 
Horner, on the mucous membranes of the stomach and intestines, in 
1827; of Gross, on strangling, in 1883 ; of Wetherill, on adipocere,8 in 
1855 ; and of Fleming, on blood-stains, in 1859.9 
Contributions by my countrymen to the progress of Medical Jurispru- 
1 See B. 257; also, Coste’s second livraison, “Histoire du Developpement,” 1849; and 
the adoption of Coste’s views in Lon get’s “Traite de Physiologic,” 11. p. 88, 1850. 
2“ An objective to s'o- inch distinguishes human blood-corpuscles in stains (but not m 
dried masses of blood) from those of the ox, pig, sheep, cat, horse, deer, and goat.” (bee 
B. 320,373,374, 376,377.) 
3 Since the delivery of this address, eminent microscopists have made on the pre- 
ceding periods two criticisms. First, that the word “ discovery” is misused—since it has 
long been known that the blood-corpuscles of the “ certain animals” are much smaller 
than those of man, as also that high powers render this difference in size more appa- 
rent. Second, that the words “ with certainty” demand a modifying explanation, since 
able observers declare that cases do occur wherein human corpuscles in dried stains 
shrink, so as to be as small as those of the “ certain animals”: hence, that the expert 
when 'confronted with such small corpuscles cannot swear “with certainty” whether 
these be human; but if the Specimen of corpuscles approximate those of man in size, 
then the expert can swear “ with certainty” that they are not those of any one of the 
“ certain animals,” inasmuch as corpuscles in dried stains do shrink, but do not enlarge. 
The issue thus raised is as to the amount of shrinkage of human red blood-corpuscles in 
dried stains ; Dr. Richardson asserts that this does not exceed ten per cent.; while others 
assert that this may be thirty per cent., the corpuscle shrinking in size to 33150, or 
even to - A inch. 
4 B. 375. 5 Yan Been, 1862, and A. S. Taylor, 1868. 
e 1782. * jan Schreyer, 1682. 8 Fourcroy, 1785-7. 
9 See B. 205, 215, 225, 267, 287. To this list might be added Brown-Sequard’s experi- 
ments in 1851 on Cadaveric Rigidity. (Am. Journ. Med. ScL, Oct. 1851.) ADDRESS 01ST MEDICAL JURISPRUDENCE. 
179 
deuce during a century, present a field for investigation so extensive, 
that some of these contributions may have escaped my search, or may 
have been inadequately appreciated. To rectify, at least in some mea- 
sure, any such defects, I present, with this address, a Bibliography of 
American Medical Jurisprudence, to which attention is invited. The 
next inquiry is:— 
IY. What culture of Medico-legal Science is evinced by our Literature ? 
1. General Treatises.—The embryonic stage of medico-legal litera- 
ture in our mother-tongue is attested by the following “ footprints on 
the sands of time.” Farr’s “ Elements of Medical Jurisprudence,”1 an 
abridged translation of Fuseli us, was the first general treatise in the 
English language, and the only one from 1788 to 1815, when another 
worse little duodecimo was added by Bartley.2 In 1816 Male contributed 
an insignificant “ Epitome of Forensic Medicine,”3 borrowed from 
Elenck,4 and in 1821 John Gordon Smith, M.D., published a small book, 
which was the first original and meritorious treatise in our language.5 
In 1823 appeared, in two large octavo volumes, the American, Theo- 
dric Romeyn Beck’s “Elements of Medical Jurisprudence,”6 which, in 
spite of the merit of Smith’s book, and of the greater merit of Paris’s and 
Fonblanque’s English treatise,7 also published in 1823, quickly sup- 
planted these wherever the English language was spoken. From the 
date of its publication, which may be deemed the origin, in fact, of 
Anglo-American medico-legal science, its twelve successive editions have 
ably kept pace with the progress of legal medicine. Filling many offices 
of trust and honor, a member of twenty American and seven foreign 
scientific societies, Prof, Beck8 lived to witness the issue of ten editions 
°f his treatise ; of these, several were published in England, and even the 
prolific mother of medico-legal literature issued in 1828 a translated 
German edition. But to Beck’s merit no testimony can be more con- 
vincing or pleasing than that gracefully given by the three eminent 
authors whose works eventually succeeded in largely supplanting his 
treatise in Great Britain, Traill, the distinguished Scotch professor and 
author, eulogizes it as “the best work on the general subject which has 
appeared in"the English language;”9 Guy “acknowledges his obliga- 
tions in a special manner to Beck’s learned and elaborate Elements of 
Jurisprudence;”10 and Taylor, than whom there is no higher 
living authority, testifies that he, when a student, was stimulated by 
Eeck’s work to study medical jurisprudence in 1825, when no lectures 
Were delivered in England on the suliject, and this book was the leading 
authority for both lawyers and physicians; and that it “ will carry 
down” the author’s “name to future years as one of the most erudite and 
distinguished writers on medical jurisprudence.”11 
.To these testimonials from abroad may be added the eloquent eulogy 
°1 that son of America whom its medical profession delights to honor as 
one of its noblest representatives, and as its President on this occasion. 
His voice, generous to all, even loving to worth, declares that “this 
grand book” “ was in its day the most comprehensive, able, and erudite 
Production on the subject of which it treats in any language,” and that 
P “constitutes a lasting monument to the genius, industry, judgment,: 
' B. 150, also 207. 2 B. 151. 3 B- 152, also 207. 
8 B- 47. 5 B. 153. 6 B. 209. 7 B. 154. 
Born in 1791; died in 1855. For the biographies of Brs. T. R. Beck, John B. Beck, 
an‘‘ More ton Stille, see Gross’s “American Medical Biography,” 1861. 
B. 158, 2d Ed. 10 B. 161, 2d Ed. 11 B. 359. 180 
C H AIL LE , 
and learning of its lamented author,”1 It is pleasing to learn from the 
same source"that, in honoring this famous author, we are honoring the 
memory of a good and noble man; and this pleasure is enhanced by re- 
calling the humble estimate which he himself accorded to his “world- 
renowned book.” For his own statements were that his “ highest ambi- 
tion would be gratified” if his “ collection of detached essays should “in 
some tolerable degree” “prove useful.” Knowing that these modest 
words will find a generous echo in the hearts of all noble men, to them 
is commended the lame oi America’s first and greatest medico-legal 
author. 
In 1850, Prof. Amos Dean, a lawyer, published his brief but excellent 
text-book, the “ Principles of Medical Jurisprudence,”2 which has passed 
through three editions. 
A lawyer and a physician united to produce in 1855 the voluminous 
and admirable general treatise, “ W barton and Stills s Medical Juiispiu- 
dence.”3 After completion, but prior to its publication, profession and 
country had cause to mourn the death of the young and gifted Moreton 
Stilled His legal associate, deriving from other able pens indispensable 
medical aid, has lived to issue three editions of a work which both pro- 
fessions accept as one of the highest standard authorities^ 
Evidence of our increasing appreciation of legal medicine, as also of 
■our obligations to foreign sources, is found in the republication, since 
1819, of nine books by British authors on the general subject, viz., 
Oooper’s collection of the earliest English tracts (1819), the nume- 
rous valuable articles in the “Cyclopaedia of Practical Medicine (1845), 
which deserve mention with the general treatises of Ryan (1832), Chi tty 
(1836), Traill (1841), Guy (1845), and Woodman and Tidy (1876); and 
of still greater value Taylor’s “Manual,” as also his “ 1 rinciples and 
Practice of Medical Jurisprudence” (1845 to 1873).5 
2. Treatises, Essays, etc., on Special Subjects. Besides tlie excellent 
books of Ray, Elwell, Ordronaux, Wormley, Reese, and the Kew York 
“ Medico-Legal Society,” the essays and articles on special topics have 
been too numerous to permit full examination, or more than a partial 
sketch of this important branch of my subject. 
Infanticide and foeticide received from Prof. John B. Beck attention in 
1817 f and this thesis, enlarged and improved for the various editions of 
his brother’s “great work,” displays a combination of erudition, original 
research, sound sense, and rhetorical excellence, which render it one of the 
most classical essays in the medical literature of the English language. 
Abortion has been further illustrated by the essays of Hodge (1839, 
1873), Storer (1866, 1867), Heard (1868), and others ;7 as also by numerous 
valuable articles in our periodical literature.8 Apparently increasing 
with the pressure of population, this stain on modern civilization has 
become one of the most serious and hopeless problems within the province 
of Legal Medicine, and demands the grave consideration of every enlight- 
ened citizen. 
1 See pp. 39, 65, “History of American Medical Literature” (1776-1876), by S. D. 
Gross, 1876. „ , ,OC£. 
2 254. 38. 264. 4 Born 1822 ; died 1850. 
5 B. 207, 245, 223, 231, 239, 246, 390, 247, 358. 6 B. 205. 
7 B. 236, 279, 305, 309, 314, 310, 315, 325, 341. „ 
Bln the “ Specimen Fasciculus of a Catalogue of the National Medical Labi ary, io/o, 
pp. 24-5, are reported from our medical journals thirty-nine articles on this subject, since 
1825, by Americans; of these, twenty-three have been published in the last ten years. ADDRESS ON MEDICAL JURISPRUDENCE. 
181 
Elwell’s “Malpractice and Medical Evidence”1 (1.860,1871) and Ordro- 
naux’s “ Jurisprudence of Medicine”2 (1869) are very valuable works— 
legal rather than medical—and unique, it is believed, in medico-legal litera- 
ture. In connection with malpractice, Hamilton’s noted essay on “De- 
formities after Fractures”3 (1855) and his standard treatise on “Fractures 
and Dislocations” (1860-1875) deserve mention, since more than half of 
all trials in the United States for malpractice have originated from the 
results of these injuries.4 
Supplied with domestic editions of Orfila (1819, 1826), Christison 
(1845), and Taylor (1848-1875), on Poisons, and with Haquet’s Legal 
Chemistry (1876),5 native authors have produced two meritorious works 
on Toxicology. Wormley’s “ Micro-Chemistry of Poisons”6 (1867) has 
received the most flattering commendation from the highest authorities, 
who report this book to be the result of original researches which enrich 
it with the treasures most valuable to science. Ho more will be said, 
because the author is not only living but present,and no praise from me can 
enhance the reputation of his work. The same considerations prohibit 
more than reference to Peese’s excellent “ Manual of Toxicology”7 (1874), 
which has been republished in London. 
On the most important specialty, America has produced one treatise, 
Pay’s “ Medical Jurisprudence of Insanity.”8 In 1888, when first pub- 
lished, there were few such treatises extant,9 and it at once assumed, and 
th roughout an English, a Scotch, and live American editions, has 
deservedly maintained, the first rank in Anglo-American medical litera- 
ture. An able advocate of “ moral mania”—the present battle ground 
m the Medical Jurisprudence of Insanity—Dr. Ray does not forget, 
while urging a larger charity for disease, to demand ample and better 
legal protect society. Besides this treatise, essays of value 
have been published by Hammond (1866, 1878), Fisher (1872), and 
Oowperthwait (1876),10 and numerous meritorious reports and articles 
have richly adorned our periodical literature,11 It would require a volume 
to do justice to the medico-legal labors of the Superintendents of our 
Insane Asylums, and to record the evidences of progress presented solely 
111 the “ American Journal of Insanitywhile some of the most valua- 
ble essays on this and other special subjects are to be found in the pub- 
lications of the Hew York Medico-Legal Society.12 
There are four other works which, treating incidentally of the Medical 
Jurisprudence of Insanity, deserve mention: the notable “Diseases of 
the Mind” (1812-1835), by Benj. Rush, a father of this republic and “ the 
father of its medical literatureSeguin’s “ Idiocy” (1866); Echeverria’s 
“Epilepsy” (1870); and Hammond’s “ Diseases of the Hervous System” 
(1871-1876).13 
Fourteen foreign books on insanity have been republished in the 
United States. Five treat specially of its legal relations, viz., those by 
1 B. 290. 2 B 317. 3 B. 266. 
B. 330, pp. 55 and 587 ; and B. 213. 5 B. 206. 212, 244, 252, 389. 
9 B- 307. v B 362. s B. 234. 
m t Z': Haslarn’s. 1807; Hoffbauer’s, 1809; Georget’s, 1827; Cnnolly’s, 1830. 
B. 304, 338, 348, 385. 
B. 216, 265, 275, 278, 282, 283, 284, 285, 295, 296, 302, 304, 311, 316, 322, 323, 324, 
r’ 331’.332, 347, 353, 354, 357. 365, 366, 368, 369, 379. 
i . 11 addition to the above, Dr. John S. Billings, U. S. A. (Surgeon-General’s Library) has 
• y furnished a selected list of 88 medico-legal articles by Americans on unsoundness of 
°f these, the first was in 1827 ; 79 since 1850; and 41 of the 88 since 1865. 
B- 363. -3 B. 203, 303, 321, 326. 182 
CHAILLE, 
Highmore (1822), Blandford (1871), Maudsley (1874), Sheppard (1875), 
and Browne (1876);] and nine treat of these relations incidentally, viz., 
those by Combe (1834), Prichard (1837), Esquirol (1845), Brierre de Bois- 
mont (1855), Bucknill and Take (1858), Winslow (1860,1866), Maudsley 
(1867, 1871), Take (1873), and Wynter (1873).* . 
This incomplete sketch of our medico-legal literature attests that it has 
since its origin progressively increased, and that a very large proportion 
has been furnished during the last ten years; thus indicating a diffusion 
of this knowledge to an extent which encourages the hope that such 
appreciation of its importance is in growth as will insure its proper use. 
That our progress in this literature may be properly estimated, as far 
at least as increase of quantity is concerned, it is indispensable to'corn- 
pare it with that of other nations. As concerns general treatises, this 
nation, beginning in 1823, has produced three;3 Germany, beginning a 
century earlier, published at least forty before, and more than twenty 
since 1823 ;4 France beginning in 1796 published nine before, and seven 
since ;5 and Great Britain, making its first creditable eftoit in 1821, pub- 
lished its second in 1823, and has issued eight since.6 If a comparison 
as to special treatises be instituted, a like result ensues, and a search into 
periodical literature proves even more unfavorable. Since 1782, Germany 
alone has had, and now has, several journals of great merit devoted ex- 
clusively to Legal Medicine, from which flow, to the benefit of all nations, 
a constant stream of medico-legal knowledge. France has had, only 
since 1829, one of the ablest journals7 in the world devoted to State 
Medicine, but not one to Medical Jurisprudence exclusively. Great 
Britain has no such journal, nor has this nation except in so far as repre- 
sented, since 1874, by the valuable “ Psychological and Medico-Legal 
Journal” of Prof. Hammond. 
These facts tend to prove that the culture of medico-legal literature 
is proportionate to the use made ot it by the law; and prompt the com- 
ment that, however valuable compilations may be, these and the pro- 
gress of every science depend ultimately on original research, and the 
fabor of practical workers. Germany has produced many, Franee several, 
and Great Britain one or two, practical medico-legal experts of wide- 
spread fame. This people has 'never had, nor is it likely to have, one, 
until it provides for him honorable and lucrative employment. 
Y. What illustrations of medico-legal progress are to be found in the Insti- 
tutions, Laws, and Judicial Decisions of our States?— Originated by vital 
statistics, nourished by medical selection, protected by medical evidence, 
Life Insurance, the wondrous child of Medicine and Finance, encourages 
the hope that it will repay our science the debt it owes. Causing 
numerous medico-legal suits, its vast interests are deeply involved in the 
leo-al reforms indispensable to the progress of Medical Jurisprudence; 
for these interests are often sacrificed by the negligence of coroners,8 the 
incompetence of experts, and the inefficiency of our medico-legal methods. 
While Life Insurance suits have most frequently grown out of intem- 
perance and suicide, yet there would seem to be few medical issues on 
which they may not depend, even on whether death was due to consump- 
i B. 208 334 371 382 388. 2 B. 226, 232,243, 270, 286, 297, 313, 335, 360, 361. 
38. 209, 254, 264. ’ 4 29 to 94. 58. 114 to 128. 
68. 153't0 164. 7 Annales d’Hygibne et de M6decine Legale, Paris. 
8 The issue has recently beeh raised, in reference to a case, the subject ot a coroners 
inquest, whether death was due to intemperance or to heart-disease. A medico-legal 
autopsy would have probably prevented any such issue, but this was totally neglected. ADDRESS ON MEDICAL JURISPRUDENCE. 
183 
tion or to diphtheria.1 To illustrate the progress and extent of the 
medico-legal interests involved, it deserves record that, in 1840, there 
were in the United States only three or four companies having an insig- 
nificant amount of business ; that in 1874 there were seventy-seven 
companies insuring $2,226,000,000 upon 910,000 policies; and that the 
annual average number of lives insured during the past three years has 
exceeded 200,000.2 
The growth of Life Insurance is one of many examples which illustrate 
the fact that the importance of Medical Jurisprudence has constantly 
increased with the progress of medicine, and the requirements of civili- 
zation. Hone the less, there are instances where, through legal and 
other causes, the bounds of Legal Medicine have been restricted. 
When suicide ceased to be a felony,3 it ceased to concern Legal Medicine, 
except when the suicide’s life was insured; feigned diseases have under 
our laws little importance; and, with the abolition of imprisonment for 
debt, and of slavery, there disappeared from the courts many medico-legal 
questions. To education,4 Forensic Medicine owes a diminution of its 
duties in deciding the degree of criminal responsibility of the deaf and 
dumb; allot' whom, long held as “ legal idiots” under the “ perpetual 
pupillage of the law,” were disabled from making a contract, will, or 
valid marriage. Possessing no institutions for their education until 
1817,5 the United States had, in 1875, forty-eight institutions, with 5309 
pupils, so that “nearly all the deaf mutes of school-age within the country 
are now receiving instruction” ; and, since “ all pupils on leaving school 
take their places as responsible members of society, in possession of full 
civil rights,” they cease to be of special medico-legal interest.6 
In this, as in every civilized nation, the best examples of medico-legal 
progress are furnished by the institutions, laws, and decisions benefiting 
1 I have been summoned (1876), as a medical expert, to testily to my opinion as to 
whether a death was due to consumption, as the main issue, and, secondarily, whether due 
to consumption or to diphtheria. 
2 For these statistical facts I am indebted to Mr. 0. 0. Hine, Editor of the Insurance 
Monitor, No. 176 Broadway, New York City. Mr. Cornelius Walford, of London, the 
highest authority on this subject, has kindly furnished, for comparison with the United 
States, the following among other interesting facts; Life Insurance was begun in the 
United Kingdom (Great Britain) on a scientific basis in 1762, and reached its maximum in 
1865-1868; in 1874 there were 120 companies, which issued 47,516 policies, and had in 
force an unstated number of total policies insuring £362,238,534. In France it was first 
legalized in 1787, and fettered with many legal restrictions which were removed in 1819; 
In 1870 there were 166,474 Life Policies, insuring £66,312,000, and 58,572 annuity ccm- 
tracts, securing annual annuities amounting to £1,528,600; and in 1874 there were t2 
companies, having in force an unstated number of total policies insuring £49,906,400. In 
Germany (including German Austria and German Switzerland) Life Insurance was begun 
iu 1827 ; in 1874 there were 51 companies, having in force 645,989 policies insuring a little 
under £100,000,000; and the new policies issued in one year (1873) were 98,692. 
3 By English law the suicide was required to be buried in a highway “ with a stake 
driven through the body” (repealed in 1823), and his property confiscated. Juries, more 
humane than the law, generally decided that suicides were insane, and therefore irre- 
sponsible. Beck in 1823 (B. 209, Ist Ed.) congratulates the United States that “we do 
not war on the dead body in this country.” 
.4 The Abbe de I’Epee published in 1759 the first modern method to teach mutes, by 
sign-language. To him and to his disciple, the Abbe Sicard, civilization owes the initiation 
of the education of mutes. The first educational institution was established in France in 
1760. Europe had about thirty of these institutions in 1817. 
5 The first institution founded in the United States was the American Asylum, Hartford, 
lBl7. 
6 I am greatly indebted for the above statistical and other interesting facts to Mr. I. L. 
Ueet, Superintendent of the New York Institution, the second one founded in the United 
States, viz., in 1818. (See B. 340.) 184 
CHAILLE, 
all who, no longer possessed or seduced by a legalized devil, are in fact 
afflicted with u unsoundness of mind,” from mental disease, deformity, 
or debility.1 P>y legislation many measures (still very incomplete in 
most, and not complete in any, of our States) have been adopted for the 
counter-protection of both the insane and the sane. The corner-stone of 
these measures has been the establishment of Insane Asylums. Beginning 
our national existence with two of these, having only eleven in 1830, we 
now possess about eighty public asylums,accommodating more than 30,000 
of our 45,000 insane population.2 The knowledge derived from these 
schools for scientific observation, is destined to benefit those without, 
even more than those within, their walls. Stimulated by this knowl- 
edge, the law is extending its protection, from insanity, to all who by 
intemperance “have lost the power of self-control.” In this reform, 
Hew York, in 1854, pioneered the way with the first legislation pro- 
viding for the restraint in a public asylum of habitual drunkards. In 
1858,"this State, as also Massachusetts, supplied the asylums indispensable 
for the execution of the law. With an origin thus recent, there are now 
at least seven asylums in five States, and four additional States have 
legislated to accomplish the same end.3 The best interests of society 
require that this progress shall continue until the laws of every State 
provide for every person, whose abuse of his own liberty outrages the 
rights of others, ample protection both for himself and for society.4 
"Maine and Hew York illustrate additional progress in the jurisprudence 
of insanity. It is conceded that, within this century, unfortunates have 
been legally murdered for illegal acts, the product of disease and not of 
a “ vicious will.” To prevent these “ bitter mockeries of justice,” Anglo- 
American law, so jealous of the “liberty of the subject,” fails not only 
to provide him, when his life is imperiled through brain-disease, with 
competent experts, but also to provide these with proper time and oppor- 
tunity to decide a question so difficult as doubtful sanity. It is not 
strange that decisions reached through such defective means should 
cause constant dissatisfaction, nor that this should have been more 
serious prior to the establishment of State Lunatic Asylums ; for it then 
occurred that he who might be acquitted of homicide, because of insanity, 
was freed by the law, and permitted to live a constant danger to society.5 
Maine, in 1847, wisely enacted that “when any person is indicted for 
a criminal offence, or is committed to jail on a charge thereof, . . . 
1 This progress has been especially notable since 1830. 
2 For these statistics I am indebted to Dr. John P. Gray (my colleague on this occasion), 
who reports 54 State Asylums in 1875, accommodating 21,542 patients; 9 State Asylums 
in process of erection to accommodate 4600; 18 other public asylums accommodating 
6064; and 10 private asylums accommodating 254 insane. 
3 Our effective Inebriate Asylums are: the Washingtonian Home, Boston, Mass., since 
1858; the State Inebriate Asylum, Binghamton, N. Y., since 1858; the Inebriates’ 
Home, King’s Co., N. Y., since 1867; the Washingtonian Home, Chicago, 111., since 1864; 
the Sanitarium, Media, Pa., since 1867; the Harlem Asylum for Inebriates, Baltimore, 
Md., which was opened in 1871; and the Franklin Reformatory Horae for Inebriates, in 
Philadelphia, Pa., opened in 1872. California enacted the requisite laws in 1870, and 
Connecticut in 1874. It is believed that Texas and Kentucky have legislated on the 
subject. For the facts stated lam indebted to Dr. Albert Day, Sup’t of the Washingtonian 
Home, Boston; to Dr. D. H. Dodge, Sup’t of the Binghamton Asylum; and to the 
Annual Reports (since 1871) of the “American Association for the Cure of Inebriates.” 
4 In connection with intemperance, it deserves record that only within the present 
century have Anglo-American Judges inclined to admit drunkenness in extenuation of 
crime, depriving it of premeditation. (See B. 329, p. 567.) 
58. 3 19,1, p. 759. An eminent lawyer asserts that this still occurs in some of the States, 
notwithstanding the State Lunatic Asylums. ADDRESS ON MEDICAL JURISPRUDENCE. 
185 
any judge of the court before which he is to be tried, when a plea of 
insanity is made in court, or he is notified that it will he made, may 
• . . order such person into the care of the superintendent of the in- 
sane hospital, to be detained and observed by him till the further order 
°f the court, that the truth or falsity of the plea may be ascertained.” 
■New York, in 1874, enacted laws which provide for “ an investigation 
of the sanity or insanity of the accused, as a separate and independent 
proceeding from the trial of the indictment,” and, after such preliminary 
investigation,u leave the question of the guilt or innocence of the accused 
to be tried by itself.”1 Thus have Maine and New York lessened the 
fi'equent difficulty of choosing between “ inhumanity to disease, and in- 
dulgence to crime.” 
Five States2 have aided the solution of this problem by progress in 
another direction. For, by the abolition of capital punishment, the cruel 
alternative between the asylum and the gallows has been obviated, and 
no shocking injustice can be perpetrated by confining in a penitentiary, 
rather than in an asylum, him proved dangerous to. society. It was a 
great advance in civilization when the victor ceased to slaughter, and by 
enslaving utilized the lives of the vanquished. Will it not be proof of 
like progress when society has fully leSrned how best to utilize the lives 
°f all its criminals?3 
_ Notwithstanding that there is still great lack of uniformity in the de- 
vious of our courts as to what are the proper tests of insanity, there has 
keen decided progress. Until Pinel’s day (1792), insanity had never been 
Properly studied, hence physicians werelittle less ignorant and superstitious 
Bi regard to it than the public. In the absence of medical knowledge, 
wkat could the law do other than establish tests for itself? Until 1800, 
the savage test of Anglo-American criminal law was that he alone should 
ke adjudged insane, who was “ totally deprived of his understanding 
and memory, and did not know what he was doing any more than an 
]nfant, than a brute, or wild beast.” In 1800, it was, for the first time, 
rnercifully decided that those whose crimes were due to an “ insane de- 
lusion,” should not be hung, even though not yet wild beasts.4 In 1812, 
P was decided that the correct test was whether the criminal alleged 
insane had, as to matters generally, “ the power of distinguishing right 
k’om wrong;” and since 1843, in England, and to a large extent in this 
country, the judges’test has been, whether such criminal had, as to his 
special crime and at the moment it was committed, “ a sufficient degree 
°f reason to know that he was doing an act which was wrong.” 
Nut, since 1800, alienists have taught, in constantly increasing number, 
that a capacity to distinguish right from wrong is an inadequate test, 
’ B/364. 
.Michigan in 1846; Rhode Island in 1852; Wisconsin in 1853; lowa in 1872; and 
; «ne in 1876. Blackstone, referring in 1769 to England’s “ dreadful list of 160 capital 
ences,” hoped for “ such a gradual scale of punishment to be affixed to all gradations of 
&111 t, as may in time supersede the necessity of capital punishment, except for very 
f locious crimes.” (Book IY. p. 371.) In the various States, other than the above, capital 
rYment 18 novv inflicted for only from three to eight “ very atrocious crimes.” 
inf krief allusions to the “abolition of capital punishment” and to “moral mania,” 
th lluUe. c?nvictions which may cause misapprehension. For until our present defects in 
full ministration of justice, in the constitution of our juries, and in the means needed to 
as Prefect society, be remedied, I shall believe that our courts have gone generally as far 
.and often much further than, the best interests of society require, 
the f Box’d Erskine initiated the first enlightened legal discussion of insanity; and 
jr , ttorney-General of England then declared tixat the “ wild beast theory ” of Lord 
1 e had never been contradicted, but had always been adopted. 186 
CHAILLE, 
and that, not infrequently, while the reason is apparently able to make 
this distinction, the will may be so enfeebled, and the morals so perverted 
by disease, as to deprive the sufferer of that “ vicious will” necessary to 
constitute a crime. The first Anglo-American judges to adopt these 
lessons of medical science, were Shaw, of Massachusetts, in 1848, and 
Edmonds, of New York, in 1845. They ruled that insanity was proved 
if the homicide “ had no power of control “if his moral or intellectual 
powers were so deficient that he had not sufficient will; and uif he did 
the act from an irresistible and uncontrollable impulse.”1 The learned 
Edmonds took occasion to observe that “the law in its slow and^cau- 
tious progress still lags far behind the advance of true knowledge, and 
the history of the progress of Legal Medicine proves the truth of this 
observation as to every medico-legal topic. How can this be otherwise 
while, as another legal authority asserts, our “ legislatures are much 
better versed in the miserable tactics of party, than in the . . • laws 
of physiology,” and while judges, as well as legislators, mindful as they 
should be of precedent, that friend to uniformity and stability of the law, 
do, in their superstitious reverence, often forget, not only that “ the law 
of nature, being coeval with mankind and dictated by God himself, is of 
course superior in obligation to tfhy other,5 2 but also that science is con- 
stantly engaged in revising and adding to our knowledge of this supreme 
law, thus increasing man’s power to “ think the thoughts of God!” 
Improving on Shaw and Edmonds, Judges Bell, Perley, Ladd, and 
Doe, of the Supreme Court of New Hampshire, have, since _ 1864, 
announced the only principles worthy of both legal and medical science,3 
and have thereby merited the profound gratitude ot the medical profes- 
sion, and lasting commemoration in the annals of Anglo-American 
Medical Jurisprudence. None announced the true principles of the law 
more clearly than Judge Doe, who (in 1869) charged that “ at present, 
precedents require the jury to be by experts in new medical 
theories, and by judges in old medical theories ; and that, in this, “ the 
legal profession were invading the province of medicine, and attempting 
to install old exploded medical theories in the place of facts established 
in the progress of scientific knowledge. But, he adds, u that cannot 
be a fact in law which is not a fact in science ; that cannot be health in 
law which is disease in fact; and it is unfortunate that courts should 
maintain a contest with science and the laws of nature upon a question 
of fact, which is within the province of science, and outside the domain 
of the law.” “ The legal principle, however much it may formerly have 
been obscured by pathological darkness and confusion, is, that a product 
of mental disease is not a contract, a will, or a crime. It is often diffi- 
cult to ascertain whether an individual has a mental disease, and whether 
an act was the product of that disease, but these difficulties arise from 
the nature of the facts to be investigated, and not from the lawT; they 
are practical difficulties to be solved by the jury, and not legal difficulties 
1 In the record of progress in the legal tests of insanity, it deserves notice that Drs. 
Gooch and Combe, about 1830 (B. 226), “first announced the great principle that the 
mind of one supposed insane should be compared with his own mind when in its natural, 
habitual state,” and not with some ideal average mind of health. This principle has been 
extended by the laws of New York to homicide in self-defence, etc., modifying the inter- 
pretation of “apparency of danger,” “cooling time,” “intent,” and ‘ premeditation. 
(See Homicide; by F. Wharton, 2d Ed., 1875.) 
2 Blackstone, I. p. 41. 
3 State v. Wier, State v. Pike, State v. Jones, Boardman v. Woodman, 1864, 1869, 1870. ADDRESS ON MEDICAL JURISPRUDENCE. 
187 
for the court.” “If the tests of insanity are matters of law, the practice 
of allowing experts to testify what they are, should be.discontinued; if 
they are matters of fact, the judge should no longer testify without being 
sworn as a witness, and showing himself qualified to testify as an ex- 
pert.” In fine, all symptoms and all tests of mental disease are purely 
matters of fact to be determined by the jury from the evidence of com- 
petent witnesses ; and since “ legal precedent was one way, legal principle 
the other,” precedent should be abandoned, and principle be followed. 
Side by side with the enlightened views of these American judges, will 
be recorded, for the instruction of astonished posterity, that as late as 
1862 the Lord Chancellor of England did, in referring to insanity, 
declare in the House of Lords that “ the introduction of medical opinions 
and medical theories into this subject has proceeded upon the vicious 
principle of considering insanity as a disease,” and that he condemned 
“the evil habit which had grown up of assuming that it was a physical 
disease” I 1 Can this fail to revive the recollection that ninety-three years 
anterior to this Lord Chancellor, Blackstone, an abler lawyer than he, 
thus fulminated (1769): “to deny the possibility, nay, actual existence 
of witchcraft and sorcery is at once to flatly contradict the revealed word 
of God,” . . . “and the thing itself is a truth to which every nation 
in the world hath in its turn borne testimony”?2 This Lord Chancellor 
affords, however, a psychological lesson much needed even now ; for his 
opinions illustrate what profound furrows the ancestral bigotry and 
superstition of centuries can plough into even the best endowed brains 
of the descendants—as we all are—of uneducated barbarians.3 
One more hopeful example must close my record of our progress. In 
1867, Medicine and Law, uniting for the first time in history tor such a 
purpose, founded “The Medico-Legal Society of Hew York;” now 
numbering among its members more than four hundred physicians and 
lawyers of influence and distinction, its brief life has been adorned with 
good deeds. It has established a medico-legal library, which promises 
'to become, if it is not already, the best in existence ; it is about to issue 
a second volume of valuable essays, the first having been published in 
1874 ; it has, by critical vigilance, elevated the standard of medical 
experts, and in one noted conviction its criticisms instigated a second 
trial with acquittal; wisely imitating its junior, “La Societe de Mede- 
Gne Ldgale de France,”4 in its efforts to furnish a substitute for the 
negligence of the State, it has (May, 1876) appointed three medical and 
three legal experts as a permanent commission to investigate any medico- 
legal issue referred to it; it has called attention to the condition and 
criminal responsibility of uneducated mutes, and to the laws necessary 
for their protection; and it has influenced the legislation of Hew York 
as to abortion, as to robbery under the influence of chloroform, and as 
hj the trial and punishment of all homicides, whether sane or insane. 
Thus instructing the public, and inaugurating reforms, it seems destined 
1 Hansard. CLXY. 1297. 2 Blackstone, IY. p. CO. 
It deserves record, in connection with the progress of judicial decisions, that, at the 
Present day, Anglo-American law does not regard the killing of an infant prior to its 
complete expulsion from the vagina [i. e. to its being “fully born alive”) as infanticide. 
n English Judge recently charged a jury that, “if of opinion that the prisoner had 
§1 angled her child before wholly born, she must be acquitted ol murder.” (See B. 292, 
p. 542; and B. 358, 11. pp. 359-61.) Ellwell (B. 290, p. 555) says, “Infanticide may 
be committed upon an unborn live child.” 
Organized February, 1868, and formally recognized by a decree of the French govern- 
ment, January, 1874. 188 
CHAILLE, 
to render Yew7 York the pioneer of all the States in medico-legal progress: 
and finally, in promoting scientific intercourse and discussion between 
the two professions, it has forcibly taught that the invidious bigotry of 
the one is as misplaced as that of the other, and that the common weal 
loudly demands the united efforts of the best minds of both.1 
What labor so god-like as the dispensation of justice; what efforts in 
its behalf can be more important than those designed to enable the law 
to reap promptly the full benefits of science—of that knowledge which, 
having done so much for human development, now7 proffers unappre- 
ciated boons, and by incessant progress assures mankind a higher destiny? 
Shall medicine and law7, standing aloof, not only endure but even blindly 
honor ancestral evils? ? Is it needful in 1876 to remind two learned profes- 
sions that the author of our imperishable Declaration of 1776 declared; 
“ The Gothic idea that we are to look backwards instead of forwards for 
the improvement of the human mind, and to recur to the annals of our 
ancestors for what is most perfect in government, in religion, and learning, 
is worthy of those bigots in religion and government by whom it has 
been recommended, and whose purposes it w'ould answmr. But it is not 
an idea which this country will endure”? 
This historical sketch requires for its completion a record of the 
measures proposed to correct our medico-legal evils, which, often de- 
nounced since 1823 by the medical profession, continue unappreciated 
by the people. To test the value of these proposed measures it is indis- 
pensable to understand the following premises, accepted by the highest 
medical and legal authorities. 
While one would suffice to maim, our law 7 adopts two methods to 
murder, Medical Jurisprudence; both so result that it is a vulgar mockery 
of medical knowledge and of justice to term such medical evidence as 
is attained, “ the best attainable.” In one case, the law neglects to 
secure competent experts to testify, as “ordinary witnesses,” to facts 
obtained by them from inquests and all medico-legal examinations. In 
the other case, the law fails to provide such experts to testify, as “ skilled 
witnesses,” not to facts they have personally witnessed in the case, but 
to their “opinions,” as to wffiat conclusions are deducible from the 
medical facts sworn to by ordinary witnesses; for this marked difference 
between the ordinary and the skilled witness, Anglo-American law7 
deplorably fails to make any provision, while German and French law 
wisely recognize that the skilled witness is not an ordinary witness, but 
an arbitrator. Further, it is manifest that the experts thus needed, 
for tw;o distinct purposes,can never be supplied except by the State; that 
the competency of these experts can never be secured except by special 
and practical instruction; that the chief instruction must be given by 
medical men; and that the instructors alone are competent to attest the 
competency of their pupils. 
These premises cannot be refuted, and force the general conclusions that 
no measures could fully correct our evils except such as, in the first place, 
would reform altogether the office of coroner, and supply competent 
experts for its duties, and, in the second place, would provide a legal 
status for skilled witnesses, and secure their skill; and that these two 
indispensable ends can never be gained except through an organized 
system of medico-legal officials, specially trained as medical experts, and 
1 B. 356, 363, 364, 380, 387. ADDRESS ON MEDICAL JURISPRUDENCE. 
189 
attested as competent by competent judges. Alas! these irrefutable conclu- 
sions are most discouraging, for no American can fail to appreciate how 
difficult and distant is their realization. But when the remedies are not 
forthwith at hand to cure a disease, should we cease its study, and our 
efforts both to discover and to obtain all the remedies necessary ? A full 
understanding of the indispensable remedies, will at least enable us to 
test the value of the seven which have been proposed. Their introduc- 
tion requires two comments: first, there is no one of them which would 
Rot prove decidedly beneficial, since, fortunately in this regard, there is 
no change of our law which could possibly aggravate our present evils; 
and second, the first four to be mentioned apply to only one of our 
two great evils. 
One proposal is that special juries be provided for special cases,1 and 
another is that a medical assessor be appointed to advise and assist the 
courts;2 either would provide better judges of medical testimony, but 
neither makes any attempt to supply “ the best attainable evidence.” 
A third measure proposes a commission of experts chosen either by 
mutual consent,3 or one by each party and a third by the judge.4 This 
great improvement could probably be adopted more readily than any 
other measure suggested; but none of those thus authorized to appoint 
have the knowledge necessary to enable them to select competent experts, 
and therefore this measure would certainly not secure “ the best attain- 
able evidence.” A fourth proposal is the adoption of the French law 
which empowers the judge to appoint a medical commission.5 French 
authorities, while urging the adoption of the German system, denounce 
their own with even contemptuous bitterness,6 asserting that their judges 
J’arely appoint competent experts, but generally their own family-physi- 
cians and practitioners of merely popular repute.7 A fifth proposal, 
which would require all graduates in medicine to be competent experts, 
as well as practitioners,8 has long been, and is daily becoming so much 
more impracticable, as to deserve no notice except as illustrating how 
inadequately is estimated the extent and character of the special know- 
ledge necessary to a medico-legist. 
Prof. Gross9 urged, in 1868, that the Judges of the Supreme Court of 
each State should appoint a commissioner in every judicial district, to 
elicit and estimate medical evidence; and that he should be provided 
with two or more medical experts as assistants, to make all medico-legal 
examinations. This is the only measure, thus far considered, which aims 
a practical blow at both our evils. But, if French experience be appli- 
eable to us, then judges of law are not good judges of experts, and should 
eot be authorized to appoint them, except from those whose competency 
nas been attested by competent judges of experts; and, if German experi- 
enye be applicable to us, then a medical commissioner, long ago tried 
J. Pitz Stephen’s “ Criminal Law of England, London, 1863 and Dr. I. Ray (B. 234). 
A. S. Taylor and many others. 3 Beck (B. 209) and others. 
Ordrouaux (B. 318), etc. 5 Urged by many. 
See Podere, Orfila, Devergie (B. 114, 121, 124); and especially the Preface to Yol. I. 
1 e<j- °f Orfila. Some at least of the French courts have made the improvement ot ap- 
pointing a permanent commission of experts for all medico-legal cases, instead ol a special 
commission for each case. 
_ 11 the French system be satisfactory, if the State provide, as it should, “ the best at- 
atriable evidence,” then why should there be in Paris, as in New York City, an unofficial 
a s commission of volunteer experts ? 
9 Unitty (B. 231), and very many others. 
1 resident’s Address, Trans. Am. Med. Assoc., 1868. 190 
CHAILLE, 
and abandoned in Germany,1 is superfluous, provided the law supplies 
a proper system and competent experts to present to the courts “ the best 
attainable evidence.” 
Finally, others advocate some such modification, as may be practicable 
under our form of government, of that German system which, the growth 
of two centuries of experience, alone gives satisfaction at home, and at 
the same time commands the admiration of the medico-legists of every 
civilized nation.2 The Prussian system has four grades of medico-legal 
officials. (1) To a specially educated official expert is submitted every 
medico-legal case.3 His examinations, made in presence of the judge 
(in some cases), and of medical men and students, insure by their publi- 
city thoroughness and impartiality, and are the foundation of Germany’s 
medico-legal clinics which provide the practical instruction indispensable 
to the education of competent experts. All the facts and proofs derived 
from the examination, and essential to a conclusion, are made parts of a 
written report, and these reports, with subsequent action thereon, are 
preserved in official archives, and have been the source of Germany’s 
fruitful medico-legal literature. (2) It prosecution or defence be dissatis- 
fied, the expert’s report, with all proofs preserved, is forwarded to a 
Medical Court of Appeal, which, consisting of from four to six members, 
exists in each province. (3) If this second decision prove unsatisfactory, 
there is a final appeal to a Scientific Deputation, composed of experts of 
national reputation.3 (4) Finally, one of the highest officers of the gov- 
ernment, the Minister of Medical Affairs, presides over an educational and 
a sanitary, as well as over this medico-legal organization, and in fact 
rules a department of State Medicine. 
Has State Medicine become necessary to a nation’s progress in civili- 
zation? Can services essential to the welfare of a people be rendered by 
other than medical officers? Who will deny that no well-governed State 
can dispense with medical instructors; with in charge of its 
hospitals and asylums; with medico-legal experts ; with inspectors to 
watch over the execution of proper laws for prohibiting quackery and 
the sale of quack, foeticidal, poisonous, and adulterated drugs and food, 
and also to certify to every death with its cause, after personal examina- 
tion f with registrars of vital statistics to record not only marriages, 
1 See Preface to tlie French edition of Casper (B. 88). 
2 Sheldon Amos, Esq., Prof, of Jurisprudence, University College, London (see “Science 
of the Law,” New York, 1874), in discussing the expert problem, says: “Almost all the 
solutions point to the public organization of bodies of skilled witnesses in each of the im- 
portant departments in which they are constantly demanded, and to a special preference 
being given to their evidence in the administration of justice.” Francis Wharton, Esq., 
(B. 264, 11. p. 1120) urges that the German system is the only one worth imitating In 
these views 1 thoroughly concur, notwithstanding the serious objections urged by such high 
authorities as J. Pitz Stephen, Esq., and I. Ray, M.D. 
3 There are circumstances, says Casper, where any doctor may be called on, as an expert, 
in Prussia. 
ill 1 i m _ , _ _ . 
4 Formerly in Prussia (probably still in parts of Germany) the collegiate medical facul- 
ties were appealed to, whenever the primary reports of the official experts were not satis- 
factory to both litigants. 
5 The English system of determining and certifying to death and its cause is certainly 
not inferior to any such system (or lack of system) existing in the United States; and yet 
so inefficient is this superior system that Prof. A. S. Taylor reports that a man registered 
his own death, and then based a fraudulent claim on the certificate of his death and on the 
fact of his burial, which he himself had supervised ; and he further asserts that “ all that is 
requisite for future murderers by poison to do, is to use small doses, combine the use of 
various drugs, and subpoena the proper medical witnesses for the defence.” (bee B. 358, 
I. pp. 167-8 and 196.) ADDRESS ON MEDICAL JURISPRUDENCE. 
191 
births, and deaths, but also prevailing diseases with their causes ; and, 
finally, with sanitary officers to guard the public health by vaccination, 
quarantine, seclusion, disinfection, and all known means? 
While such services to the State would now confer incalculable benefits, 
these are not a tithe of those which the progress of medical science 
assures the future. But a patchwork of ill-digested laws cannot secure 
these benefits, nor mere practitioners of medicine render these services. 
To this end a well-organized system of State Medicine, administered by 
specially educated medical men, is indispensable; and however dis- 
couraging'the difficulties, educational, legal, and political, in our path, 
these must be eventually overcome, or our country prove a laggard in 
the triumphant march which civilization, led by the hand of science, is 
now treading. One of these difficulties, an increase of officials, dangerous 
to a republic, repugnant to the people, is more serious in appearance than 
in reality ; for our present posts for coroners, and for sanitary and other 
medical officers, would suffice for, at least, the initiation of an organized 
system of State Medicine. Far more serious difficulties are presented by 
those causes which now so often fill these posts with unqualified men, 
by the continual elections and “ rotations in office,” through which the 
people, with suicidal folly, eliminate from public service responsible and 
efficient servants. If the demoralizing political principle, “to the victors 
belong the spoils,” is to continue its mastery over the virtue and intelli- 
gence of a great people, then all hope of efficiency in any system of State 
Medicine, as well as in every public service which requires special skill 
aud experience, must be abandoned. But, if the cardinal maxim of our 
political faith be well founded, if it be true that a republican govern- 
ment is better adapted than any other to secure the greatest good to the 
greatest number, then, though public enlightenment develop slowly, 
the day must come when all impediments will be overthrown, and 
an efficient system of State Medicine be organized by our laws. This 
progress, as all others, must pass through stages of evolution, and expe- 
diency force the acceptance, as now, of mere make-shifts ; but this con- 
viction should not deter the attempt to measure the full extent of our 
detects and of our needs, nor prevent us, while conscious that we are but 
scratching the surface of great evils, from striving to direct our efforts 
to their very root. 
Honored Members of this International Medical Congress: Laboring on 
the task now completed, professional instinct prompted as sedulous a 
search for the symptoms of disease which skill might alleviate, as tor the 
evidences of health which need no aid ; for the instruction of my suc- 
cessor of 1976 (the one man who, should there be no other, will study 
this Address), I have deemed it as needful to record that which has 
been left undone, as that which has been done ; and, while mindful of 
gratitude’s debt to the honored living aud illustrious dead, I have en- 
deavored to keep in mind that the chief object of history is to teach 
wherein and why we have failed, that we may do better in future. 
Actuated by these motives, I have thought no time more appropriate 
note our failures than this Centennial Year, which gathers from far 
|)eyond our own vast domain, conclusive evidences of the might and 
fame of this nation. To its colossal power, how harmless is the voice of 
qialice ; to its dignity, how offensive should be the voice of flattery ; to 
Bs honor, how unwelcome aught save the voice of truth ! What higher 
evidence of true greatness, what better pledge of continued prosperity, 192 
CHAILLE, 
can this people give, than by proofs that now, in the clay of its supreme 
vigor and renown, it is intent upon its own shortcomings ; and that, 
beneath a flimsy veil of national vanity, there sturdily stands “ the pith 
o’ sense, and pride o’ worth”! If I have dwelt unduly on my country’s 
faults, it has not been from lack either of devotion to its form of govern- 
ment, or of just pride in its many noble deeds in humanity’s behalf; but 
that I would have our Republic foremost in every good work, its pro- 
gress endless, and its glory deathless. 
BIBLIOGRAPHICAL APPENDIX. 
Explanations and Abbreviations. 
To economize space, the titles and places of publication of the general treatises in foreign 
languages have been omitted, except in a few instances of those of great note. For the 
same purpose, each author has been numbered, and is referred to by number in the notes to 
the Address, and in the final indices to this bibliographical appendix. Dates separated by 
a hyphen, e.g. 1621-58, indicate that the publication of the book in different parts was 
begun in 1621, and completed in 1658; dates separated by a comma, e.g. 1598, 1602, 1671, 
indicate the dates of the publication of different editions; and dates repeated, or closely 
approximating, indicate the publication of different editions in different places. 
This contribution to the bibliography of American Medical Jurisprudence is 
preceded by a bibliographical record of the medico-legal literature of Italy, 
Germany, France, and Great Britain ; and the whole has been arranged chrono- 
logically to illustrate the origin and progress of medico-legal science. 
Wildberg’s “Bibliotheca Medicines Forensis, 1819,” records 2980 treatises, 
essays, etc., published from the origin of medico-legal literature (about A. D. 
1600) to 1818. Orfila’s Medecine Ldgale, 4th ed., furnishes a list of 168 treatises 
(to 1848), on poisons generally; of these 100 were German, 33 French, and 19 
English. An English authority, the New Sydenham Society’s “Year Books” 
for°lßs9 and 1860, reports the chief literary contributions of all nations to 
Medical Jurisprudence and Toxicology during the two years 1858 and 1859 ; 
the total number was 498, viz., 250 for Legal Medicine and 248 for Toxicology: 
and of the former, Germany contributed 201, and of the latter, 118. These, with 
other facts, indicate that Germany continues to contribute more to medico-legal 
literature than all other nations combined ; and that a complete bibliography 
of the Medical Jurisprudence of all languages must report many thousands of 
books, essays, and articles. Hence the bibliographical sketch of foreign litera- 
ture attempts no more than the record of treatises and manuals on the general 
subject; preceding these with a list of the books on special subjects which were 
published prior to the first general treatise; and following these with a reference 
to a*few authorities of great repute on special subjects. It deserves note that 
in every language the number of publications on special subjects, after the issue 
of the* first general treatise, has been very great, and proportionate to the 
number of general treatises. 
The contribution to the bibliography of American Medical Jurisprudence 
attempts to report all the treatises, books, essays, and pamphlets, by native 
and foreign authors', published in the United States; the republication of foreign 
works being indicated by a j". Only a few articles from Journals are cited, 
and these for a special purpose. The bibliography of Medical Jurisprudence, 
as represented by “articles in journals, transactions, and collections,” giving 
“the results of the examination of about 5000 volumes of such publications,” 
will constitute a part of the “ Catalogue of the National Medical Library,” 
now in course of preparation by Dr. John S. Billings, Asst. Surgeon U. S. A., 
and Librarian; and will probably be published in 1877. Further, the New 193 
ADDRESS ON MEDICAL JURISPRUDENCE. 
York Medico-Legal Society is preparing for publication an extensive bibli- 
ography of Medical Jurisprudence. These two sources will no doubt supply 
all defects and omissions in this contribution. 
For articles and reports of merit, the reader is referred especially to the 
American Jurist and Law Magazine, Boston, 1829 to 1843 ; American Journal 
of Insanity, Utica, N. Y., since 1844; Reports of the Association of Medical 
Superintendents of Hospitals for the Insane in North America, since 1844 ; 
Transactions of the Medical Society of the State of New York, prior to 1845 ; 
Transactions of the American Medical Association, since 1848 ; Albany Law 
Journal, since 1810 ; Annual Reports of the American Association for the Cure 
of Inebriates, since 1871; the Psychological and Medico-Legal Journal, N.Y., 
and the Series of Papers by the N. Y. Medico-Legal Society, both since 1874. 
Italy, 
General Treatises.—l. Fidelis, Fortunatus, He Relationibus MedicornmT 
1598, 1602, 1671. 2. Zacchias, Paulus, Questiones Medico-legales, &c., Books 
I. to X., 1621-58, 1651, 1655-61, 1657, 1666, 1688, 1674-1701; Nuremberg, 3 
vs. 1720; Yenise, 1737. 3. Tortosa, “best book to its date,” 2 vs. 1802, 1809. 
4. Sidoti, 1806. 5. Barzelotti, “very excellent,” 2 vs, 1818, 1823-4, 1839. 
6. Martini, 3 vs. 1825. 7. Taurini, 4 vs. 1832, 1841-4. 8. Speranza, 1833. 
9. Grotanelli, 1834. 10. Cledillot, 1836. 11. Riscica, 1836. 12. Gianelli, 
1836, 13. Perrone, 2d ed. 1840. 14. Presutti, 1841-4, 15. Treschi, 3 vs. 
1846. 16. Lazzaretti, 1859. 17. Gandolfi, 1854, 1863. 
Special Treatises.—lB. Morgagni, De Sedibus et Causis Morborum, 1761. 
19. Beccaria, Scriptura Medico-Legalis, 1764 ; and “ Crimes and Punishments;” 
republished in Italian, 1821; French, 1821; English, sth ed. 1804; Phila- 
delphia, 1778 and 1793. 
Germany. 
Earliest Trealises on Special Subjects.—2o. Condronchus, Methodus Testifi- 
eandi, 1597. 21. Libavius, De Cruentatione Cadaverum, 1599. 22. Ain man n, 
Irenicum, &c., 1619, and Medicina Critica, 1677. 23. Behrens, Medicus Legalis, 
1696. 24. Wolf, Cogitat. Med.-Leg. 1697. 25. Yalentini, Pandectse Med.-Leg. 
HOI, and Novell® Med.-Leg. 1718. 26. Fischer, Consilia Medic., &c., 1703-6, 
and Responsa Pract. et Forens. Select. 1719. 27. Bohn, De Officio Medici, 
1104, and De Renunciatione Yulnernm, 1689, 1710 (both of note). 28. Zittman, 
Medicina Forensis, 1706. 
General Treatises.—2d. Yalentini, Corpus Juris. Med.-Leg. (“best book to 
its date”), 2 vs. 1722. 30. Teichmeyer, Institutiones Med.-Leg., &c. (“long 
the Manual of Students”), 1722, 173 L 1740,1762, 1769. 31. Albertus, System® 
Jurisp. Medic®, &c. (“very excellent”), 1725, 1733-47, 1756. 32. Goelicke, 
1123. 33. Loew, 1725. 34. Storck, 1730. 35. Tropanneger, 1733. 36. Eschen- 
Wh, 1746, 1775. 37. Hebenstreit, Anthropologia Forensis, &c. (“ much valued 
by lawyers”), 1751. 38, Furstenau, 1752. 39. Boerner, 1756. 40. Bernhold, 
1160. 41. Ludwig, 1765, 1774. 42. Faselius, Elernenta Medicin® Forensis, 
1167, 1775 (“'foundation” of Farr’s Elements of Med Jurisp., 1788, the first 
Geatise in the English language). 43. Braendel, 1768,1789. 44. Kannegiesser, 
1168, 1772, 1777, 1778. 45. Baumer, 1778. 46. Sikora, 1780,1792. 47. Plenck, 
Elementa Med. et Chir. Forensis, 1781, 1786, 1802 (foundation of Male’s 
Epitome of Forensic Medicine, London, 1816). 48. Haller, 1782-4. 49. 
chlegel, Collect. Opuse. Select, ad Med. For. Spect., 6 vs. 1785-90 (“best 
b°ok to its date”). 49. Loder, 1793. 50. Metzger, System, der geridhtl. 
Arzney. (“best book to its date”l, 1793, 1794, 1798, 1803, 1814, 1820, and two 
French editions: Autun, 1812; Paris, 1813. 51. John, 1795. 52. Palmer, 
13 194 
CHAILLE, 
3 vs. 1795-1800. 53. Muller, 4 vs. 1796-1802. 54. Erhard, 1800. 55. Schraud, 
1802. 56. Schmidtmuller, 1804. 57. Masius, 1810, 1812, 1821-3. 58. Bene, 
1811. 59. Wildberg, 1812, 1824. 60. Henke, Lehrb. der gerichtl. Med., 1812, 
and Bergmann’s 13th ed,, 1859. 61. Niemann, 2 vs. 1813. 62. Bernt, 1813, 
and sth ed. 1846. 63. Dorn, 1813. 64. Klose, 1814. 65. Sprengel, 1816. 
66. Mende, Handb. der gerichtl. Med. (“a remarkable book”), 6 vs. 1819-32. 
67. Meckel, 1821. 68. Plainer, 1824. 69. Niemann, 3 vs. 1827-9. 70. Wagner, 
1833-40. 71. Sporer, 1837. 72. Siebenhaar, 2 vs. 1838. 73. Freidreich, 2 vs. 
1839, 1843, 1848, 1855. 74. Rolff, 1840. 75. Nicolai, 1841. 76. Ney, 1845. 
77. Bergmann, 1846. 78. Brach, 1846, 1850. 79. Siebold, 1847. 80. Meckel, 
1848-53. 81. Schiirmayer, Lehrbuch der gerichtl. Med., 1848, 4th ed., 1874. 
82. Quentner, 1851. 83. Glintner, 1851. 84. Krahmer, Handb, der gerichtl. 
Med., 1851, 1857; and 85. Handb. der Staatsarzneik., 1874. 86. Bocker, 2d 
ed., 1857. 87. Hanska, 1857-69.. 88. Casper, Handb. der gerichtl. Med., 1857, 
1858 ;3d was the first complete ed., 1860,1864; Liman’s sth ed., 1871; French 
ed., 2 vs. 1862; English ed., 4 vs. 1861-5; and translated into several other 
languages. 89. Holman, 1860. 90. Pichler, 1861, 1867. 91. Lion. 1861, 1867. 
92. Schauenstein, 1867. 93. Biichner, 1867; 2d ed,, 1872. 94. Kraus und 
Pichler, Encyc. Worterbuch d. Staatsarzneik., 2 vs. 1873. 
N. B.—Five of the above sixty-five German general treatises have been 
published since 1870, viz.: Casper (Liman’s sth ed.), 1871; Buchner, 2d ed., 
1.872; Kraus & Pichler, 1873; Krahmer, 1874; Schiirmayer, 4th ed., 1874. 
Special Treatises.—Among the most distinguished German authors on 
special subjects have been: 95. Roose,Grund. Med.-gerichtTories., 1798, 1800, 
1802; translated into French by Marc, Manuel d’Autops. Cadav. Med.-Leg., 
Paris, Bvo. 1808. 96. Hoffbauer, 1802, 1807, 1809 ; translated into French, 
Med. Leg. relative aux Alienes, &c., Paris, 1827. 97. Heinroth, 1812, 1825. 
98. Mittermaier, 1856, 1858, 1865. 99. Krafft-Ebing, 1868, 1872, 1875. All 
of these in reference to the Medical Jurisprudence of Insanity or Medico-Legal 
Psychology. 
France. 
Earliest Treatises on Special Subjects. —lOO. Pare, Ambroise, Medical 
Reports, Monstrous Births, Feigned Diseases, 1575, 1582, and (Euvres Com- 
pletes, Paris, 3 vs. 1840. 101. Pineati, Integ. et Corrup. Virgin., 1598. 102, 
Riolan, Les Monstres, 1605. 103. Tagereau, L’lmpuissance, 1611. 104. Duval, 
L’Hermaphrodisme, 1612. 105. Sebitz, La Virginity et L’Hymen, 1630, 1638. 
106. Gendri, Moyens de bien rapporter a justice, 1650. 107. Blegni, La Doct. 
des Rapports de Chirurgie, 1684. 108. Devaux, L’Art de faire des Rapports 
en Chirurgie, 1693, 1701, 1730, 1746. 109. Bruhier, L’lncertitude des Signes 
de la Mort, &c. (180 cases of living, treated as if dead), 1742. 110. Verdier, 
La Jurisp. de la Mdd., &c., 1752. 111. Prevost, Principes de Jurisp., &c, 
Med.-Leg., 1763. 112, Louis, A. Signes de la Mort, &c.; Exps. sur les Noyes; 
Recueil d’Observations, &c.; Causes Celebres (first 43 vols.), 1752-88. 113. 
Chaussier, Obs. Chirur.-Legales, &c., 1790, 1824, 1838. 
N. B.—The most noted of these were Par£, Gendri, Blegni, Devaux, Louis, 
and Chaussier. 
General Treatises.—ll4. Fodere, Traits de Med. Leg. et d’Hyg. Pub., 3 vs. 
1796; 2d ed., 6 vs. 1813. 115, Mahon, 1801, 1807, 1811. 116. Belloc, 1801, 
1811, 1819. 117. Yignd, 1805. 118. Bertrand, 1817. 119. Lecieux, &c., 1805. 
120. Biessy, 1821. 121. Orfila, Le§ons de Medecine Legale, 3 vs. 1821-5, 1828, 
1839; 4th ed., 1848. 122. Briand, Manuel de Medecine Legale, 1821, 1828; 
Briand et Bresson, 3d ed., 1830; Briand et Chaude, 1846, 1852, 1858, 1864, 
1869; Paris, 9th ed., pp. 1102, Bvo. fort., 1874. 123. Sedillot, 1830, 1833. 
124. Trinquier, 1836-8. 124 a. Devergie, Medecine Legale, 3 vs. 1837, 1840, 
1852. 125. Bayard, 1844. 126. Legrand du Saulle, Ortolan, et Naquez, 1870. ADDRESS GIST MEDICAL JURISPRUDENCE. 
195 
127. Legrand du Saulle, Traite de Medecine Legale et de Jurisp. Med., Paris, 
pp. 1268, 1874. 128. Bergeron, 1876. 
Special Treatises. Among the most distinguished French authors on 
special subjects may be mentioned: 129. Pinel, Ph., 1800, 1805, 1809. 130. 
Georget, 1820, 1826, 1828. 131. Esquirol, 1832, 1838. 132. Marc, 1840. 
133. Brierre de Boismont, 1827-1860. (All on Medico-Legal Psychology.) 
134. Capuron, Obstetrical Medical Jurisprudence, 1821. 135. Trebuchet, 
Jurisp. de la Medecine, &c., 1834. 136. Poilroux, Manuel de Med.-Leg. 
Criminelle, 1834, 1837. 137. Tardien, A., numerous experimental and literary 
contributions, entitling him to the first rank among the medico-legists of the 
present time, 1845 to 1876. 
Great Britain, etc. 
Earliest Treatises on Special Subjects.—l3B. Percival, Thos., Essays Med. 
and Exp., &c., 1778-90. 139. Win. Hunter, Uncertainty of Signs of Murder 
in Bastard Children, 1783. 140. Goodwyn, Submersion, Strangulation, &c., 
1788. 141. Crichton, Mental Derangements, 1798. 142. Haslam, Insanity, 
and Medical Jurisp. of Insanity, 1798, 1809, 1817, 1819. 143. Johnstone, 
Madness, Med. Jurisp. of, 1800. 144. Perfect, Insanity, 2d ed., 1801. 145. 
Collinson, Lunacy, Law of Idiots, Lunatics, &c., 1812. 146. Johnson, C., Signs 
of Murder in New-Born Children (from the French of Mahon), 1813. 147. Hill, 
Insanity, 1814. 148. Hutchinson, Infanticide, 1820. 149. Burrows, Insanity, 
1820, 1828. 
General Treatises.—lso. Farr, Sami., Elements of Medical Jurisprudence 
(founded on the German of Faselins, 1767, see 42), London, 12mo. 1788 ; 2d ed., 
Pp. 139,12m0. 1814. 151. Bartley, Treatise on Forensic Med. (said to be very 
insignificant), Bristol, 12mo. 1815. 152. Male, Epitome of Forensic Medicine 
(largely from the German of Plenck, see 47), London, 12mo. 1816 ; 2d ed., 1818. 
153. Smith, John Gordon, Principles of Forensic Medicine (the first book in 
the English language of any original merit), London, pp. 503, Bvo. 1821; 2d ed., 
1824; 3d ed., 1827. 154. Paris and Fonblanque, Medical Jurisprudence (best 
hook to its date), London, 3 vs. 1823. 155. Forsyth, Synopsis of Modern 
Medical Jurisprudence (denounced by Beck as a wholesale plagiarism), London, 
PP- 600, 1829. 156. Ryan, Manual of Med, Jurisp., London, pp. 309, Bvo. 
1831; 2d ed., 1836. 157. Chitty, Med. Jurisp. (never completed), London, 
I3art I. Bvo. 1834. 158. Traill, Outlines of Med. Jurisp., Edinb. 12mo. 1836 ; 
2d ed., 1840. 159. Brady, Med. Jurisp., Dublin, 1839. 160. Taylor, A. S., 
Elements of Med. Jurisp., Yol. 1., pp. 511, Bvo., London, 1836 (a second volume 
never published). Manual of Med. Jurisp., Ist ed., 1844; Bth ed., 1866; 9th 
ed., London, pp. 772, Bvo. 1874. N. B.—Seven American and one German ed., 
1858. 161, Guy, W. A., Principles of Forensic Medicine, London, 1843; 2d 
ed-, pp. 534, 1861 ;3d ed., 1868. 162. Taylor, A. S., Principles and Practice 
°f Medical Jurisprudence, London, 1865 ; 2d ed., 2 vols. pp. 723, 672, Bvo. 1873. 
163. Husband, Forensic Medicine and Med. Police, Edinb. 1873. 164. Wood- 
man and Tidy, Handy-book of For. Med. and Toxicology, London, 1875. 
Special Treatises.—Among the most distinguished British authors on special 
subjects, and whose books have not been republished in America (see 201 to 
390), may be mentioned—l6s. Conolly, 1830. 166. Pagan, 1839, 1843—both 
!?n Gie Med. Jurisp. of Insanity. 167. Watson, Alex., Homicide, 1837 ; 2d ed., 
342. 168. Gavin, 11., Feigned and Factitious Diseases, 1843. 196 
CHAILLE, 
CONTRIBUTION TO THE BIBLIOGRAPHY OF AMERICAN 
MEDICAL JURISPRUDENCE. 
Eepnblications of foreign works are indicated by af, and pamphlets by a*; the latter are 
for the most part reprints from Journals, etc. Some works not strictly medico-legal are 
given, because often referred to by medico-legists. 
201. fCox, J. M. Observations on Insanity, Med. Jnrisp. of, from the 2d Lon- 
don ed. Phila., 1811. 
202. Rush, Benj. Introductory Lectures (16th). Bvo. Phila., 1811. 
203. Rush, Benj. Diseases of the Mind. Bvo. pp. 361. Phila., 1812. 2d and 
3d ed.? 4th ed. 1830, sth ed. 1835. 
204. *Ducachet. Dissertation on Action of Poisons. New York, 1811. 
205. *Beck, John B. Infanticide. Bvo. pp. 95. New York, 1811. (Republished 
with additions, etc., in the various editions of “Beck's Med. Jurisp.") 
206. fOrfila. Poisons, by R. 11. Black. 12mo. pp. 240. Baltimore, 1819. 
201. f Cooper, Thos. Tracts on Med. Jurisp., viz., of Farr, Dease, Male, and 
Haslam (British). Bvo, pp. 456. Phila., 1819. 
208. fHighmore. Law of Idiocy and Lunacy. Bvo. Exeter, N. JL, 1822. 
(Is* Am. from last English ed.) 
209. Beck, T. R. Elements of Medical Jurisprudence, with the Chapters on 
Infanticide and Abortion, by J. B. Beck. (First American General 
Treatise.) 2 vols., Bvo. pp. 418, 411. Albany, N. Y., 1823. 
2d ed. with notes by Dr. W. Dunlop. London, 1825. 
3d and 4th eds. dates unknown. One at least was a London ed. with notes 
by Dunlop and Darwell. 
German edition (translated). Weimar, 1828. 
sth ed. (2d American ed.) by T. R. and J. B. Beck. 2 vols., pp. 661, 694. 
Albany, 1835. sth ed. London, 1836. 
6th ed. (3d American) pp. 610, 143. Phila., 1838. 
Ith ed., with notes by Dunlop and Darwell. pp. 1138. London, 1842. 
Bth arid 9th editions, dates and places of publication unknown. 
10th ed. 2 vols. Albany, 1850-51. 
11th ed., revised by Dr. C. R. Gilman, with Drs, D. T. Brown, R. H. Coo- 
lidge, A. Flint, Sr., B. W. McCready, S. St. John, Jno. Watson, and J. P. 
White, as Collaborators. Bvo. 2 vols., pp. 884, 1003. Phila., 1860. 
12th ed. Same Editor and Collaboi’ators. Bvo. 2 vols., pp. 894, 995. 
Phila., 1863. 
210. *Webster, J. Essay on Med. Jurisp. Bvo. pp. 52. Phila., 1824. 
211. j'Morgagni. Seats and Causes of Disease. { Cooke's English Translation.) 
Bvo. 2 vols, Boston and Phila., 1824. 
212. fOrfila. Poisons (translated by J. G. Stevenson), 12rao. Boston, 1826. 
213. Warren, J. C. Dislocations of Hip-Joint (Malpractice). Bvo. pp. 142. 
Cambridge, Mass., 1826. 
214. *Dunglison, R. Syllabus of Lectures on Med. Jurisp. Bvo. pp. 142. 
XJniv. Ya., 1821. 
215. Horner, W. E. Healthy and Diseased Appearances of the Mucous Mem- 
branes of the Stomach and Intestines. [With experiments.] Am. Journ. 
Med. Sci., pp. 1-40, Nov. 1821. 
216. *Simons, T. Y. Mental Alienation, Med, Jurisp. of. Bvo. Charleston, 
S. C., 1828. 
211. Horner, W. E. Pathological Anatomy. Bvo. pp. 460. Phila., 1829. 
218. Lobstein, J. F. D. Semeiology of Countenance, etc., in Med. Jurisp. 
Bvo. pp. 150. N. Y., 1830. 
219. *Hance, W. Appeal to Citizens of Ohio. . . . Medical Law, etc. Bvo. 
pp. 20. Columbus, 0., 1830. ADDRESS ON MEDICAL JURISPRUDENCE, 
197 
220. Rush, B. Diseases of the Mind. (See 203.) 4th ed. 1830. 
221. Dubois, W. E. Trial of Lucretia Chapman (Poison). Bvo. pp. 213. 
Phil a., 1832. 
222. Coley, H. (of London). Treatise on Med. Jurisp. Part I. Poisons and 
Asphyxia. (Never completed.) Bvo. pp. 12. N. Y., 1832. 
223. '{•Ryan. Manual of Med. Jurisp., with notes, etc., by Dr. R. B. Griffith. 
Ist Am. ed. Bvo. pp. 321. Phila., 1832. 
224. Ducatel. Toxicology [from Christison, and for practitioners rather than 
for medico-legists). 12mo. Balt., 1833. 
225. Gross, S. D. Experiments on Strangling. Western Journ. Med. and 
Surg. Yol. 9, 1833. 
226. fCombe, And. Mental Derangements (Ist Am. Ed). Bvo. pp. 336. Bos- 
ton, 1834. 
221. Beck, J. B. Researches in Medicine and Med. Jurisp. Bvo., 2d ed., 
pp. 258. N. Y., 1835. 
228. Williams, S. W. Catechism of Med. Jurisp. (Yery severely criticized.) 
18rno. pp. 205. Northampton, Mass., 1835. 
229. Beck, T. R. and J. B. Med. Jurisp. (See 209.) sth ed., 1835. 
230. Rush, B. Diseases of the Mind. (See 203.) sth ed. 1835. 
231. fChitty. Med. Jurisp. Part I. Am. ed. Bvo. pp. 509. (Never com- 
pleted.) Phila., 1836. 
232. -{-Prichard, J. C. Insanity. Am. ed. Bvo. pp. 111. Phila., 1831. 
233. -{Taylor, A. S. Observations and Experiments on Lungs of New-Born 
Ciiildren. Phila,, 1838. 
234. Ray, Isaac. Medical Jurisprudence of Insanity. (“Best hook in Eng- 
lish language to date,” reprinted in England and Scotland.) Bvo. Bos- 
ton, 1838. 
2d ed., pp. 490, 1844; 3d ed., 1853; 4th ed., 1860; sth ed., pp. 658, 1811. 
235. Beck, T. R. &J. B. Med. Jurisp. (See 209.) 6th ed., 1838. 
236. * Hodge, H. L. Criminal Abortion. Phila., 1839 ; Phila., 1854; 12mo. 
pp. 44, Phila., 1869; 4th ed., 1813. 
231. Gross, S. D. Pathological Anatomy. 2 vols., 1839. 2d ed., Bvo. pp. 
822, Phila., 1845 ; 3d ed., pp. 111, 1851. 
238. fMontgomery. Signs and Symptoms of PregnancjL pp. 220, Phila., 
1839; from London ed., 1831. 2d Am. from 2d London ed., Bvo. pp. 
568, Phila., 1851. 
239. fTraill. Outlines of Med. Jurisp.; (from 2d Edinb. ed.) Bvo. pp. 234. 
Phila., 1841. 
240. "fWinslow, F. Plea of Insanity in Criminal Cases. Bvo. pp. 111. Boston, 
1843. 
241. Ray, I. Med. Jurisp. of Insanity. (See 234.) 2d ed., 1844. 
242. Gross, S. D. Path. Anatomy. (See 231.) 2d ed., 1845. 
243. -{"Esquirol. Mental Maladies. Notes, etc., by B. K. Hunt. Bvo. pp. 496. 
Phila., 1845. 
-A4. fChristison. Poisons. Edited by Jno. Bell. Bvo. pp. 156. Phila., 1845. 
(Reprint 4th Edinb. ed.) 
245. f Forbes, Tweedie, and Conolly. Cyclopaedia of Practical Medicine, with 
additions, etc., by R. Dunglison. (Contains many valuable articles on 
Med. Jurisp.) 4 vols. Bvo. Phila., 1845. 
“46. -{-Guy, W. A. Forensic Medicine, with Notes, etc., by Chas. A. Lee. 
Bvo. pp. 111. New York, 1845. 
-Al. -{-Taylor, A. S. Manual of Med. Jurisp., with Notes, etc., by R. E. Griffith, 
M.D. Bvo. pp. 539. Phila., 1845. 
Same by Griffith. 2d Am. from 3d London ed., 1850. 
Same by E. Hartshorne, M.D. 3d Am. from 4th London ed., 1853. 
Same by Hartshorne. 4th Am. from sth London ed., 1856. 
Same by Hartshorne. sth Am. from Ith London ed., 1861. 
Same by C. C. Penrose, Esq. 6th Am. from Bth London ed., 1866. 
Same by Jno. J. Reese, M.D, Ith Am. from 9th London ed., 1813. 198 
CHAILLE, 
248. Crozier. Life and Trial of Dr. Abner Baker. Bvo.pp. 152. Louisville, Ky., 
1846. 
249. * Purple, S. S. Corpus Luteum. (Med .-Legal, from N. Y. Jour. Med.) 
Bvo. pp. 13. N. Y., 1846. 
250. Hall, B. F., Esq. Freeman Trial (Yan Nest Murder). 1841. 
251. Costill, 0. H. Pract. Treatise on Poisons. 12rao. pp. 160. Phila., 1848. 
252. *Taylor, A. S. Poisons, with Notes, etc., by R. B. Griffith. Bvo. pp. 681. 
Phila., 1848. 2d Am. from 2d London ed., 1859; 3d Am. from 3d 
London ed., pp. 188, Phila., 1815. 
253. Beck, T. R. &J. B. Medical Jurisp. (See 209.) 10th ed., 1850. 
254. Dean, Amos, Esq., Prof. Med. Jurisp., etc. Medical Jurisprudence. Bvo. 
pp. 664. Albany, N. Y., 1850. 2d ed., 1854 ; 3d ed., 1813. 
255. Bemis, G., Esq. Parkman-Webster Murder. Boston, 1850. 
256. f Taylor, A. S. Maul, of Med. Jurisp. (See 241.) 2d Am. ed., 1850. 
251. * Dal ton, J. C. Corpus Luteum. Trans. Am. Med. Asso., vol. 4,1851. 
258. *Storer, D. H. Address on Med. Jurisp. Boston, 1851. 
259. *Binney, H., Esq. Coroner, Jurisdict. of. Phila., 1853. 
260. Ray, I. Med. Jurisp. of Insanity. (See 234.) 3d ed., 1853. 
261. * Taylor, A. S. Manl. Med. Jurisp. (See 241.) 3d ed., 1853. 
262. Dean, Amos, Esq. Medical Jurisp. (See 254.) 2d ed., 1854. 
263. Hodge, H. L. Criminal Abortion. (See 236.) 2d ed., 1854. 
264. Wharton, Francis, Esq., and Stille, Moreton, M.D. Medical Jurisprudence. 
Bvo. pp. 815. Phila., 1855. 2d ed., “Wharton and Stille,” and Prof. 
Alfred Stille, M.D., pp. 1031, 1860; 3d ed., “Wharton and Stille,” and 
Drs. S. Ashhurst, Sinkler, and Amory, two vols. in three, Phila., 1813. 
265. Wharton, F., Esq. Mental Unsoundness. Phila., 1855. 
266. Hamilton, F. H. Deformities after Fractures (Malpractice). Bvo. pp. 99, 
Phila., 1855, and Tr. Am. Med. Asso., vols. 8, 9, 10. Treatise on Frac- 
tures and Dislocations, Bvo. pp. 151, Phila., 1860; sth ed., 1815. 
261. *Wetherill. Adipocere and its Formation. Folio, pp. 25. Phila., 1855, 
and in Tr. Am. Philosoph. Society, vol. 11, Phila. 
268. *Lee, C. A. Case of John Hendrickson, Jr., for Wife-murder (Poison). 
Bvo. pp. 41. N. Y., 1855. 
269. Purple, S. S. Wounds of Heart, and their Relations to For. Med., with 
42 Cases. N. Y. Med. Times, May, 1855. 
210. tßrierre de Boismont. Hallucinations. (Am. from 2d Paris ed.) Bvo. 
pp. 553. Phila., 1855. 
211. *Gilman, C. R. Relations of Medical to Legal Profession. Bvo. pp. 26. 
N. Y., 1856. 
212. fTaylhr, A. S. Manual Med. Jurisp. (See 241.) 4th Am. ed., 1856. 
213. Gross, S. D. Path. Anat. (See 231.) 3d ed., 1851. 
214. *Semmes, A. J. Med.-Legal Duties of Coroners, Bvo. pp. 16, and Tr. 
Am. Med. Asso. Phila., 1851. 
215. *Jarvis, B. Criminal Insane. Bvo. pp. 39. Utica, N. A 7"., 1851. 
216. *Earle, P. Parish Will Case (Apoplexy and Paralysis). Bvo. pp. 50. 
N. Y., 1851. 
211. *Watson, Browne, etc. Parish Will Case. N. Y., 1851. 
218. *Gilman, C. R. Case of C. B. Huntington (Insanity). Bvo. pp. 24. 
N. Y., 1851. 
219. * Suffolk Dist. Med. Society. Criminal Abortion. Bvo. pp. 13. Boston, 
1851. 
280. fOtto, J. Poisons, by W. Elderhorst. N. Y., 1851. 
281. Signs and Symptoms of Pregnancy. (See 238.) 2d Am 
ed., 1851. 
282, *Reese, D, M. Moral Insanity, Med. Jurisp. of. Bvo. pp. 26, and Tr, 
Am. Med. Asso. Phila., 1858. 
283. * Coventry, C. B. Med. Jurisp. of Insanity. Bvo. pp. 56, and Tr. Am 
Med. Asso. Phila., 1858. ADDRESS ON MEDICAL JURISPRUDENCE. 
199 
284. * Perkins, R. G. Insanity in its Legal Relations. Bvo. pp. 24. N. Y., 
1858. 
285. *Davis, T. G. C. Plea of Insanity in Case of R. C. Sloo. Bvo. pp. 53. 
St. Louis, Mo., 1858. 
286. fßucknill and Take. Manual of Psycholog. Med. Phila., 1858. 
281. *Fleming, A. Blood Stains. Pittsburg, Pa., 1861, and Am. Journ. 
Med. Sci., 1859. 
288. *Wright, M.D. Drunkenness and Inebriate Asylums. Bvo. pp. 22. Co- 
lumbus, 0., 1859. 
289. f Taylor, A. S. Poisons. (See 252.) 2d Am. ed., 1859. 
290. Elwell, J. J., M.D., Esq. Malpractice and Medical Evidence. Bvo. pp. 588. 
N. Y., 1860. 2d ed., 1866 (?); 3d ed., Bvo., pp. 600, 1811. 
291. Hall, A. G. Institutes of Med. Jnrisp. (“ A senseless monthly serial of 
a quo,ck1 having no reference, except in name, to Med. Jurisp.v) Bvo. 
pp. 5T6. Boston, 1860. 
292. Beck, T. R. and J. B. Med. Jnrisp. (See 209.) 11th ed., 1860. 
293. Ray, I. Med. Jnrisp. of Insanity. (See 234.) 4tli ed., 1860. 
294. Wharton and Stille. Med. Jnrisp. (See 264.) 2d ed., 1860. 
295. *Wharton, F. Involuntary Confessions. Bvo. pp. 36. Phila., 1860. 
296. * Wright, T. L. Med. Leg., Inquiry on Influence of Chloroform. Bvo. 
pp. 32. Columbus, 0., 1860. 
291. fWinslow, F. Brain and Mind. Ist Am. ed., Phila., 1860. 
M.B. “ War between the States,” 1861-1865. 
298. fTaylor, A. S. Manl. Med. Jnrisp. (See 241.) sth ed., 1861. 
299. * Swinburne, John. Case of Rev. H. Budge (Wife-murder). Bvo. pp. 94. 
Albany, 1862, and Tr. Med. Soc. State of N. Y., 1862. 
300. * Swinburne, J. Trial of Hendrickson (Wife-murder. Aconite). Bvo. pp. 
16. Phila., 1862. 
301. Beck, T. R. and J. B. Med. Jurisp. (See 209.) 12th ed., 1863. 
302. *Parigot, J, Legislation on Insanity. Bvo. pp. 14. N. Y., 1865. 
302 a. Elwell’s Malpractice and Med. Ev. (See 290.) 2d ed., 1866 (?). 
303. Seguin. Idiocy. Bvo. pp. 451. N. Y., 1866. 
304. Hammond, W. A. Insanity in its Medico-legal Relations. Bvo. pp. 12. 
N. Y., 1866. 
305. Storer, H. R. Why Not? (Abortion.) 12mo. pp. 91. Boston, 1866. 
[2d ed., 1811?] 
306. fWinslow, F. Obscure Dis. Brain and Mind, 2d Am. from 3d Loud. ed. 
Bvo. pp. 483. Phila., 1866. 
301, Wormley, Theo. G. Micro-Chemisty of Poisons. Bvo. pp. 668. N. Y., 
1861. 
308. Day, A. Methomania. 16mo. Boston, 1861. 
309. Storer, H. R. Is it I? (Abortion.) 12mo. pp. 154. Boston, 1861. 
310. *Le Prohon. Yoluntary Abortion. Bvo. pp. 24. Portland, Me., 1861. 
311. *Wetmore, E. Law of New York regarding the Insane. Bvo. pp. 35. 
Utica, 1861. 
312. *Forbes, W. S. History of Anatomy Act 'of Pa. Bvo. Phila., 1861. 
313. -j- Mauds ley. Mind, Physiol, and Pathol, of. Bvo. pp. 442. N. Y., 1861. 
2d ed., 1811. 
314. Storer and Heard, Criminal Abortion. Bvo. pp. 215. Boston, 1868. 
315. *Todd, J, Serpents in the Dove’s Nest (Abortion). Bvo. pp. 28. Boston, 
1868. 
316. *Lee, C. A. Report on Insanity. Bvo. pp. 32. Phila., 1868. 
311. Ordronaux, John. Jurisprudence of Medicine in its Relations to the Laws 
of Contracts, Torts, and Evidence. Bvo. pp. 310. Phila., 1869. 
318. Ordronaux, J. Appointment of a Commissioner to examine Witnesses in 
Med.-legal Trials. Tr. Am. Med. Asso., 1869. 
°l9. Hodge. Criminal Abortion. (See 236.) 4th ed., 1869. 200 
CHAILLE, 
320. Richardson, Joseph G. Blood Stains. Am. Journ. Med. Sci., July, 1869. 
321. Ecbeverria. Epilepsy. Bvo. pp. 886. N. Y., 1810. 
322. *Hammond, W. A. Case of Daniel McFarland (Insanity). Bvo. pp. 35, 
N. Y., 1810, and in Quart. Journ. Psychol. Med. 
323. *Lee, Charles A. Case of Carlton Gates (Insanity). Bvo. pp. 30. N.Y., 
1810, and in First Series of Papers of N. Y. Med.-Legal Soc. 
324. *Rav, I. Trial of John Reynolds. N. Y., 1810. 
325. *Nebinger. Criminal Abortion. Bvo. Phila., 1810. 
326. Hammond, W. A. Diseases of the Nervous System. Bvo. pp. 154. N. Y., 
1811. (6th ed., 1816.) 
321. Storer, H. R. Reflex Insanity in Women, Bvo. pp. 236. Boston, 1811. 
328. Calkins, A. Opium and the Opium Appetite. Bvo. pp. 390. Phila., 1811. 
329. Ray, I. Med. Jurisp, of Insanity. (See 234.) sth ed., 1811. 
330. Elwell, J. J. Malpr. and Med. Evidence. (See 290.) 3d ed., 1811. 
331. *Gray, J. P. Insanity, Dependence on Physical Dis. Bvo. Etica, N. Y., 
1811. 
332. *Conklin, W. J. Relations of Epilepsy to Insanity and Med. Jurisp. Bvo. 
pp. 43. Dayton, 0., 1811. 
333. *Dimon, D. Freeman Trial (Murder). Auburn, N. Y., 1811. 
334. f Blandford. Insanity, Medical and Legal, with a Synopsis of the laws 
of the several States of the Union respecting the confinement of the 
Insane, by I. Ray. Bvo. pp. 412. Phila., 1811. 
335. fMaudsley. Body and Mind. 12mo. pp. 155. N. Y., 1811. 
336. fMaudsley. Mind, Physiology and Pathol, of. (See 313.) 2d ed., 1811. 
331. Delafleld, F. Post-mortem Examinations. Bvo. pp. 316. N. Y., 1812. 
338. Fisher, T. W. Plain Talk about Insanity (Med.-legal). Bvo. pp. 91. 
Boston, 1812. 
339. Day, A. The Opium Habit. N. Y., 1812. 
340. *Peet, I. L. Physical Status and Criminal Responsibility of the totally 
uneducated Deaf and Dumb. Bvo. pp. 31. N. Y., 1812, and in First 
Ser. Papers N. Y. Med.-Legal Soc. 
341. *Yan de Warker. Detection of Criminal Abortion. Bvo. pp. 88. Bos- 
ton, 1812. 
342. *New York Med.-legal Society. Report on Criminal Abortion. Bvo. pp. 
15. N. Y., 1812. 
343. *Crothers,T. D. Trial of Mrs. Dr. E. Burleigh (Abortion). Bvo. Albany, 
1812. 
344. * Williams, P. C. Ketchum-Wharton Trial (Antimony). Bvo. pp. 31. 
Baltimore, 1812, and Med. and Surg. Report., Phila., vol. xxvi. (See 
also Am. Journ. Med. Sci., April, 1812.) 
345. *Wey, W. C. Medical Responsibility and Malpractice. Bvo. pp. 35. 
Albany, 1812. 
346. *Stevens, T. M. Med.-legal Science. Bvo. Trans. Ind. State Med. Soc. 
Indianapolis, 1812. 
346 a. Dean, Amos, Esq. Med. Jurisp. (See 254.) 3d ed., 1813. 
341. Ray, I. Contributions to Mental Pathology, Bvo. pp. 558. Boston, 1813. 
348. Hammond, W. A. Insanity in its Relations to Crime. Bvo. pp. 11. 
N. Y., 1813. 
349. Wharton and Stille. Med. Jurisp. (See 264.) 3d ed., 1813. 
350. Hodge. Criminal Abortion. (See 236.) 4th ed., 1813, 
351. *Stevens, T. M. Expert Testimony. Bvo. Indianapolis, 1813, and in 
Ind. Med. Journ. 
352. Civil Malpractice. Bvo. pp. 14. Chicago, 1813. 
353. *Field, D. D., Esq. Emotional Insanity. Bvo. N. Y., 1813. 
354. *Clinton, IT. L., Esq. Defence of Insanity in Criminal Cases. N, Y., 
1813. 
355. *Morse, D. A. Dipsomania and Drunkenness, pp. 52, and in Ohio State 
Med. Soc. Trans., 1813. ADDRESS ON MEDICAL JURISPRUDENCE. 
201 
856. *Bell, Clark, Esq. Inaug. Address N. Y. Med.-Legal Soc. Bvo. pp. 11. 
N. Y., 1873. 
357. Echeverria. Epilepsy in relation to Med. Jnrisp. and Epileptic Insanity. 
Ain. Journ. Insanity, Etica, April and July, 1873. 
358. •j'Taylor, A. S. Principles and Practice of Med. Jurisp, (Reprint of 2d 
London ed.) Bvo. 2 vols. Phila., 1873. 
359. f Taylor, A. S. Manual Med. Jnrisp. (See 247.) 7th Am ed., 1878. 
360. -j-Tuke, D. H. Influence of Mind on Body. Bvo. pp. 415. Phila., 1873. 
361. fWynter, A. Borderlands of Insanity. Am. ed. 12mo. pp. 314. N.Y., 
362. Reese, Jno. J. Manual of Toxicology. Bvo. pp. 507. Phila., 1874. 
363. N. Y. Med.-Legal Soc. “First Series of Papers.” Bvo. pp. 552. N. Y., 
1874. (By Jud«;e Campbell, Win, and Jacob Shrady, and Tillou, Esq’rs, 
Mr. I. L. Peet, and Drs. O’Dea, Rogers, Lee, Hammond, Burr, Clymer, 
1873. 
De Marraon, Parsons, and Peters.) 
364. *Bell, C., Esq. Inaug. Address N. Y. Med.-Legal Soc. Bvo. pp. 23. 
N. Y., 1874. 
365. * Beard, G. M. Legal Responsibility in Old Age. Bvo. pp. 42. N. 1., 
1874. 
366. *Morse, D. A. General Paralysis and Blackburn Case. pp. 120. 1874. 
367. *Morse, D. A. Monomania, pp. 46. This and 366 in Ohio State Med. 
Soc. Trans., 1874. 
368. * Clymer, M. Influence of Epilepsy on Criminal Responsibility. Bvo. 
pp. 25. Phila., 1874. 
369. E. L. Legal Relations of Emotional Insanity. Bvo., and 
Trans. Am. Med. Assoc. Phila., 1874. 
370. *Peugnet, B. Gunshot Wounds of Abdomen (Stokes-Fisk Murder). 
N.Y., 1874. 
371. •j'Maudsley. Responsibility in Mental Disease. Bvo. pp. 313. N. A., 
!874. 
372. fßucknill and Tuke. Manual of Psycholog. Med. Bvo. Phila., 1874. 
373. *Richardson, Jos. G. Yalue of High Powers in Blood-Stains. Bvo. pp. 
12, and in Am. Journ. Med. Sci., July, 1874, and London Mic. Journ., 
Sept. 1874. 
314. J. G. Diagnosis of Blood-Stains, pp. 5. Am. Journ. Med. 
Sci., April, 1875. 
375. Richardson, J. G. Improved Method for Micro-Spectrosc. Test for Blood- 
Stains. Phila. Med. Times, Nov. 1875. 
3 16. * Wood ward, J. J. Blood-Stains in Criminal Cases, pp. 12, and in Am. 
Journ. Med. Sci., January, 1875. 
377. Smith, J. E. Diagnosis of Blood Stains. Cinn. Med. Times, April, 18(5. 
378. *Ray, I. Duncan Will Case, 1875. 
379. * Allen, N. State Med. in its relations to Insanity. Boston, 1875. 
380. *Bell, C., Esq. Inaug. Ad. N. Y. Med.-Legal Soc. Bvo. pp. 16. Is. A.,1875. 
381. ’j’Taylor, A. S. Poisons. (See 252.) 3d ed., 1875. 
382. f Sheppard. Madness—Aled., Social, and Legal, Irom London ed. of 1873. 
Bvo. pp. 186. Phila., 1875. 
383. fPoppesis, B. Hermaphrodism (Med.-legal), Translated from the French 
by Dr. E. W. Sawyer, Chicago, 1875. 
384. ■j’Sieveking. Med. Adviser in Life Insurance, from London ed. of 1874. 
12mo. Phila,, 1875. 
385. Cowperthwait, A. C. Insanity in its Med.-legal Relations. Bvo. pp. 80. 
Phila., 1876. 
386. Hammond, W. A. Diseases of the Nervous System. (See 326.) 6th. ed., 
1876. 
pB7. *Beil,C.,Esq. Yaledict. Ad. N. Y. Med.-Legal Soc. 8v0.pp.26. N.Y.,1876. 
388. j-Brown, J. H. B, Jurisp. of Insanity (from the 2d English ed.). Bvo. 
pp. 713. Phila., 1876. 202 
CHAILLE, 
389. fNaquet, Legal Chemistry (English translation from French). [lt has 
16 pp. Bibliog. of Toxicology, etc.] 12mo. pp. 175. N. Y., 1876. 
390. "[Woodman and Tidy. Handy-book of For. Med. and Toxicol. Phila., 
1876. (In press, August, 1876.) 
Index to Subjects in the American Bibliography, 
201 to 890. 
General Subject.—Beck, T. R. 209. Beck, J. B. 227. Bell, C. 356, 364, 380, 38 u 
fChitty, 231. fCooper, 207. Dean, 254. Dunglison, 214. fForbes, etc., Cycl. Pract. 
Med. 245. Gilman, 271. fGuy, 246. Hall, 291. Hance, 219. N. Y. Med.-Legal 
Society Papers, 363. Rush, 202. fßyan, 223. Stevens, 346. Storer, 258. fTaylor, 
247, 358. fTraill, 239. Webster, 210. Wharton and Stille, 264. Williams, 228. fWood- 
man and Tidy, 390. 
Abortion and Infanticide.—Beck, J. B. 205. Orothers, 343. Hodge, 236. Le 
Prohon, 310. Nebinger, 325. N. Y. Med.-Legal Society, 342. Storer, 305, 309. Storer 
and Heard, 314. Suffolk Hist. Med. Society, 279. Todd, 315. Van de Warker, 341. 
Alienation, Mental. {lntemperance; Deaf and Dumb.)—Allen, 379. Beard, 365. 
fßlandford, 334. fßrierre de Boismont, 270. fßrown, 388. fßucknill and Tuke, 286. 
Clinton, 354. Clymer, 368. fCombe, 226. Conklin, 332. Coventry, 283. Oowperthwait, 
385. fCox, 201. Davis, 285. Earle, 276. Echeverria, 321, 357. fEsquirol, 243, Field, 
353. Fisher, 338. Gilman, 271. Gray, 331. Hammond, 304, 326, 348. f Highmore. 
208. Howard, 369. Jarvis, 275. Lee, 323. fMaudsley, 313, 335, 371. Morse, 366, 367. 
N. Y. Med.-Legal Society Papers, 363. Parigot, 302. Perkins, 284. f Prichard, 232. 
Ray, 234, 324, 347, 378. Reese, 280. Rush, 203. Seguin, 303. fSheppard, 382. Simons, 
216. Storer, 327. fTuke, 360. Watson, Browne, etc. 277. Wetmore, 311. Wharton, 
265,295. fWinslow, 240, 306. Wright, 296. fWynter, 361. [lntemperance].--Calkins, 
328. Day, 308, 339. Morse, 355. N. Y. Med.-Legal Society Papers, 363. Wright, 288. 
(Deaf and Dumb).—Peet, 340. 
Asphyxia, etc.—Coley, 222. Gross, 225. fTaylor, 233. 
Blood Stains.—Fleming, 287. Richardson, 320, 373, 374, 375. Smith, 377. Wood- 
ward, 376. 
Coroner.—Binney, 259. Semmes, 274. 
Life Insurance.—N. Y. Med.-Legal Society Papers, 363. fSieveking, 384. 
Malpractice and Medical Evidence.—Elwell, 290. Hamilton, 266. Lobstein, 218. 
McClelland, 352. Ordronaux, 317, 318. Stevens, 351. Warren. 213. Wey, 345. 
Obstetric Medical Jurisprudence.—Dalton, 257. fMontgomery, 238. Poppesio, 383. 
Purple, 249. 
Pathological Anatomy.—Delafield, 337. Forbes, 312. Gross, 237. Horner, 21*. 
fMorgagni, 211. Wetherill, 267. 
Poisons, Toxicology, Legal Chemistry.—fOhristison, 244. Coley, 222. Costill, 251. 
Ducachet, 204. Ducatel, 224. Lee, 268. fNaquet, 389. fOrfila, 206, 212. fOtto, 280. 
Reese, 362. Swinburne, 300. fTaylor, 252. Wormley, 307. 
Trials, Legal, Celebrated Gases.—Baker, Dr. Abner, Life and Trial of, 248. Blackburn 
Case (General Paralysis), 366. Budge, Rev. H. (Wife-murder), 299. Burleigh, Mrs. Dr. E. 
(Abortion), 343. Chapman, Lucretia, Trial of, for Poisoning. 221. Duncan Will Case, 
378. Fisk, Jas., Stokes-Fisk Murder (Abdominal Wounds), 370. Freeman Trial (Murder), 
250, 333. Gates, Carlton, Case of (Insanity), 323. Hendrickson, Jno., Wife-murder 
(Aconite), 268. Huntington, O. 8., Case of (Insanity), 278. Ketchum-Wharton Trial 
(Antimony), 344. McFarland, Dan’l, Case of (Insanity), 322. Parish Will Case (Apoplexy 
and Paralysis), 276, 277. Parkman-Webster Murder, 255. Reynolds, Jno., Trial of, 324. 
Steinecke-Schoeppe Case (Poisoning), 363. 
Wounds.—Peugnet, 370. Purple, 269. 
General Alphabetical Index. 
N. B. Under each letter, the authors are recorded in the following national order : Italy, Germany, 
France, Great Britain, and’the United States. Foreign authors, recorded among the American, are 
designated by a f. 
Albeetus, 31. Ammann, 22.—Allen, 379. 
Barzelotti, 5. Beccaria, 19.—Baumer, 45. Behrens, 23. Bene, 58. Bernhold, 40. 
Bergmann, 77. Bernt, 62. Bbcker, 86. Boerner, 39. Bohn, 27. Braendel, 43. Brach, ADDRESS ON MEDICAL JURISPRUDENCE. 
203 
78. Buchner, 93.—Bayard, 125. Belloc, 116. Bergeron, 128. Bertrand, 118. Biessy, 
120. Blegni, 107. Briand, Briand and Bresson, Briand and Chaude, 122. Brierre de 
Boismont, 133. Bruhier, 109.—Bartley, 151. Brady, 159. Burrows, 149.—Beard, 365. 
Beck, J. B. 205, 209. 227. Beck, T. R. 209. Bell, 356, 364, 380, 387. Bemis, 255. 
Binney, 259. tßlaudford, 334. fßrierre de Boismont, 270. fßrown, 388. fßucknill 
and Tu’ke, 286, 372. 
Cledillot 10.—Casper, 88. Oondronchus, 20.—Capuron, 134. Ohaussier, 113.—Chitty, 
157. Collinson, 145. Conolly, 165. Crichton, 141.—Calkins, 328. fOhitty, 231. 
tChristison, 244. Clinton, 354. Clymer, 368. Coley, 222. fOombe, 226. Conklin, 332. 
tGooper, 207. Costill, 251. Coventry, 283. Cowperthwait, 385. fCox, 201. Crothers, 
343. Crozier, 248. 
Dorn. 63.—Devaux, 108. Devergie, 124 a. Duval, 104.—Dalton, 257. Davis, 285. 
Day, 308, 339. Dean, 254. Delafield, 337. Dimon, 333. Dubois, 221. Ducachet, 204. 
Ducatel, 224. Dunglison, 214. 
Eschenbach, 36. Erhard, 54. Esquirol, 131.—Earle, 276. Echeverria, 321, 35/ 
Elwell, 290. fEsquirol, 243. 
Portunatus Fidelis. I.—Palmer, 52. Faselius, 42. Fischer, 26. Freidreich, /3. 
Purstenau, 38.—Fodere, 114.—Farr, 150. Forsyth, 155—Field, 353. Fisher, 338. 
Fleming, 287. fForbes, etc., Cycl. Bract. Med. 245. Forbes, 312. 
Gandolfi, 17. Gianelli, 12. Grotanelli, 9.—Goelicke, 32. Giintner, 83.—Gendri, 106. 
Georget, 130.—Gavin, 168. Goodwyn, 140. Guy, 161. Gilman, 209, 271,2/8. Gray, 
331. Gross, 225, 237. fGuy, 246. 
Haller, 48. Hauska, 87. Hebenstreit, 37. Heinroth, 97. Henke, 60. Hoffbauer, 
96. Hofman, 89.—Haslam, 142. Hunter, 139. Husband, 163. Hutchinson, 148.—Hall, 
A. G. 291. Hall, B. P. 250. Hamilton, 266. Hammond, 304, 322. 326, 348. Hauce, 
219. fHighmore, 208. Hodge, 236. Horner, 215, 217. Howard, 369. 
John, 51.—Johnson, 146. Johnstone, 143.—Jarvis, 275. 
Kannegiesser, 44. Klose, 64. Kraft-Ebing, 99. Ivrahmer, 84, 85. Kraus and 
Bidder, 94. 
Lazzaretti, 16.—Libavius, 21. Lion, 91. Loder, 49. Loew, 33. Ludwig, 41. 
Eecieux, 119. Legrand du Sanlle, Ortolan, and Naquez, 126. Legrand du Saulle, 12*. 
Louis, A. Il2.—Lee, 246, 268, 316, 323. Le Prohon, 310. Lobstein, 218. 
Martini, 6. Morgagni, 18.-—Masius, 57. Meckel, 67, 80. Mende, 66. Metzger, 50. 
Mittermaier, 98. Muller, 53.—Mahon, 115. Marc, 132.—Male, 152.—fMaudsley, 313, 
335,352. McClelland, 352. fMontgomery, 238. f Morgagni, 211. Morse, 355, 366, 367. 
Net, 76. Nicolai, 75. Niemann, 61, 69.—fNaquet, 389. Nebinger, 325. N. Y. Med.- 
Legal Society, 342, 363. 
Orfila, 121.—Ordrouaux, 317, 318. fOrfila, 206, 212. fOtto, 280. 
Berrone. 13. Presntti, 14.—Pichler, 90. Platner, 68. Plenck, 47.—Pare, 100. 
Binel, 129. Pineau, 101. Poilroux, 136. Provost, 111.—Pagan, 166. Paris and Fon- 
blanque, 154. Percival, 138. Perfect, 144.—Parigot, 302. Peet, 340. Perkins, 284. 
Beugnet, 370. fPoppesio, 383. fPrichard, 232. Purple, 249, 269. 
Quentner, 82. 
Biscica, 11.—Eolff, 74. Eoose, 95.—Riolan, 100.—Ryan, 156.—Ray, 234, 324, 34/, 
378. Reese, D. M. 282. Reese, J. J. 362. Richardson, 320, 373-4-5. Rush, 202, 203. 
tßyan, 223. 
Sidoti, 4. Speranza, B.—Schauenstein, 92. Schlegel, 49. Schmidtmuller, 56. Schraud, 
Schurmayer, 81. Siebenhaar, 72. Siebold, 79. Sikora, 46. Sporer, 71. Sprengel, 
65. Storck, 34.—Sebitz, 105. Sedillot, 123.—Smith, J. G. 153.—Seguin, 303. Serames, 
2/4. fSheppard, 382. fSieveking, 384. Simons, 216. Smith, 37/. Stevens, 346, 351. 
Storer, D. H. 258. Storer, H. R. 305, 309, 327. Storer and Heard, 314. Suffolk Dist. 
Med. Society, 279. Swinburne, 299, 300. 
Taurini, 7, Tortosa, 3. Treschi, 15.—Teichmeyer, 30. Tropanneger, 35.—'Tagereau, 
_i63. Tardieu, 137. Trebuchet, 135. Trinquier, 124.—Taylor, 160, 162. Traill, 158. 
tTaylor, 233, 247, 252, 358. Todd, 315. flraill, 239. fluke, 360. 
f alentini, 25, 29.—Yerdier, 110. Yigue, 117.—Yan de Warker, 341. 204 
CHAILLE, ADDRESS ON MEDICAL JURISPRUDENCE. 
Wagner, 70. Wildberg, 59. Wolf, 24.—Watson, 167. Woodman and Tidy, 164. 
Warren, 213. Watson, Browne, etc. 277. Webster, 210. Wetherill, 267. Wetmore, 
311. Wey, 345. Wharton, 265, 295. Wharton and Stille, 264. Williams, P. C. 344. 
Williams, S. W. 228. fWinslow, 240, 297, 306. fWoodman and Tidy, 390. Woodward, 
376. Worraley, 307. Wright, M. 1). 288. Wright, T. L. 296. fWynter, 361. 
Zacchias, 2.—Zittman, 28. 
For bibliographical and other aid I owe hearty thanks to my colleagues, Professors 
S. M. Bemiss, M.D., T. G. Richardson, M.D., Frank Hawthorn, M.D. (deceased), and to 
Drs. W. H. Watkins, and E. Dreifus, of New Orleans; to Dr. John S. Billings, Assistant- 
Surgeon, U. S. A. (Surgeon-General’s Library); to Dr. Francis H. Brown, of Boston; to 
Professors S. D. Gross, and John J. Reese, and Dr. Joseph G. Richardson, of Philadelphia ; 
to Mr. Clark Bell, ex-President of the N. Y. Medico-Legal Society, and Prof. W. A. 
Hammond, of New York City; to Prof. A. B. Palmer, M.D., of the Univ. of Michigan; 
to Prof. D. A. Morse, of Ohio; and to Prof. A. S. Taylor, of London, England. Obliga- 
tions to others have been acknowledged in the notes to the Address. 205 
ADDRESS ON MENTAL HYGIENE, 
BY 
JOEY P. GRAY, M.D., LL.D., 
MEDICAL SUPERINTENDENT OP THE NEW YORK STATE LUNATIC ASYLUM, UTICA ; 
PROFESSOR OF PSYCHOLOGICAL MEDICINE AND JURISPRUDENCE IN BELLEVUE HOSPITAL 
MEDICAL COLLEGE, NEW YORK. 
The classical phrase, “ Mens Sana in Corpore Sano,” is a general and 
true expression of the related condition of the mind' and body for the 
best functions of human life. Health of body has, in all times, been 
regarded as essential to the best balance and culture of mind, and to the 
most effective application of its activities to the concerns of the world, 
whether educational or practical, whether in the realm of Philosophy 
or in the lower plane of Manual Labor. This is true notwithstanding 
that there are notable exceptions where great intellectual activity and 
application have been conjoined with feeble physical structure, and even 
disease.1 
Indeed we must start with the proposition that what is now denomi- 
nated Mental Hygiene, is practically inseparable from Physical Hygiene. 
It is comparatively a new application of the word hygiene. Hr. Maudsley, 
in his Gulstonian Lectures for 1870, says: “ The time has come when the 
immediate business which lies before any one who would advance our 
knowledge of mind, unquestionably is a clear and searching scrutiny 
of the bodily conditions, of its manifestations in health and disease.” 
Again, “as physicians, we cannot afford to lose sight of the physical 
aspects of mental states, if we would truly comprehend the nature of 
mental disease, and learn to treat it with success. The metaphysician 
may, for purposes of speculation, separate mind from body, and evoke 
the laws of its operation out of the depths of self-consciousness; but the 
physician, who has to deal practically with the thoughts, feelings, and 
conduct of men, who has to do with the mind, not as an abstract entity 
concerning which he may be content to speculate, but as a force in nature, 
the operations of which he must patiently observe and anxiously labor 
to influence, must recognize how entirely the integrity of the mental 
functions depends on the bodily organization, must acknowledge the 
essential unity of mind and body.”2 
And the great change which has taken place in the views regarding 
insanity, within the memory of men now living, transferring it from the 
domain of mere metaphysics, to the jurisdiction of medical science, as a 
recognized physical disease, witnesses to the same thing. Hut notwith- 
standing this intimate connection of physical with psychological condi- 
tions, in the study of mental hygiene, it will not be expected that I 
should go into the former, or into the field immediately related, of Pre- 
Pr. Godman, Dr. Robert Hall, the historian Prescott, and numerous other instances 
Wight be cited. 
2 Body and Mind, pp. 1, 108. 206 
GRAY, 
ventive Medicine, as that whole subject has been assigned to ray learned 
confrere. Dr. Bowditch, who has already explored and expounded it in 
the most exhaustive and satisfactory manner. My range of thought 
must, therefore, rather be general, and less limited by professional metes 
and bounds than if it were a strictly medical or a purely psychological 
one, and may, therefore, not prove as satisfactory to my professional 
brethren. I shall also be pardoned, I trust, on this National Centennial, 
if I refer to our own nation largely in elucidation of principles, and for 
practical illustrations. 
This whole subject was formerly confined within the range of phi- 
losophy alone. In the days of ancient civilization, before real science 
was born, when the oracle “ know thyself,” had only a subjective meta- 
physical meaning, men like Plato and Cicero placed all mental hygiene 
in the delights of literary conversation and philosophizing. The Academic 
Groves were the resorts of dreamy contemplation of a State and a World 
that never could be realized. The Tusculan Villa was a refuge from the 
clamor of Senates and the wrangles of the Forum, where Cicero and 
his friends sought their otium cum dignitate, secure from the jealousies 
and conspiracies of politics, whether Caesar or Pompey should triumph. 
They knew little of the physiological functions of the body, while they 
indulged in their acute and poetical, and sometimes touching, specula- 
tions upon the immortality of the soul; but modern science, in studying 
and dignifying the visible temple of the immortal spirit, has only con- 
firmed and followed in the track of Christianity, which first promised to 
the human body an equal dowry of immortality with the human soul. 
The Resurrection staggered the Stoics and Epicureans ; but it is at least 
the best warrant in the diploma of modern medical science, now perhaps 
somewhat disposed to spiritualize even matter itself, to endow it with 
the “ promise and potency of every form and quality of life.” On the 
other hand, the expression “mental physiology” has been coined to iden- 
tify the study of mind with that of body, and some would even attempt 
to resolve all psychology into physiology. 
Mental hygiene may be variously classified,but, as a whole, it embraces 
all that relates to the development, exercise, and maintenance of mental 
activity in individuals, communities and nations, and must, therefore, be 
considered from an individual, social, and national point of view. It 
involves education, social culture, religion and national life. With the 
individual, it begins at birth, and takes cognizance of even the constitu- 
tional tendencies, under laws of heredity, as well as of all the circum- 
stances of subsequent life. To the individual then, in a general way, it 
consists in that general and special training which will most perfectly 
and harmoniously develop the body and the mental faculties for the 
duties of life. At the outset, therefore, on this point, we are met with 
the questions, who is the individual ? What has he to do as an occupa- 
tion of life? However we may settle on general principles, the rules for 
individuals must be special. Practically,"we must consider classes and 
conditions. The occupation and pecuniary condition of parents ; their 
culture, social status, and surroundings ; clothing, food, and climate; 
proximity to schools, churches, and places of amusement; density or 
sparseness of population ; laws, government, etc., must all be considered 
as among the efficient and constantly modifying conditions of any system 
of hygiene proposed. 
Thus, it will be seen, it is a many sided and all-embracing subject, evi- 
dently too vast for one, in an address of an hour, to do more than simply ADDRESS ON MENTAL HYGIENE. 
207 
glance at its main features. Though it may be looked at from various 
stand-points, as men contemplate life, its duties, objects, and ends, from 
the work they are doing in the world, the fundamental ideas must be the 
same, to lead to any practical results. The views which the minister, the 
lawyer, the teacher, the scholar, the physician, the scientist, and the 
statesman, may take, will be directed, or colored somewhat, by their field 
of observation, and their bias of education; but on general principles 
they must be in accord. Mental hygiene covers all the broad field of 
human energy, embracing all the professions and every branch of indus- 
trial life. It looks after man’s moral as well as his intellectual nature, 
for the two cannot be separated. It enters into his domestic and social 
conditions, and follows him in his duties as a citizen. 
I. It first looks at human nature—at man as he is born—his utter help- 
lessness, his passions, his needs, physical and mental, and his social, moral, 
and spiritual wants, and then must devise a scheme for his development. 
Is this an easy task ? The science that would do this perfectly, must, 
from the realm of physiology, single out the laws written on his members, 
and harmonize them, in their development and action, with the laws of 
the spirit written on the psychological side of his nature, and put these 
in harmony with the laws of nature around him, in whose realm he 
dwells, and bring all in obedience and loving accord with the eternal 
truths of God. Mankind has been working upon this problem ever since 
Adam first contemplated the tree of knowledge, in the Garden of Eden, 
and was sent forth to his toil and to his own reflections. It will continue 
to be a problem, for human nature will not change ; the human passions, 
in all their wide scope, are not to be obliterated under culture, but regu- 
lated and controlled. Indeed, the discipline of the passions is, in a large 
measure, the moral side of this great question. Except for speculative 
study, there is no separation of the intellectual and moral elements, and 
the regulation of the passions and their proper development become a part 
°f education. 
A fundamental principle, therefore, in mental hygiene, is harmonious 
intellectual and moral culture, under the recognition of man’s essential 
nature as a spiritual being. This cultivation is imperative, in order that 
man may be able to recognize not only his own needs, but his relations 
to others; that he may, while taking care of himself, be able to see that 
he forms an integral part of a social organization absolutely essential for 
his own welfare. The machinery for the preservative harmony and ele- 
vation of social life, must reach to every class and condition; otherwise, 
the antagonistic elements would impede, if not prevent, all progress, and 
engender discord. 
Common customs, common schools, and common laws, are the most 
fundamental, and also the most powerful, equalizing agencies in the 
great machinery of the politico-social life of a people. Through these 
means the rich and poor meet on common ground, and acquire a certain 
degree of unity in physical and mental training, and a certain likeness 
°t character and harmony of thought on the great questions of education, 
morals, politics, and religion, highly favorable to stability, both social 
and national. Thus great general principles of government become more 
readily and universally received, and there are left for difference and 
discussion only the methods and forms of development and application. 
Still, these means only partially reach into the home life of individuals, 
where influences are constantly limiting and modifying development, 
both physical and mental. Indeed, however distinctly the laws of 208 
GRAY, 
physical and mental hygiene may be stated, like fundamental proposi- 
tions in law and morals, their individual application may be difficult. 
The circumstances surrounding and controlling, may not only modify, 
but entirely forbid, their application; and persons, families, and whole 
communities, do thus drift away from any regulated plan of life, or any 
reasonable principles of action, as the history of moral epidemics, not 
only in the past but the present, would abundantly show. Poverty and 
ignorance, the breeders of vices and crimes, and the enemies of culture, 
may render all principles nugatory, except as they are enforced by law. 
And in this direction political economy is a most important element in 
the study of mental hygiene, in its broad application to the interests of 
mankind. 
Thus we see in hygienic science the ideas which lead to the study of 
pauperism and crime, and the care of the dependent classes, whether 
made so by disease or misfortune; to the origination of means for pre- 
venting social evils of every character; to the enactment of laws for the 
regulation of morals by limiting vices, as in licensing prostitution and 
the sale of intoxicating drinks; laws for the suppression of gambling, 
and providing punishment for the publication of obscene literature; laws 
to prevent the spread of contagious and infectious diseases; and also 
that higher and grander step, laws for compulsory education, thus com- 
pelling the elevation of the masses by undermining ignorance and super- 
stition, the prolific sources of human misery and degradation. This is 
itself a wide field of inquiry; a field where Christianity and moral 
hygiene, social and medical science, and sanitary police, must join 
hands with education and law, to lift into social order the victims of 
evil and hereditary influences which they are powerless in themselves 
either to avoid or to conquer. 
That mental activity is highly favorable to physical health and develop- 
ment, when systematically directed into useful channels, need hardly be 
argued in this day. Intellectual labor seems, as a rule, to contribute to 
longevity. It was formerly a sort of proverb, that “ one of the rewards 
of philosophy is long life.” The ancient philosophers, especially the 
Peripatetics, pursued their studies and imparted their instructions largely 
out of doors, amid the varied objects of nature. The amount of physical 
exercise taken in the open air was a remarkable feature in the life of 
antiquity, even among its scholars; and wTe have among them numerous 
examples of great longevity in men of intellect. Homer, Pythagoras, 
Plutarch, Thales, Galen, Xenophon, Carneades, Sophocles, Zeno, Hippo- 
crates, Xenophanes, Democritus, and others, reached the age of ninety 
and upwards, while the majority of such men passed the limit of three- 
score and ten. 
In the early days of this Republic, with simplicity and plain living, 
we find the same rule holding good. Chief Justice Marshall and Thomas 
Jefferson reached eighty-four; Benjamin Franklin and John Jay, eighty- 
five ; James Madison, eighty-seven; and John Adams ninety-one. All 
these men certainly had not only vast intellectual labors to perform, but 
great burdens of care, anxiety, and responsibility to carry, and even 
serious privations to encounter; and we might greatly lengthen this list. 
Bearing on this point I have recently been informed by Governor Sey- 
mour, of Xew York, who has given great attention to the history and 
character of the Xorth American Indians, that the more intelligent 
tribes were not only the dominant and conquering ones, but that they 
afterwards met the struggle with civilization more successfully than ADDRESS ON MENTAL HYGIENE. 
209 
those giving themselves up wholly to physical exercises; that they also 
maintained a higher physical and mental standard, and lived to a greater 
age; that these tribes, this day, number nearly as many as in the early 
history of this country; that they maintain their language, and largely 
their simplicity of life, in the midst of civilization.1 
The ancient gymnasia, as well as the modern signification of the word 
gymnasium, bear witness to the sense ot the importance of combining 
mental and physical culture. Mental culture is a powerful influence in 
developing the symmetry of the bodily organism, the tone and expres- 
sion of the face, the organs of special sense, and the harmony of co-ordi- 
nating movements of the whole body. One can see this illustrated in 
our common schools at any time. The power of attention in the ma- 
jority of young children, in any community, is not much aroused iiwndi- 
nary life, and'they often look dull and stupid on this account. These 
children enter school, and the direction ot the attention to a few” simple 
exercises, in common, awakens the power ot attention ; and soon, at the 
tap of a rule, the sound of a musical note, or the word ot the teacher, the 
whole school instantly responds, Xow, under such simple but common 
and systematic exercises and study, the whole expression of the school 
changes. The bodily organism soon conforms to the habit of attention 
and to the systematic mental training, and awkwardness and dulness are 
soon transformed into gracefulness, courtesy, and intelligence. 
1 Extract from Appendix to Address by (lov. Horatio Seymour, ot New Yoik. at the 
dedication of the Kirkland Monument, Clinton, N. Y., June 25, 1873.—The superiority ot 
the Indians of New York, over those of adjoining States, is proved, not only by contempo- 
raneous history, but by striking facts within our own observation. 1 heir pride, heroism, and 
victories, through a long series of years, affected not only their mental and moral characters, 
but even their physical organizations Beyond the evidences ot then supenoiity 
to be found in history and science, we have living proofs of the vitality and mgoi ° t1& 
Iroquois. All others of the Indians, who once lived in the States lying east ot the Mississippi, 
have been swept away, except a few who linger in the wild regions south ot Cake bupenor, 
None of them have withstood the power and influence of the whites, except the lioquois. 
The Mohawks went to Canada, during the Revolutionary War, and most ot the Oneidas 
removed to Wisconsin about forty years since. The other tribes still live in New York, in 
all their homes they are surrounded by the whites, and by high civilization, yet their numbers 
do not diminish at this time. For a while after the whites went among them, they tell oti 
about one-third in population, but they now hold their number, with a slight increase in 
some cases. But the strength of their character is more strikingly shown by another tact. 
Although the Indians of New York, for three generations, have lived in the centres ot 
civilization surrounded by a dense white population, with whom they are in constant con- 
tact, as their reservations are small, yet they retain their own language, their own customs, 
and about one-half hold their old religions faith; yet they have white teachers and preachers 
who live amo no- them. In sermons or addresses, they must be spoken to in their own tongue, 
or through interpreters. At the celebration of the Kirkland Monument, a deputation ot 
Oneidas was present. They belonged to a small remnant of their tribe, numbering less 
than one hundred and fifty, who did not go with their people to Wisconsin, t hey and their 
fathers and grandfathers always lived in the heart of New York, in the vicinity o largo 
cities and villages. The tract of land they own contains but a few hundred acres, yet those 
present at Clinton, who were well-dressed men and women, could only speak to the assembly 
through an interpreter. In private conversation, with a few exceptions, they speak the 
English with hesitancy, as their thoughts are all conceived in the Indian language. Jhe 
whole world is sending representatives of every lineage, language, and nationality to our 
country; all of these in a few years speak our tongue and adopt our customs, and in a little 
time are assimilated in all respects with our people. Even the most stubborn races ot Asia 
yit‘ld to our phases of civilization. There is not in ethnology a moie extraordinary fact 
Ilian the resistance for more than a hundred years of our influences by this little band ot 
Natives. The continued existence of the Iroquois, while their kindred tribes have been 
swept away, and their resistance to our language and mode of thought, while all other 
lineages in our land have been assimilated, give proof ot the vigor and marked peculiarities 
ct their race. 210 
GRAY, 
Another common illustration is the change we mark in servants 
under the training of intelligent masters; under simple example and the 
stimulation of mind in the direction of systematic attention to duties, 
how quickly they are transformed, if they have any reasonable degree of 
capacity. The same may also be said of soldiers. Hume, in his Essay 
on National Character, says: “The human mind is of a very imitative 
nature ; nor is it possible for any set of men to converse often together 
without acquiring a similitude of manners, and communicating to each 
other their vices as well as their virtues.” 
The great power of mental activity and attention, in modifying expres- 
sion, bodily habits and movements, as well as general manners, may not 
only be seen in individuals and schools, but in whole communities and 
even nations. This is far more than imitation, it is substantial individual 
culture, the development of all the faculties in more or less symmetry. If 
we were asked the secret of the physical prowess and conquering power of 
the Roman people for a thousand years, we should answer it was the mili- 
tary education and discipline of the whole population from seventeen 
years of age, with its stern system of self-restraint and self-regulation. It 
was a civilization based upon the rigorous principles of the Lacedaemo- 
nians. rather than the lighter and more artistic life of Athens. The modern 
meaning of the word virtue was the cause of its Latin meaning, as con- 
fined to the behavior of men in battle, a stern temperance and self-control 
behind unflinching courage and endurance. It was once said by an 
American orator1 that Rome was thrice mistress of the world, by her 
arras, her religion, and her law. It is in the last only that she retains 
supremacy, for there is hardly a civilized nation in which the maxims 
of Roman civil law do not form the basis of equity. And this is all the 
result of the primitive training of that great people both physical and 
mental. The same principle was illustrated in the Puritan Cromwell’s 
troops, the soldiers of William the Conqueror, the German armies of 
Frederick William in the Franco-Prussian War, and conspicuously in 
the Revolutionary patriots of America and in their descendants, the 
soldiers on both sides of the contest in the recent war of Rebellion, in 
this country. 
The more we examine into this question of mental hygiene, the more 
it seems to resolve itself, on the mental side, into a statement of the best 
methods of education and training to secure the highest and truest cul- 
ture. And this is the line of thought which forces itself upon the mind 
as the true exposition of the words mental hygiene—a system of culture 
embracing all the interests of man in all his relations of life; education 
in its highest expression and broadest application ; education to secure 
not simply a knowledge of man, and of nature and her laws, and the 
awakening of the faculties to a deep obedience which will make man 
reverence her in all her works and ways, or, in the beautiful language of 
Prof. Huxley, “the instruction of the intellect in the laws of nature, 
under which name I include not merely things and their forces, but men 
and their ways, and the fashioning of the affections and the will into 
an earnest and loving desire to move in harmony with these laws,” adding 
“for me education means neither more nor less than this”—clear empha- 
tic words of which no one can mistake the meaning; but far more than 
this, we should demand a broad and deep culture of man which would 
do all this, and which would also awaken in the soul a full conscious- 
1 Hon. Hugh. S. Legare, of South Carolina; N. Y. Review, 1841. ADDRESS ON MENTAL HYGIENE. 
211 
ness of its responsibility to One by whom all things exist; an education 
which would not only raise man to harmony with the laws of nature, 
but which would also raise him to obedience to the laws of God ; which 
would make his life real, earnest, pure, and useful. To accomplish this, 
mental hygiene must include, therefore, not simply the mental and moral 
training in a general but also in a particular way ; must as well include 
social restraints and duties, as I have heretofore indicated, and embrace a 
supreme regard for the welfare of the country—a true patriotism. 
It is not out of place in this centenary year of the nation, to remind 
ourselves that this element of moral and religious restraint and discipline, 
this spirit of subjection to an overruling power above nature, was not 
left out of the practical life and training of its original founders. The 
first settlers of this continent began their conflict with wild nature, and 
still wilder savages, under a system of self-discipline and sense of religious 
responsibility, sterner even than that of the old Romans. It was indeed 
their virtue that brought them through successfully in their contest with 
the mightiest empire of Europe, and enabled them to lay the foundations 
of a governmental fabric which has been the astonishment and the study 
of European statesmen. 
But to follow up the subject of mental hygiene in relation to indi- 
vidual life, it must be evident that I should have to enter into details 
not possible in such an address as this ; I should have to take into 
consideration, not only the whole scope of what I have denominated, 
in a general way, educational means and influences, including domestic 
life, but also age, sex, civil condition, heredity, passions, the influence of 
climate, social customs, religion, etc., in all their varied relations as 
found in action in individuals, as also the questions of food, water, exer- 
cise, air, sleep, etc., all essential conditions and vital questions in the 
study of individual hygiene. 
11. When we come to the question of mental hygiene in communities, 
we include all hygiene as to individual life, and at the same time enter 
the wide domain of sociology or social science. Here again we meet the 
great problems of education, social customs and laws, intermarriage, 
amusements, and indeed all the conditions of social and civil life, together 
with religious culture, which, though I have named it last, is really first 
and fundamental. In this age of books and thinking, no man can 
this latter point if he would. While I have never been able to 
see any conflict between Science and Religion, certainly the tendencies 
°_t the times are rather to question closely their relations and their respec- 
tive domains. Christianity has been challenged by science, in some 
quarters, and the old questions of faith, freewill, responsibility, necessity, 
etc., are again discussed in the light of increased physical knowledge 
and physiological investigations, and the more advanced views of psy- 
chology. 
The literature of the age itself illustrates the subject of mental hygiene. 
Bulwer, in his “ Caxtons,” gives an admirable chapter on the hygiene of 
books. He suggests that reading should be governed by the mental 
Gate; that it should be suited to the morbid drift ot thought, or the 
Dialady of the individual. As an illustration, he speaks of the folly of 
attempting to amuse a man in the midst of a great sorrow; and nothing 
could be more in accord with sound psychology. Referring to Goethe 
taking up the' study of a science, after the death ot his son, he says, 
Ah 1 Goethe was a physician who knew what he was about. In a 
great griet like that you cannot tickle and divert the mind.” He re- 212 
GRAY, 
commends for the sorrows of middle life find old age, “bringing the 
brain to act upon the heart.” He would thus have philosophy lead and 
temper the emotions and the will, and enrich the true life by contem- 
plating the lessons of experience. He says: “ For that vice of the mind, 
which I will call sectarianism, not in the religious sense ot the word, 
but little narrow prejudices that make yon hate your next-door neighbor 
because he has his eggs roasted, when you have yours boiled, and gos- 
siping and prying into people’s affairs, and backbiting, and thinking 
heaven and earth are corning together if some broom touch a cobweb 
that you have let grow over the window-sill of your brains—what like 
a large and generous, mildly aperient dose of history ! How it clears 
away"all the fumes of the head .. . how your mind enlarges beyond 
that little feverish animosity to John Styles V' Here we have a strong 
hint, not only against the cultivation of a narrow range of thought, but 
also of the great value of that wide mental scope which takes in the 
interests of others, and occupies the mind in public and social interests 
and affairs of State. 
Again he says; “I remember to have cured a disconsolate widower, 
refused every medicament, by a strict course of geology. 
I dipped him deep into gneiss and mica-schist. Araidst the first, strata, 
I suffered the watery action to expend itself upon cooling crystallized 
masses; and by the time I had got him into the tertiary period, amongst 
the transition chalks of Maestricht and the conchiferous marls of G-osan, 
he was ready for a new wife.” Hut all men and women cannot giasp 
geology. Ho, but all can find, in morbid states, some serious mental 
occupation, if it be only their own sphere of labor, or some useful course 
of reading which will occupy them out of themselves; this is the secret, 
out of themselves. This would be substituting action for mere sentiment, 
a most important principle in mental culture. Ho lesson is more impor- 
tant than this, and it gives emphasis to what all experience teaches, that 
in the substantial realities of life are to be found the true sources of 
healthful mental discipline and growth ; that while amusements are 
useful as recreation after toil and responsibility, they are not to be looked 
upon as the daily pabulum of the individual or of society; that, in ex- 
cess, amusements become a kind of dissipation which creates a distaste 
for systematic and useful labor, and for the quiet of home life and its 
practical duties, and for all rational social intercourse. Thus real life 
grows tame and insipid ; a constant, restless desire for excitement is 
substituted for the deep, solid stimulus of duty, of domestic responsi- 
bility, and of that substantial mental culture which alone can give to 
society strength and virtue. 
Sentimentalism is a tendency of the age, and has a most important 
place, but it should not become so dominant in social life and in educa- 
tion as to exhaust the mental energy in trivialities, or in mere expression 
of the feelings, instead of leading it to action and duty. Mere senti- 
mentalism, whether in social life, religion, or politics, demoralizes and 
emasculates all life and action; it is but a sensual indulgence at the 
expense of all vigor and energy in the practical advancement of the indi- 
vidual or of society. What the school of sentiment, as headed by Rous- 
seau, did for France—the extravagances, the follies, and the fanaticisms 
to which it led—is patent enough from French history since the Revolu- 
tion of 1789. By sentimentalism is here meant that exaltation of the 
feelings and sympathies of the mind which is always expending itself 
upon unworthy objects or causes, or in the mere contemplation ot those ADDRESS ON MENTAL HYGIENE. 
213 
that are worthy; which Butler, in his Analogy, has pointed out with 
great psychological penetration, as mere emotional impulse, with no 
practical object, and no outlet for reasonable action, and which is, 
therefore, always enervating and destructive to mental character. 
This tendency is not found simply in the immense indulgence in novel- 
reading in these days; in the graphic and picturesque portrayal of 
crimes"and social vices; in newspaper serials, which flood the country, 
and which are brought before people at every book-stand and in all the 
avenues of travel; in the publication, broadcast, of the minute details ot 
crimes, suicides, and court trials, where sickly sentiment, and social 
vices, and the passions of mankind, become the staple and the sum ; but 
this tendency is also seen in science and in much quasi-religious teach- 
ing, as well as in a multitude of so-called social and humanitarian 
schemes which promise to lift man into a realm of thought and feeling 
where he will necessarily, as by a law of his being, drift to the good. 
This spirit of sentimentalism and restless love of novelty is only a form 
of scepticism, and drifts into sensualism in morals, into useless and 
vague speculations in science, and into transcendentalism and infidelity 
in religion, and in all its tendencies leads to morbid, unhealthful, and 
impracticable mental action. 
Carlyle has said that “the proper task of literature lies in the do- 
main of Belief, within which, poetic fiction, as it is charitably named, 
will have to take a quite new figure, if allowed a settlement there,” and 
that “the exceeding great multitude of novel writers and such like, 
must do one of two things, either retire into nurseries, and work for 
children, minors, and semi-fatuous persons, or sweep their whole novel- 
fabric into the dust cart, and betake them with such faculty as they 
have, to understand and record what is true, ot which there is, and ever 
will be, a whole infinitude unknown to us;” and he adds, “ poetry will 
more and more come to be understood as nothing but higher knowledge, 
and the only genuine Romance for grown persons, Reality.” 
Bulwer, with a sort of prophetic fore-glimpse over the field of these 
developing tendencies, speaks in the chapter already mentioned, of 
u curing a young scholar, at Cambridge, who was meant tor the Church, 
when he suddenly caught a cold fit of free-thinking, with great shiver- 
lugs, from wading out of his depth in Spinosa.” He failed when he 
tried him on the divines, but succeeded by dosing him first with chap- 
ters of faith, in Abraham Tucker’s book; then strong doses of 
Richte; after these the Scotch metaphysicians ; ending up with a plunge 
bath into certain German trancendentalists. He adds, “ having con- 
vinced him that faith is not an unphilosophical state of mind, and that 
he might believe without compromising his understanding, tor he was 
mightily conceited on that score, I threw in ray divines, which he was 
now fit to digest, and his theological constitution since then has become 
so robust that he has eaten up two livings and a deanery.” How “ wading 
out of his depth in Spinosa” is admirable. These youths are now grown 
fluite numerous, and count among them some of the ablest scientists, who 
seem to be carried away by “winds” or by “doctrine” into what St. 
Raul styled, in his dajq “science falsely so-called.” They drift so far 
out as to get into what they call the “ unknowable” and the “ unthink- 
able,” which phrases, if the veil of time was removed, would disclose 
underneath the inscription of the Athenian philosophers on a certain 
altar, noticed by St. Paul, as he entered that learned city eighteen 
hundred years ago. 214 
GRAY, 
If we look through the history of such mental drifting, we cannot but 
recognize it as productive of vast evil. Certainly such speculations have, 
as yet, made no scholar wiser or better, judging by what they have 
imparted to the world on the subjects of Christianity or Revelation. To 
be sure, we are aware that doubt has been even dignified as an essential 
condition of mind for the highest perception of Truth ! Row the mental 
hygiene suggested by Bulwer was as admirable as his diagnosis. He 
did not strand his patient, at the start, by discussion and dialectics, but 
led him by a line of thought, natural to the patient, through the regions 
of apparent contradictions and doubt, according to his powers of mental 
digestion, and finally cultured him to the full truth, and at length made 
a t)ean of him, where he had the widest scope for faith and works, as 
well as a field for mental action in the highest range of human duty. 
A most notable instance of this “ wading out” is the case of a late 
President of the British Association. A brilliant man, withrare powers 
of analysis of physical facts and phenomena, his trained in this 
direction, he launches out on the track of the great spiritual ocean, to 
which he applies his physical tests, and fails. He is followed instantly 
by another brilliant mind in physical science, who takes down his system 
of astronomy to follow" the wake of a new leader. These are conspicu- 
ous cases, and in other times the former might have become the founder 
of a sect; but instead of that, his structure falls to pieces as he contem- 
plates it. Besides, he confesses that he has moods, which is equivalent 
to unsoundness, when moods are confessed in explanation of statements 
and opinions. This is encouraging, for it shows that the great and con- 
stantly increasing body of truth, extended in all directions, is not only 
unmoved by scepticism, but is gradually undermining it by explaining 
the phenomena on which it rests for the title of its existence,and is also 
revealing principles so much mightier and broader than man’s theories 
of Nature and of God, that Scepticism dies in the light of Truth. 
Newton, after reaching far into the arcana of nature, and finding his 
vast knowledge so little of the whole that he compared it to a few peb- 
bles on the shore of the ocean, is the modest but grand symbol of true 
progress. He illustrates the majesty of science, and her respectful homage 
at the feet of the Creator. That science which is “ puffed up,” and which 
stands ready to unveil the sanctuary, and to enter into the holy of holies 
and reveal the Almighty to man by chemistry and telescope, and thus 
find out the secret of his creation and existence, and discover the 
government of the moral world in a series of correlated forces, is not the 
science of religion which can captivate the world of to-day. However 
man may move in a cycle of the same truths and deceptions, in kaleido- 
scopic variation from age to age, God is unchangeable, and has declared 
Himself to be “ past finding out.” 
So principles are eternal, though our methods change. The ideas of 
God in ancient philosophy, which Pythagoras and Socrates, Plato and 
Cicero, sawr dimly through the body of science and truth then developed, 
cannot, at this day, be accepted as religion, though their faith and loyalty 
to an invisible Creative power stand unquestioned, and like a rock in 
the desert of centuries. Though Plato is perhaps the grandest figure 
standing forth in the history of human mind, his theories are but as the 
dawning light to the mid-day sun, in the abstract truths, developed sci- 
ence, and revelation of to-day. Much less can we accept Democritus and 
his followers. When Horace sang of the “ Integer vitce, scelerisque gu- 
rus” he but struck a glimpse of the same truth which belongs to the ADDRESS ON MENTAL HYGIENE. 
215 
province of religious culture, and wliicli had long before been uttered by 
the Royal Psalmist, “ Blessed is the man who hath not walked in the 
counsel of the ungodly, nor stood in the way of sinners, nor sat in the 
seat of the scornful, hut his delight is in the law of the Lord.” The 
psalm of Horace and the psalm of David are alike devout confessions of 
the blessedness of purity, and are tributes to the importance of moral 
culture as an essential to the full development of mind and mental 
balance. 
Indeed, without this moral culture, we may say, it is well nigh im- 
possible to understand even Nature herself. Certainly this is so, as far 
as the ideas of purpose and design are concerned. As Baring Gould has 
well put it, the world is a visible exhibition of the ideas of God, a mighty 
book to be read. But who is to spell out this Created speech and compre- 
hend its significance? Those who are to catch and understand the ideas 
of God, must have a spiritual nature capable of perceiving such_ truths. 
“Therefore, he who is to read Creation, must be neither mere spirit nor 
mere body, but must have a spiritual nature combined with a corporeal 
nature, so that, through the things revealed to the mind by the bodily 
senses, the thoughts of God may be perceived.” Mental hygiene or cul- 
ture, from this standpoint, recognizes the essential nature of man as a 
spiritual being, and points to the necessity of educating his moral nature 
in harmony with his intellectual, to bring forth the full man. 
In this view the verv wastes and solitudes of nature come to have their 
moral and spiritual uses. In a burst of enthusiasm, Baring Gould ex- 
claims ; “ The time of Alpine snow has come; age after age has seen it 
powdered on the mountain peaks, slide down the flanks in ice, and flow 
away in rivers to the sea, unesteemed save for the water it yielded. But 
its time has come, its value is known. There is no medicine to a weary 
brain, like the golden light on a distant bank of Alpine snow. . . . 
I remember a mountain scramble, leading me suddenly, from rough rocks 
and sear grass, upon a dell of rich greensward girt about with pines. 
Set in the turf was here and there a fallen star—a yellow anemone ■, on 
the rocks the carmine Alpine rhododendron was in full blaze of blossom, 
and over all the sward was a tender bloom of forget-me-not. Over head 
burnt a glacier in the summer sun, and a thread of silver fell in powder 
from it, waving in the soft air. lam not ashamed to tell you that that 
vision filled my heart to overflowing. God spake through that 
through every flower, out of the mountain, out of the ice. Ihe voice of 
God, walking in that garden, was as audible as of old in Paradise, when 
Adam heard it in the cool of the day.” 
No reflecting man can fail to see that the attention given to education, 
all over the world, is a most significant fact in the history of this period. 
That education, in some degree, shall be universal, seems to be a common 
sentiment. That this is essential to the progress of civilization, needs 
only to be stated. The great questions that arise are, what shall educa- 
tion be, and what shall it include? Shall it include religious instruction 
in all fundamental training? is the real problem, however the question 
may be stated. And reaching higher in the scale, the same great ques- 
tion intrudes itself only in a different form. The scientific theory of 
culture, set forth by the school of which Professors Huxley and Tyndall 
are exponents, as Principal Shairp has so well pointed out, gives little 
account of and makes no provision for the moral elements of human 
nature, and this would seem to be its deej3 defect. As he truly says, 
“ the knowledge of the highest things, those which most deeply concern 216 
GRAY, 
us, is not attained by mere intellect, but by the harmonious action of 
understanding, imagination, feeling, conscience, will—that is, of the 
whole man—reason in its highest exercise, intelligence raised to its 
highest power.” .And this tor the single reason that no science can call 
our whole nature into play at once. This can only be done by religion, 
which alone calls upon the whole of man. When Prof. Huxley presents 
life as a game of chess, with an invisible player, he endeavors to save 
the idea that a man must respect the rights o± others; but there is no 
more room for such an idea in his scheme than there is in a shipwreck, 
or in Darwin’s doctrine of the survival of the fittest. It is not a natural 
impulse of man to respect the rights of others, or “ to love one’s neighbor 
as one’s self;” as Principal Shairp has well said, it requires the whole 
weight of Christian motive to do either. 
111, When we come to examine mental hygiene from a national point of 
view, we see that it comprises all that gives intelligence, character, dignity, 
progress, and stability to national life. In this greater field the lesser are 
included. That hygiene which tends to elevate a people, both mentally 
and physically, by a true and rational culture, is in fact mental, moral, 
and physical training, resting on definite principles, and these so accepted 
as to become the prevailing and growing habit of the people; or, in 
other words, culture extending itself into national habits, thoughts, and 
pursuits. Whatever theories we may adopt as to the equality of man, 
the best practical result of national training must be to give to each class 
of minds that bias which will serve to develop useful individual tenden- 
cies, and at the same time, in the main, correspond with its social status. 
For whatever general education or fundamental culture we may rest upon 
as a prescribed system for general application, the professional man, the 
merchant and business man, the mechanic, the farmer, the clerk, and 
the laboring man, need different training to fit them for practical life. 
The question of mental hygiene is therefore not simply how we may best 
train men so as to cultivate mental health and physical vigor, but also 
how we are to bring about the use and application of all the principles 
and agencies which are best adapted to develop, expand, and maintain 
in balance the mental and spiritual life of individuals, communities, and 
nations, so as to insure progress in civilization, a healthy state of general 
and domestic morals, and, at the same time, the advancement of culture, 
arts, and industries. 
It is only within a comparatively short period, that the study of 
general and mental hygiene has been demanded, under the progress of 
science. This study has been stimulated by the developing necessities of 
civilization, the greater attention to sociology, and the progressive ideas 
of personal liberty and responsibility. All the ancient civilizations were 
but little concerned in the welfare of the individual, as a unit going to 
make up national life. Knowledge and the exercise of governmental 
functions were confined to the few. The great masses were only so much 
brute force, or mere physical elements, in the hands of rulers and leaders, 
to carry out their own ends; and to all this the masses gave almost 
absolute assent. The lives of the people were held cheap by the rulers, 
as well as by the people themselves. Even the great revolutions, from 
time to time, were not movements of the people, but were simply brought 
about by kindred though antagonistic governing families, and the people 
were used in their respective interests, being aroused under the temporary 
stimulation of the passions of the hour. They had no appreciation of 
the ultimate tendencies of public movements, and no hope or desire ADDRESS ON MENTAL HYGIENE. 
217 
for personal elevation or advancement. In such a state of national life, 
mental culture could have no wide significance, and no place except 
among the learned, as a mere subject of contemplation. Therefore 
tor manv ages we have little on the subject ot mental hygiene, in any 
direction, beyond the philosophic declarations and fables of learned men. 
The priestly orders, indeed, in ancient times combined and exercised 
largely the professions of minister, teacher, and physician, and were 
the" trusted advisers of kings. The Mosaic law laid down the rules of 
hygiene, as it did those of morals, intermarriage, and worship, in a single 
code. 
The aphorisms of Hippocrates embrace about all that is valuable in 
medical literature of the pre-Christian centuries. The Code of Health 
of the School of Salernum, for hundreds of years a medical classic, con- 
tains the recorded knowledge on the subject of health down to the six- 
teenth century. A recent translator, Prof. John Ordronaux, says ot it, 
“it was for ages the Medical Bible of all Western Europe, and held un- 
disputed sway over the teachings of its schools, next to the writings of 
Hippocrates and Galen.” It contains a great many precepts and dietetic 
I'ules, but deals little with mental hygiene; and this is the sum:— 
“Salerno’s School, in conclave high, unites 
To counsel England’s King, and thus indites: 
If thou to health and vigor wouldst attain, 
Shun weighty cares—all anger deem profane, 
From heavy suppers and much wine abstain. 
Nor trivial count it, after pompous fare, 
To rise from table and to take the air. 
Shun idle, noon-day slumber, nor delay 
The urgent calls of Nature to obey. 
These rules, if thou wilt follow to the end, 
Thy life to greater length thou mayest extend. 
Shouldst Doctors need ? be this in Doctors’ stead—• 
Rest, cheerfulness, and table thinly-spread.” 
The author closes with a valedictory which would indicate that he 
Hit be had accomplished a great work;— 
“The Flower of Physic endeth here its strain; 
The Author, happy o’er his garnered grain, 
Prays that in Heaven there be prepared for him 
A seat near Christ, and His blest Seraphim. 
Arnen!” 
We must not forget, however, the great services rendered, during the 
dark ages, to Science and Literature by the Monks and Peligieux while 
buried in their cloisters, as well as their work in preserving the treas- 
ures of learning from the all-surrounding devastation. It is admitted 
by all historians that, in days of violence and anarchy, the Church was a 
defence and refuge of the poor and the oppressed, as well as of the learned, 
Against the hand of tyranny and rapacity. To the Benedictine orders, at 
least in their constant and systematic attention to the cultivation of the 
s°il, and the implements and improvements of agriculture, we owe a 
great lesson of that primitive truth, that in the sweat of man’s face shall 
be eat bread. It may even be said that the motto of this order, laborare 
esi orare, has become the watchword of modern civilization, for in no 
period of the world has labor been so dignified as in these times, and the 
Machinery of labor so multiplied for the uses of man. 218 
GEAY, 
' Mental hygiene, from a national point of view, would also cultivate in 
the people aAiarmonious and universal aim towards elevated and yet 
practical ideas. A national sentiment, fostered and dignified by govern- 
ment, in favor of education, mechanics, agriculture, arts, becomes a most 
powerful mental stimulant to individual effort, and seems to give breadth, 
tone, and visor to national mind and character. Ho people, perhaps, ever 
gave more earnest and practical attention to educational power and the 
value of morality, as elements in government, than the Puritan stock ot 
New England. From the first, the church and the school-house rose 
side by side, and whatever economy and frugality they exercised in 
affairs and they were marvels in these virtues, they never stinted the 
head and the heart. They had lofty ideals, and they practised stern 
virtues, and when national oppression came they had stout hearts, 
willing hands, and clear heads, to offer in the struggle for liberty and 
the founding of a nation. The sentiments ot Union and Liberty, eaily 
and deeply "rooted in the mental soil of the early inhabitants ot the 
American Republic, have propagated their influences and spread their 
roots and fibres through the blood-soil of children’s children, and we see 
the result in millions of active intelligent minds, carrying forward with 
united and persistent purpose the vast interests of this great nation, and 
subduing this mighty continent, in its multiplied physical resources, to 
the utilities of mankind, as though governed by a single national 1111- 
** The founders of the Republic, in every part of the land, seemed to 
have been thoroughly permeated with the spirit of personal and public 
duty. With them, Liberty meant Law and obedience to ot 
Justice—an obedience, as beautifully expressed by Ruskin, “ chastise- 
ment of the passions, discipline of the intellect, subjection of the will, 
fear of inflicting and shame of committing a wrong ; respect for all who 
are in authority, consideration for all who are in dependence; venera- 
tion for the good, mercy to the evil, sympathy with the weak; watch- 
fulness over all thoughts, temperance in all pleasures, and perseveiance 
in all toils.” , . , 
Had our ancestors cultivated the softer graces, and given themselves 
up to games, sports, and ease of life, and the government contented itse 
with hereditary dignities, leaving the mass of the people in ignorance 
and to think and act only in the narrow sphere of providing daily bread 
by daily toil, how different would have been the mental status of this 
nation to-day I If, on the other hand, the inhabitants of this country 
should ever become so demoralized and degraded as to find their con- 
tentment, like the people in the latter ages of Rome, in material com- 
forts alone—panem et circenses—mere bread and amusements-—then, too, 
like the later Romans, they would soon become the prey of family feuds 
and contending factions, ending in the despotism of a swift succession of 
flagitious rulers, till the whole political system would sink into final 
disintegration and ruin. , . , 
This Centennial, a part of the movement of which this international 
Medical Congress represents, is a great national thought, and almost 
powerful influence in stimulating national mind, as well as individual, 
in the direction of healthful mental activity. Indeed, it is_ itself a vast 
and far-reaching means of culture, which touches a responsive chord in 
nationalties of the most diverse social and political character, but never- 
theless in harmony in the one direction of progress. To impress men by 
such magnificent displays of wealth, mechanism, and art; to show them ADDRESS ON MENTAL HYGIENE. 
219 
that life is more than meat and drink; that a nation is great and power- 
ful in proportion as its citizens are cultured to refinement, utility, mo- 
lality, and personal responsibility ; that these constitute the foundation 
stones of national greatness and prosperity, is in itself a great national 
hygienic measure. As the accumulation of patrimonial treasures, learn- 
ing, and office, give dignity to families, and stimulate to higher culture, 
so the accumulation of treasures of all kinds, and the recognition and 
cultivation of art and learning by nations, tend to dignify national repu- 
tation, and to stimulate citizens of all classes to higher efforts and more 
patriotic lives. 
Thus a nation secures mental and moral growth and breadth of enter- 
prise. No one can look at the wonderful Exposition, now held in this 
city, without realizing this fact. The world seems, indeed, to be here 
assembled. The Egyptian, the oldest civilization, stands before us to- 
day as it stood in the days of the Pharaohs. The march of progress and 
the attrition of nations may have modified her national life in some out- 
ward things, but the central ideas remain the same; her escutcheon is 
unchanged, and she sends to this Centennial, as an essential treasure, the 
head of Raineses, thus typifying her original and perpetual dignity, 
unbroken through the long tide and flow of centuries. And so down 
through the roll-call of nations, to our own, each has its own grand 
representative idea. At the end of a hundred years wm stand at the 
statue of Washington, and relate his virtues, as embodying the central 
ideas out of which grew, and on which rests, the deep, broad, and sure 
foundation of this Republic. Egypt may come to us ; she may take our 
ploughs and reapers, our engines and printing presses: but she will only 
unthrone Washington when she accepts our ideas. 
The true greatness and dignity of any nation will always be measured 
by the standard of its mental and moral culture, not simply by the in- 
tellectual standard it presents in its military power, its science and arts, 
and its dynamic forces, but also by its will and capacity for morally ele- 
vating its citizens, without clash of caste ; maintaining universal freedom, 
with all men equal before the law. The present Emperor of Russia, real- 
izing such a sentiment as essential to the dignity, prosperity, and perma- 
nence of the government, transformed, in a day, millions of serfs into free- 
nien, the grandest ukase in the history of time. This is the substance 
°f Magna Charta, the glory of England. This was the ostensible aim of 
Caesar. His memory is quite as much dependent on his philosophic 
culture, and his assimilation to the people, as on his conquests. He shed 
lustre on Rome, and on mankind, by his amazing combination of sim- 
plicity, learning and statesmanship, with the greatest capabilities of a 
soldier, all of which he illustrated in the midst of a galaxy of the most 
magnificent minds in the annals of the world. His name fitly repre- 
sents the power of mental culture in the direction of definite ideas, in a 
ruler looking to the elevation of a people as the true source of national 
power. 
Rome lost in prestige when she accustomed her people to ideas of 
conquest and personal ease, above moral culture, in its wide meaning. 
Indeed, no nation has ever maintained permanent elevation and power, 
which has encouraged or permitted public opinion to act outside of the 
pre-ordained boundaries of religious truth. The belief in a God must 
be the corner-stone on which a nation rests. Both Greece and Rome 
flourished in power, arts, and arms, so long as they clung to a belief 
111 a supreme Providence, above Nature. But when the speculative 220 
GRAY, 
philosophy of Epicurus and Lucretius, with its absorbing sensualism, 
usurped the ancient worship, they perished beneath the blight of a 
cold scepticism. The glory of Egypt was clouded with Cleopatia, who 
represented deified sensuality on tiie throne ot a Nation. Ihe gieat 
Assyrian Empire, in like manner, fell under Sardanapalus, the gilded 
monarch of Asiatic licentiousness. France well nigh perished when 
she installed the Goddess ot Reason in the seat ot Worship, and hei Cliiet 
Assembly voted Death to be an Eternal Sleep. _ . 
Under the cultivation of the ideas, and the practice of the principles, 
to which I have referred, by the founders of this Republic, we have the 
national fruit, not only in a great and well-established nation, but con- 
spicuously in the wonderful development of the resources of high civili- 
zation all over this continent. It is a truth, well worthy to bear in mind 
always, that education, with them, embraced ideas of religious freedom, 
which were cultivated together, no matter what the calling in life. And 
it is not too much to say that in the rigid spirit of utility and the high 
sense of responsibility of the early fathers, we have the seed fiom wluc i 
has germinated, over this broad land, the personal independence of char- 
acter, the inventive genius, the subjection to law, and matchless 
energy, which have made us equal in power to the older nations ot the 
world, which have also given us an individual national character- 
stamped us as Americans—notwithstanding that we represent all the 
nationalities of Europe ; which have developed a national mental hygiene 
which reduces and conforms the cosmopolitan ideas of the vast and 
constant drift to our shores, to the national standard, which prevents any - 
thing antagonistic to the fundamental principles of the government from 
taking root, and which assimilates-and harmonizes all the seeming anta- 
gonisms to the genius and spirit of the constitution, the moment they 
are subjected to its dominating idea, “ government of the people, by the 
people, for the people.” . 1 
I might properly allude to the great influence exerted on the national 
mind by such men as Franklin, Rush, "William Penn, Robeit Monis, 
Richard Henry Lee, John Jay, the Adamses, Hamilton, Jefferson, 
Madison, and others, if there were time; but such influence, however 
special and potent, was, after all, only the projection and happy presen- 
tation of principles which, when thoroughly impressed, acted on the 
mind of the people in moulding national thought. The work of these 
men was done through the reason and judgment, and not by popular 
display and glamour,"and it was abiding. _ Economics and population, 
education, statesmanship, finance, constitutional law, Political Economy 
in all its wide bearings, received from them the most earnest and pro- 
found discussion. However great their attention to religion, they did 
not confound it with state morals ; but, on the one hand, they main- 
tained Christianity and the highest responsibility to God, and, on the 
other, they sought to work out, under laws, the mutual rights and 
relations of men under their new social and political conditions of 
government. T . 
Their lives were illustrations of the principles they advocated; W illiara 
Penn exercised a wide and mighty influence in securing not only the 
mutual co-operation of savages, but also of classes of men bied in othei 
traditions and in bringing all to the formation of national habits and 
character.’ Yet he represented no victor with temporary plaudits, no 
sensational or dramatic phase of social life or regeneration. His power 
illustrates what education, aided by elevation of character and equi- ADDRESS OK MENTAL HYGIENE. 
221 
librium of the intellectual life and passions, may do in a man who is 
controlled by truth and directed by spiritual light. Wilberforce, in 
England, illustrated the same great influence on national mind. He 
showed how a strong mind, panoplied in its convictions of universal 
justice, might gradually undermine historic precedents, against all the 
forces of conservatism arrayed in opposition, as well as against the 
apparent interests of the nation. Slavery was then a part of the national 
wealth, but it died through the influence of this one peaceful mind, 
breathing condemnation upon it, and this in the very presence of those 
whose material relations to it were of the closest character. Thus a 
whole nation was transformed b}r a mental revolution, wrought solely in 
the name of universal philanthropy, justice, freedom, and religion. 
Such are some of the higher triumphs of national culture, when it 
embraces the moral and spiritual elements of Christianity, Though 
this age may be characterized as one of liberal tendencies ot thought, in 
fill directions, it has been permeated by the principles of Christianity, 
and to-day there is more respect for religious truth, and a firmer beliet 
in the necessity, for both man and nations, of faith in a God, than when 
the century commenced. When, in the recent French Revolution, the 
Archbishop of Paris, Monsiegneur Darboy, was struck down by the Com- 
mune, the nation turned from the act with horror. Yet the Bishop was 
only a man, and one among the hundreds of noble men who thus perished. 
But he represented Religion, and millions of people, alike Protestant 
and Catholic, condemned the deed as one of infamy, and as a diabolical 
defiance of the very instincts of humanity, as well as of the traditional 
sentiment of Christendom. 
The lesson of mental hygiene, for nations, which we learn from all 
example, is, not that education and wealth, nor the refining influences 
of aesthetic art, will suffice for the highest development of national mind, 
but that, if underneath and through all these are not interwoven the 
great truths of moral responsibility to the author and upholder of all 
governments, lifting man above the dominion of the baser passions, the 
Ration dies as an individual dies ; for “ unless the Lord build the house, 
they labor in vain who build it.” 
In the Convention at Philadelphia, in 1787,f0r forming a constitution 
for the United States, after some weeks had passed in fruitless debate, a pro- 
position having been made for daily prayers, Dr. Franklin rose and said 
In the beginning of the contest with Britain, when we were sensible ot 
danger, we had daily prayers in this room for Divine protection. Our 
prayers were heard and graciously answered. All of us who were en- 
gaged in the struggle must have observed frequent instances of a super- 
intending Providence in our favor. To that kind Providence we owe 
Ibis happy opportunity of consulting in peace on the means of establish- 
ing our future national felicity. And have we forgotten this powerful 
friend ; or do we no longer need His assistance ? I have lived a long 
time, and the longer I live the more convincing proof I see of this truth, 
that God governs in the affairs of men. And if a sparrow cannot fall to 
the ground without His notice, is it probable that an empire can rise 
without His aid ? We have been assured in the sacred writings that, 
except the Lord build the house, they labor in vain that build it. I 
firmly believe this, and I also believe that without His concurring aid 
We shall succeed no better, in this political building, than did the builders 
°t Babel.”1 The motion was carried. 
1 Debates on the Constitution. 222 
GRAY, ADDRESS ON MENTAL HYGIENE. 
This illustrates the sentiment and temper of those who founded this 
nation, and may we not sa}7, standing where we do, that the influence of 
this illustrious example has had some share in determining the tone and 
the practice, in that respect, of this renowned University from its founda- 
tion, whose successive Provosts have been eminent examples of the 
essential harmony between the different qualities of Faith and Science? 
These latter thoughts have come into my mind since entering this hall, 
while looking round upon the long line of Reverend Provosts speaking 
out from the canvas, and then reading over the door of entrance the 
grand inscription, “In Honorem Dei.” An institution, like a State, 
which writes over its portals, “in honor of God,” cannot fail of success 
and power, before the people, as more than a century has here demon- 
strated. And this is my Alma Mater. 
For individuals and communities, the quaint lines of George Herbert, 
with which I close this Address, are a suggestive and pregnant sum- 
mary : 
Slight those who say amidst their sickly healths, 
Thou livest by rule. What doth not so but man ? 
Houses are built by rule, and Commonwealths. 
Entice the trusty sun, if that you can, 
From his ecliptic line ; beckon the sky. 
Who lives by rule then, keeps good company. 
Who keeps no guard upon himself, is slack, 
And rots to nothing at the next great thaw. 
Man is a shop of rules, a well-trussed pack, 
Whose every parcel underwrites a law. 
Lose not thyself, nor give thy humors way ; 
God gave them to thee under lock and key. 223 
ADDRESS ON AMERICAN MEDICAL LITERATURE. 
LUNSFORD PITTS YANDELL, M.D., 
OF LOUISVILLE, KENTUCKY. 
I have attempted in this Address to give some account of the books 
Which have been written by the physicians of the new world, since the 
settlement of America by white men. The history embraces a period of 
nearly two hundred years, and includes the names of as many authors, 
and the titles of more than as many publications. Restricted as I am, 
both in space and time, my notices are necessarily brief. As to most of 
them, they are nothing more, indeed, than a catalogue of names and 
titles. But it occurred to me that I could not in any other way so well 
meet the wants of the profession in an address like,this, as by presenting 
a full list of our medical works in the order in which they have appeared, 
so that we may see, and that those who shall come after us may learn, 
what the medical men of America have done in the first century of our 
national existence. My references are confined almost exclusively to 
books, but occasionally I have noticed pamphlets and articles in Transac- 
tions of Societies, which appeared to me to possess unusual value. To do 
justice to the medical literature of America, would require something 
more than a single discourse. All that is proposed in this, is to give an 
outline of the subject ; and, with all the pains I have taken to make my 
Lst complete, I can hardly hope that it will not he found chargeable with 
many omissions. 
The Literature of Medicine had acquired but little extension, and was 
still expanding slowly in Great Britain, when the first emigrants for 
America left her shores. Harvey was just then announcing his grand 
discovery of the circulation of the blood. Sydenham had not been born, 
aud it was half a century afterward that his works, conceived in the true 
spirit of the Baconian philosophy, and the standing glory of English 
medical literature, made their appearance to put a new countenance upon 
fbe Science of Medicine. Mead and Cheselden were born more than half 
a century afterward. The writings of the Hunters, and of Cullen, 
appeared only as the Colonies were ready to set up in the world for them- 
selves; and the discoveries in chemistry which imparted to it the 
character of a science, were made by Black and Priestley on the eve of 
°ur great political revolution. 
It is not surprising, then, that hardly anything was accomplished in 
the way of authorship by the physicians of the Colonies during the first 
century of their settlement. For fifty years nothing at all was published 
by them, of which we have any record. The first essay came out in 1677, 
bearing the title “A Brief Guide in the Smallpox and Measles.” It was 
published in the province of Massachusetts, thirty years before the first 
Newspaper was issued in America, and more than forty years before one 
was established in Philadelphia. Its author, Dr. Thomas Tha'cher, as 224 
YANDELL, 
was not uncommon in the new settlements at that day, united in his 
person the two professions of divine and practitioner of medicine. He 
was the first minister of the Old South Church, in Boston, and was 
accounted “a great divine” as well as “a learned physician,” who, 
preaching and practising “ to general approbation” as long as he lived, 
had his name worthily perpetuated in the Magnolia of the famous Cotton 
Mather. His unpretending essay, composed especially for the instruction 
of the people, seems to have remained more than half a century without 
a successor. It was not until 1720 that the next tract relating to medi- 
cine appeared. Dr. Cadwallader Colden, in that year, published an account 
of the climate and diseases of Hew York, founded on his own observa- 
tions and experience; and from that time medical publications followed 
in quicker succession. 
Three essays respecting inoculation for smallpox were published within 
a few years of each other, by three Boston physicians. Dr. Hathaniel 
Williams, one of the three, was, like Thacher, both physician and 
preacher; another was Dr. Benjamin Column; and the third was the 
celebrated Zabdiel Boylston, who was the first physician to make trial 
of the hazardous practice in the new world, and who narrowly escaped 
falling a martyr to it. Pharmacy and the Medical Botany of the new 
territory, attracted the attention of its physicians at an early day; and 
treatises on the preparation of drugs, the polygala senega, and the great 
water dock, were written by Dr, Howard, Dr. Tennent, and Dr, Coldhn. 
Dr, John Clayton, of Virginia, produced, in 1748, a Flora Virginica, so 
highly.esteemed that an edition of his work wTas issued some years after- 
ward in Leyden. An essay on fevers was written by Dr. Walton in 1732; 
one on scarlatina, by Dr, Douglas in 1786; one on the iliac passion, by 
Dr. Cadwalader in 1740; and one on yellow fever, and a second on the 
causes of the variety of Colors in people of different climates, by Dr. John 
Mitchell in 1743. Dr. Lining also wrrote an account of yellow 7 fever, in 
which he started the idea, never before advanced, that persons who have 
suffered with the fever are not subject to a second attack. 
Douglas, in his paper, w7as the first to recommend calomel in scarlet 
fever. Cadwalader had the good sense to condemn the use of quicksilver 
and drastic purgatives in lead colic, which he described as the “ iliac 
passion,” and advised opiates as preparatory remedies in that affection. 
The letters of Mitchell on yellow fever are of peculiar interest, as having 
led to the heroic practice in the disease for which Dr. Rush was noted 
at a subsequent day. Dr. Chalmers, of South Carolina, published a paper 
on tetanus in 1754. Dr, Bond, of Philadelphia, published, in 1759, an 
essay on the use of bark in scrofula; and in 1760 Dr, John Bard, of Hew 
York, made public the facts in a case of extra-uterine foetation which 
had come under his notice. Dr. Bard, the same year, also published a 
valuable essay on the nature and causes of “Malignant Pleurisy,” as it 
prevailed on Long Island in the winter of 1749, a disease since recognized 
in the epidemics of typhoid pneumonia which have more than once swept 
over our continent. In 1769 some letters on malignant sore throat were 
published by Dr, Ogden, of Hew7 York; and Dr. Kearsly, of the same 
place, sent the same year a paper to the Gentleman’s Magazine, at Lon- 
don, on angina maligna. The thesis of Dr. John Moultrie, of Charleston, 
the first graduate in medicine from South Carolina at Edinburgh, w7as 
printed in 1749. It described yellow 7 fever as he had seen it in his native 
city. The theses of Morgan, Shipper!, Kuhn, Rush, Bard, Kissam, and 
other American students, w7ere printed at Edinburgh from 1749 to 1776. ADDRESS ON MEDICAL LITERATURE. 
225 
Some of these essays, treating of the diseases incident to the new 
world, deserve to be rescued from the oblivion that has overtaken them, 
and if collected would form a volume acceptable to the profession. But 
it is to be remarked that they were all issued in a fugitive form ; many 
of them treated of subjects the interest of which has long since passed 
away ; most of them were brief papers, such as would now make arti- 
cles in our medical journals, and nearly all are now wholly inaccessible. 
At most, they can be regarded as nothing more than an introduction to 
the medical literature which in the course of the century succeeding 
them has become so voluminous. 
The medical literature of America may with truth be said to have 
commenced with the century whose years we have just numbered. Just 
as it was about to open, Dr. John Jones, ot Yew York, foreseeing the 
need of surgical knowledge likely soon to arise, prepared, in the autumn 
of 1775, and in anticipation of t]re impending struggle, a little volume 
on wounds and fractures. It is the first, in time, ot American works on 
surgery. Its claims to merit were small, if regarded as an original work, 
since it was little more than a compilation; but the compiler was a sur- 
geon familiar with the art about which he was writing, and his volume 
proved highly serviceable to our inexperienced and young surgeons during 
the war. In 1776, an able work was published in two volumes, on the 
Climate and Diseases of South Carolina, by Dr. Lionel Chalmers, of 
Charleston. 
But ten years before this time, an event occurred which marks an epoch 
in the medical history of the country. I refer to the creation ot a pub- 
lic school of medicine. This, more than any other movement recorded 
in our history, has shaped our medical literature and contributed to its 
growth and development. The school was inaugurated under circum- 
stances that invest it with uncommon interest. The address delivered 
on the occasion was published, and is extant in our libraries. Among 
the Trustees of the College, who weighed the arguments urged tor the 
erection in it of a Medical Department, was Benjamin Franklin, President 
of the Board. Dr. John Morgan and Dr. William Shippen, its founders 
and earliest professors, were medical scholars such as might rightfully 
aspire to ]&y the foundations of medical education in a new empire. They 
had prepared themselves for teaching by long and laborious study. An 
Imposing assemblage of the citizens of Philadelphia was present to 
witness the commencement in their college, and to hear Dr. Morgan s 
address on the institution of medical schools in America. 
“ It is now,” he said, “ more than fifteen years since I began the study 
°f medicine, and I have arrived at the middle age of life endeavoring, 
to lay up treasures of knowledge.” And he continued, in words that 
proved prophetic, “ Perhaps this medical institution, the first of its kind 
in America, though small in its beginning, may receive constant increase 
°f strength, and annually exert new vigor. It may collect a number of 
young persons of more than ordinary abilities, and so improve their 
knowledge as to spread its reputation to distant parts. By sending 
those abroad duly qualified, it may give birth to other institutions of a 
similar nature calculated to spread the light of knowledge through the 
whole American continent wherever inhabited.” • 
In the great concourse of “ respectable citizens” gathered to hear this 
discourse, was a young student of medicine who was destined to become 
not only the great luminary of the school, but the foremost of American 
medical teachers and writers. Benjamin Bush bad been for three years 
15 226 
YAN DELL, 
a student under Dr. John Redman, in Philadelphia, translating Hippo- 
crates, and making memoranda on yellow fever and other current epi- 
demics of the time. Three years later he was admitted to the degree of 
Doctor of Medicine in the University of Edinburgh, having defended a 
thesis De Cone action e Ciborum in Ventriculo. Returning home he was 
elected, in August, 1769, when under twenty-four years of age, Professor 
of Chemistry in the Philadelphia Medical College, now the University 
of Pennsylvania. 
With Rush, to teach was to write. The motto on which he was in the 
habit of insisting most strongly to his pupils was, leg ere sine calamo est 
somnere; and he studied his profession with pen in hand, recording ob- 
servations which are still of value to writers on yellow fever. The year 
after his election he appeared before the public as author of what he 
styled “ Sermons” to young men on temperance and health. Three years 
later he was invited to deliver the annual oration before the American 
Philosophical Society, of which Franklin and Jefferson were members. 
He chose as his subject “ The Natural History of Medicine among the 
Indians of North America, and a comparative view of their diseases and 
remedies with those of Civilized Nations.” This oration makes the first 
paper in his “Inquiries,” the first volume of which was issued in 1788. 
No one can read it without a feeling of profound respect for the talents 
and scholarship of its author. It is philosophical in tone, rich in original 
observations, and written in a simple, graceful style. The volume to 
which it forms the introduction raised its author at once to a position 
among the leading medical writers of the time. Of the other papers in 
the volume, one is devoted to pulmonary consumption, and it is interest- 
ing to remark that in his-treatment of that disease Dr. Rush anticipates 
the therapeutics of the present day. He gives a graphic description of 
“breakbone fever,” in which he was the first to note the unwonted de- 
pression of spirits which attends the disorder. For scarlet fever, on 
which he has a chapter, he thought that he had found a specific in calo- 
mel, which he believed to be as sure a remedy for croup, also, as bark is 
for intermittent fever. 
A second volume of “Inquiries” followed on the 4th of July, 1793. 
Another oration before the American Philosophical Society forms the 
first paper in this volume. Its subject is “The Influence of Physical 
Causes on the Moral Faculties.” The titles of his orations indicate the 
decided turn of his mind to philosophical disquisitions ; the matter com- 
posing them proves how closely and widely he had observed, and how 
profoundly he had reflected on, the subjects of discussion. A second 
paper of great interest in this volume is an inquiry into the causes of 
the increase of bilious and intermittent fevers in Pennsylvania. A 
third relates to pulmonary consumption, to which he returns in his 
second volume to insist, with greater emphasis, on the utility of iron, 
cold baths, and horseback exercise, in the early stage of the disease. 
Another chapter is given to an inquiry into the state of the body and 
mind in old age, with observations on its diseases and their remedies. 
It is, perhaps, the best in the volume. It is a charming article, and will 
compare most favorably with any essay on the subject to be found in 
arty literature. 
Dr. Rush’s third volume was issued in 1794, and is taken up with a 
history of the yellow fever, which ravaged Philadelphia the year before. 
It will be read, it is safe to say, while yellow fever continues to scourge 
the human race. No more graphic account of a pestilence was ever ADDRESS ON MEDICAL LITERATURE. 
227 
written by a medical man. It possesses all the charm of a personal nar- 
rative. The author reveals the state of his feelings under the varying 
aspects of the epidemic. “ Heaven alone,” he says, “ bore witness to the 
anguish of my soul in this awful situation,” baffled in every attempt to 
stop the ravages of the disease. And when, after reading the manuscript 
account of the fever by Dr. Mitchell, he became successful, he says; 
‘'Never before did I experience such sublime joy as I now felt in con- 
templating the success of my remedies. It repaid me for the toils and 
studies of my life. The conquest of this formidable disease was not the 
effect of accident, nor of the application of a single remedy ; but it was 
the triumph of a principle in medicine. The reader will not wonder at 
this joyful state of my mind when I add a short extract from my note- 
book, dated the 10th of September; ‘Thank God, out of a hundred 
patients whom I have visited or prescribed for this day, I have lost 
none.’ ” 
The principle by which Dr. Rush was conducted to these happy re- 
sults, was that the debility attending this malignant fever is apparent 
merely—an indirect debility—in which the abstraction of blood and 
evacuation by purgatives tend to raise the pulse and increase the 
strength of the patient. His practice consequently was to bleed again 
and again, and give calomel and jalap in active doses, reducing heat by 
cold water. Finding the dose of ten grains of each drug too slow in its 
operation, he increased the quantity of jalap to fifteen grains. But the 
pleasure derived from his great triumph was attended by a serious draw- 
back; his practice was denounced in unmeasured and bitter terms by 
many of his professional brethren. The effect of this was to excite such 
a prejudice in the public mind against his mode of treatment that he 
found it difficult to carry it out. Two of his colleagues, Kuhn and Wis- 
far, united in its condemnation. Currie, a practitioner and writer of 
note and influence, declared in the public prints of Philadelphia that it 
“ could not fail of being certain death.” The report was started by 
some enemy that Dr. Rush was insane, and he relates that one of his 
fqrrner patients, a lady, “ who had believed the report, expressed her 
surprise at perceiving no deviation from his ordinary manner in a sick 
room.” It was even proposed by some of his excited fellow citizens to 
“ drum him out of the city.” 
The terms in which Dr. Rush referred to the conduct of his enemies, 
Under these trying circumstances, are worthy to be reproduced in this 
narrative, as illustrating the magnanimity of his nature. He says: “ I 
ullude to these slanders now only for the sake of declaring, in this public 
manner, that I most heartily forgive them ; and that if I discovered at 
any time an undue sense of their unkindness and cruelty, it was not 
because I felt myself injured by them, but because I was sure they would 
U’reparably injure my fellow citizens, by lessening their confidence in 
the only remedies that I believed to be effectual in the reigning epi- 
demic. I commit the calumnies which have followed my opinions and 
practices in this fever to the dust.” 
The fourth and last volume of the “ Inquiries” was issued in 1796; 
and in this the author took occasion to announce that he was engaged 
m preparing a work on Diseases of the Mind. This volume opens with 
an account of another epidemic of yellow fever, by which Philadelphia 
was visited in 1794. Dr. Rush contends earnestly tor the doctrine, so 
unpalatable to the citizens, that the fever was of local origin, and de- 
pended upon accumulations of filth which it was in their power to 228 
YAYDELL, 
remove, even going so far as to say that he believed the time would 
come when municipal authorities would be held responsible for the 
spread of all such fevers. “ Seasons and climates,” he continues, “ are 
not necessarily sickly. The sun would seldom strike by day, nor the 
moon by night, were pains taken to prevent the accumulation and putre- 
faction of those matters which occasion malignant fevers.” He believed, 
when first asserting this opinion, that it was new, but, discovering his 
error, he was careful to state that it had been advanced by Hr. Thomas 
Bond, as early as 1766, in a clinical lecture at the Pennsylvania Hospital. 
At one time Hr. Rush regarded the fever as contagious, but he candidly 
admits that he was convinced by the arguments of his pupil, Hr. Charles 
Caldwell, that “the pestilence is devoid of any such power.” 
One of the papers in this volume is an inquiry into “the proximate 
cause of fever,” which he found in spasm of the extreme bloodvessels; 
but the leading paper is a defence of bloodletting, which brings out all 
his power and eloquence as an advocate. It is written with the earnest- 
ness and spirit of one who felt himself engaged in establishing a great 
truth ; who believed that he was contending for a principle that involved 
the interests of his race. While candid in its statements, his defence is 
heroic in spirit, and its influence in popularizing the use of the lancet 
was felt in every part of our country. The practice is now spoken of as 
“ atrocious.” There can be no doubt that bloodletting was carried to 
excess by Rush and his followers, but it admits of a doubt whether the 
practitioners of the present day have not run to the other extreme. 
In this volume, and in connection with bloodletting, Hr. Rush repeats 
a belief which he had before expressed, that the pains of labor would be 
annulled by the discovery of an anaesthetic. This was no mere guess, but 
an opinion reached by a process of induction. “ I was encouraged to 
cherish this hope,” he says, “ by having known delivery to take place in 
one instance during a paroxysm of epilepsy ; and having heard of another 
during a fit of drunkenness in a woman attended by Hr. Church, in both 
of which there was neither consciousness nor recollection of pain.”1 
In 1798, Hr. Rush published a volume of “Essays; Literary, Moral, 
and Philosophical,” which had previously appeared in the magazines of 
the day. It is in one of these that he contends against the ancient lan- 
guages as a necessary part of the education of students of medicine. In 
1801 he added to his other works a volume of Introductory Lectures, in 
one of which he unfolds his views on the unity of disease. Nosology 
appeared to him mischievous, as directing the attention of practitioners 
to the name rather than the character of the disease; and in his lectures 
he inveighed warmly against it. Rising from his chair, to give greater 
emphasis to his words, he would exclaim, Nosologia delenda est! But this 
question, in which he was able to create a lively interest while he was 
the popular teacher of the period, has long since been put to rest. His 
great work on Hiseases of the Mind appeared in 1812, only a short time 
before the death of the author, which took place in 1813. 
This work, the result of a lifetime of careful observation and honest 
inquiry, is, of all his writings, the one now most read and most fre- 
quently quoted by medical authors. Nearly all who have followed him 
on psychological medicine, refer to it as one of the most instructive of the 
treatises on that subject, and as especially rich in facts. Adopting the 
enlightened views which Pinel had just promulgated in France, Hr. 
1 Inquiries, vol. iv. p. 376, 3d ed. ADDRESS ON MEDICAL LITERATURE. 
229 
Hush gave an impetus to the revolution which this country has wit- 
nessed in the management of the insane ; and it is his noble eulogy that 
he aided “in onening the prison doors of the maniac, unbarred his 
noisome dungeon, and knocked the shackles from his limbs, substituting 
moral treatment for brute force, and love for fear.”1 He saw, as the 
great French alienist had pointed out, that the law of kindness is the 
true one in the management of lunatics; his work gave currency to the 
novel idea, and, as a result of the light diffused abroad by him, the con- 
dition of the insane in all our asylums has been one of steady improve- 
ment from his day to our own. 
In the century that has passed away since Rush appeared as an au- 
thor, no one of all the medical writers of America has attained to the 
popularity which he enjoyed, nor exerted so wide and lasting an influ- 
ence on the professional mind of his country. During the generation in 
which he lived he was more generally read and followed, not only than 
any other medical author of this country, but than all our other writers 
on medicine put together. FTor is it likely that his name or his works 
will be forgotten. His writings form, as a whole, a body of philosophi- 
cal medicine—defective, indeed, in many points—but exhibiting a 
breadth of view, an originality of thought and conception, an accuracy 
and extent of observation, and a terseness, vivacity, and clearness of 
style, that compare well with the best medical works of their period.2 
A host of minor writers on yellow fever was brought out by the epi- 
demics, as they appeared toward the close of the last century in our 
Atlantic cities. Among these was Dr. William Currie, of Philadelphia, 
whose writings on that subject were only less voluminous than those of 
Hush. He was an independent thinker, a careful investigator of the 
diseases of the country, and a faithful observer and recorder of facts; 
but he is likely to be longest remembered for the violence with which he 
assailed Rush’s doctrines and practice. It is, however, due to his memory 
to record that he retracted publicly, soon after making the harsh stric- 
tures on his great contemporary.3 
1 Dr. Edward Jarvis. 
2 Before the first volume of Rush’s Inquiries was written, Samuel Stanhope Smith, D.D., 
President of Princeton College, had published a small volume on “ The Causes of the 
Variety of Complexion and Figure in the Human Species,” which was republished, with 
notes, in Edinburgh, by a professor of that university. Dr. Caldwell reviewed it with 
great acrimony, urging the insufficiency of the causes assigned to produce the existing 
varieties. The question has been much discussed since that day, but remains still ini an 
Unsatisfactory position. In 1781, Dr. James Tilton published a short treatise on the Dis- 
eases and Management of Military Hospitals. Dr. Samuel Tenney published, in 1783, an 
Account of the Saratoga Springs. In 1786, Dr. Matthew Wilson produced an essay on 
fhe diseases arising from the air, contending that most of them are generated by miasmata. 
The same year he wrote for Atkins’s American Magazine an account of a malignant lever 
which prevailed in Sussex County, Delaware, in 1774; and also an account of the seveie 
winter of 1779, which appeared in the Transactions of the American Philosophical Society. 
Jn 1788, the Medical Society of the County of New Haven, Conn., published a volume of 
transactions, which was much quoted by British writers. In 1793, part of a volume of 
transactions was published by the Philadelphia College of Physicians, which, after many 
years, began to issue a quarterly summary, and now publishes annual volumes. Dr. 
Charles McLean wrote a work, in 1797, to prove that pestilential diseases weie dependent, 
ln all cases, upon certain altered conditions of the atmosphere, and were never communi- 
cated by contagion. An oration delivered at the University of Virginia, by M. Coste, 
Medical Director of the French forces, in 1782, forming a volume of 103 pages, Bvo., was 
Printed at Leyden in 1783. Dr. John Leigh, of Virginia, obtained in 1785 the Harveian 
prize for an essay on the properties of opium, which was printed at Edinburgh in 1786. 
3 Dr. Currie published, in 1792, a historical account of the climate of the United States. 
In 1798 he wrote on the causes and cure of remitting or bilious fevers. In 1800 he wrote 230 
Y ANDELL, 
Few of our authors on yellow fever are entitled to more honorable 
mention than Dr. Richard Bayley, of Few York, who before writing on 
this subject had acquired a reputation abroad by his researches in mem- 
branous croup. His history of yellow fever in Yew York is one of the 
most graphic and instructive produced in our country, and affords evi- 
dence of powers which might have placed him in the front rank of our 
writers, had he lived to develop them ; but his fearlessness in visiting the 
localities in which the epidemic raged, brought on an attack of the fever, 
which terminated his life just as his labors promised the greatest useful- 
ness to his profession. Another writer, who afterwards rose to great dis- 
tinction, was Dr. Charles Caldwell. He began to write on yellow fever 
while yet a student of medicine, having seen much of the epidemic in 
Philadelphia, in 1793. Of those who contended against its contagious- 
ness, and for its domestic origin, he was among the first and the most 
earnest. He also wrote against the expediency of quarantine. Dr. John 
Beale Davidge, at that time a young physician in Baltimore, was also an 
early writer on yellow fever. He published a paper on that subject in 
1798, in which he contended for the doctrine that the fever originated 
in the places where it prevailed, believing, when he asserted it, that it 
had not before been taught in this country.1 
Our medical journalism commenced in Yew York towards the close of 
the last century. The first journal was a reprint, in 1790, of the 
Journal de Medecine Militaire, annotated from the French by Joseph 
Brown. The Medical Repository made its appearance on the 26th of 
July, 1797, under the editorial care of Dr. Elihu H. Smith, Dr. Ed- 
ward Miller, and Dr. Samuel L. Mitchill. Its origin marks an im- 
portant era in our medical history. Its editors were men of marked 
ability. Dr. Mitchill was especially noted as a theorist, but he was 
admirable for the extent and diversity of his attainments, and in ver- 
satility of powers had no superior amopg the medical men of his day. 
Dr. Miller was an original thinker, an acute observer, of solid judgment 
and learning, and a pleasing writer. Dr. Smith, the projector of the 
work, and the most gifted of the remarkable triumvirate, fell a victim 
to yellow fever in the twenty-seventh year of his age, but not until 
after he had achieved a national reputation. Among the productions 
a sketch of the rise and progress of the yellow fever of 1798 in Philadelphia. In 1811 he 
wrote a treatise on the diseases most prevalent in the United States at different seasons of 
the year; and in 1815 he published a synopsis of the theories and doctrines of disease. 
Other writers were the following: Deveze, who has the distinction of having been the first 
American writer to declare against the contagiousness of yellow fever ; Cathrall, who wrote, 
in 1796, on the synocha maligna of Philadelphia; Dr. J. O’Reilly, who, in 1798, wrote on 
the “Contagious Epidemic Yellow Fever” of that city; Seaman, who wrote, in 1796, on 
the yellow fever of New York ; and Dr. Samuel Brown, who, in 1797 and 1800, wrote on the 
yellow fever of Boston. Noah Webster also published, in 1796, two volumes on Pestilential 
Diseases, forming a valuable work of reference. Among other writers at that period were 
Hardie, Tytler, Pfaff, Hosack, and Davis. J. Henry C. Helmuth, of Philadelphia, wrote 
a tract in German “for the reflecting Christian,” in which he presented the subject in its 
religious bearings. Ffirth, a few years later, published a number of experiments made to 
determine the question whether the disease could be communicated from person to person. 
One of these experiments was to swallow the black vomit. 
1 To the list of our early writers on yellow fever, the following names are to be added : 
Matthew Carey, Pascalis, Oondie and Folwell, Chadwell, Manly, Eushtou, Addoms, Mar- 
tin, Monson, and Monson, Jr. The various publications relating to the early epidemics 
of yellow fever on our continent would form a curious body of medical literature, which it 
would be interesting to study. While the discussions were going on about the nature and 
treatment of yellow fever, Drs. Yates and McLean found time to write a volume of a hun- 
dred and fifty pages on the Brunonian theory of Life. ADDRESS ON MEDICAL LITERATURE. 
231 
left behind him to testify to bis genius, is a poetical introduction to 
Darwin’s “ Botanic Garden.” The Repository, under these gentlemens 
guidance, acquired great popularity and influence, reaching every part of 
the country, and receiving contributions from its best writers. Among 
other articles were Physick’s report of his autopsies in yellow fever, and 
the papers of Stearns and Prescott announcing the oxytocic properties 
of ergot. In the hands of numerous editors the Repository continued 
until it reached its twenty-third volume,1 
In 1805, Dr. Caldwell, who had become widely and favorably known 
by a translation of Blurnenbach’s physiology, and by his writings on 
yellow fever and quarantine, issued a volume ot Select Theses, wiitten 
by graduates of the University of Pennsylvania, with a preliminary 
discourse and appendix from his own pen. A second volume followed 
in the succeeding year, the appendix containing a paper by the editor 
on the “vitality” of the blood,” one of his favorite doctrines. It was 
his purpose to continue the work annually, but the trustees, by the 
advice of the Medical Faculty of the University, saw fit to relieve can- 
didates of the burden of printing their theses, and in consequence Cald- 
well’s publication fell through. Strangely enough, he looked upon the 
action of the faculty in this matter as “ a measure of vengeance and 
mischief” to himself. 
Dr. Caldwell was one of the most prolific of American medical authors. 
His writings were fragmentary, consisting of essays, reviews, and dis- 
courses, scattered through the literary magazines and medical jom nals of 
the day, but if collected would make not less than ten octavo volumes of 
a thousand pages each. Almost always in a controversy on some point in 
medicine or medico-theology, he was seldom lost to the public ay e fiom 
the time he entered his profession till near the close of his life. He was a 
man of varied attainments,but his learning was remarkable for extension 
of surface, rather than accuracy qr depth; and, while he wrote on a great 
variety of subjects, it cannot be said that he added much to Die stock of 
medical science. It was a peculiarity of his mental constitution that 
he continually set himself to advocate opinions and systems generally 
rejected, and to assail the most cherished beliefs of “Better 
occasionally broach startling error, than deal continually in time-beaten 
truisms,” was one of his maxims; and it may be said that he wasted his 
flue powers, as another great scholar declared he had wasted a life, “ in 
levities and strenuous inanities.” Many of his best years were devoted 
to the exposition and defence of phrenology, which, towards the close of 
his career, was superseded by mesmerism and spiritualism. Such was 
1 The New York Medical Repository was followed, in 1803, by a periodical at Ph'iadel- 
phia, the Philadelphia Medical and Physical Journal, edited by Ur. Benjamin Smith Ear- 
ton ; but this contained too much botany and zoology to suit the profession, and it expired 
at the end of the third volume. It was succeeded, in 1806, by the Medical Museum, under 
the editorial care of Dr. John R. Coxe, which was continued seven years, in 1808 a jour- 
nal was started at Baltimore, by Dr. Tobias Watkins, the Baltimore Medical and I hysical 
Recorder, which had a brief career, and gave place to another in that city, ot still shorter 
duration, edited by Dr. Nathaniel Potter, under the name of the Medical and 1 hilosophical 
Lyceum. In 1810 the American Philosophical Register was set on loot by Di . Mosack and 
Dr. J. W. Francis, at New York, its fourth volume containing the famous letters of Dr. 
Mitchell to Dr. Franklin on yellow fever, communicated by Dr. Rush to Ur. Hosack. Ihe 
Eclectic Repository and Analytical Review was started at Philadelphia in 1811, by Drs. 
Otto, Hewson, James, and other physicians of that city, and reached its tenth volume, 
when it was discontinued. Among its notable papers is a brief account ot McDowell’s 
renowned operations for diseased ovaria. In 1812 the New England Journal ot Medicine 
and Surgery was established by a number of the physicians of Boston. 232 
YANDELL, 
his assurance of the truth of organology, that he advised the use of the 
trephine to the head in mania, over the part of the brain indicated by 
phrenology as affected. He wrote an analysis of fever which would have 
possessed value if it had been the fruit of clinical observation ; but it was 
purely a work of the closet. As a writer of critical reviews, he was one 
of the readiest, most affluent, and most formidable of his day; in tone 
somewhat too domineering and dogmatic, and in language often unne- 
cessarily bitter, but always vigorous and independent. His most elabo- 
rate work was an autobiography published since his death, which has 
added nothing to his fame. Exhibiting, throughout, the temper which 
caused him to suspect his old friends and teachers in the University of 
Pennsylvania of framing “a measure of vengeance” against him, he is 
everywhere unjust to the memory of his contemporaries. 
About the beginning of the present century, the first works on syste- 
matic medicine began to appear, nearly all up to this time having been 
monographs. In 1801, Hr. B. S. Barton published some contributions for 
an essay towards a Materia Medica of the United States, having com- 
menced in 1798 to make collections for such a work. In 1803, he issued 
a work on the Elements of Botany, with some references of a desultory 
character to vegetable physiology. Hr. J, R, Coxe, in 1806, compiled a 
Hispensatory, which in the scarcity of medical books at the time proved 
of much service to practitioners. 
In 1807, Hr. Samuel Bard, of Hew York, gave to the profession a 
small but admirably written volume on the Science and Art of Mid- 
wifery. His “ compendium” was the vade-mecum of our accoucheurs for 
more than a quarter of a century, and is still quoted with respect by 
writers on obstetrics. Its sound judgment and good sense made it a safe 
guide, and the clearness and simplicity of its language adapted it to the 
capacity of midwives, in whose hands, when it appeared, was most of 
the obstetrical practice of the country.1 Jn 1810, Hr. James Thacher pre- 
pared a valuable Hispensatory, on a plan which had been proposed by the 
Medical Society of Massachusetts for securing uniformity in the Phar- 
macopoeias of the United States; this work remained long in use by the 
profession. 
In 1811 appeared the System of Anatomy, by Hr. Caspar Wistar, of 
the University of Pennsylvania, which was the popular text-book in 
American medical schools for more than thirty years. It passed through 
nine editions, enriched and enlarged by successive editors, its author 
having died shortly after the publication of the second volume. Wistar 
was the first writer on anatomy to describe accurately the extremities of 
the ethmoid bone, which previously had been supposed to belong to the 
sphenoid, and hence they have ever since been known as “ the pyramids 
1 Dr. George C. Shattuck, in 1808, published three dissertations on Boylston prize-ques- 
tions for 1800 and 1807. They treated of Diseases of the Skin, Mortification, and Biliary 
Concretions. Dr. Edward Cutbush, of the U. S. Navy, wrote in 1808, a work on Preserv- 
ing the Health of Sailors and Soldiers. In 1808 q,nd 1811, the monograph of Dr. Bayley 
on Membranous Croup appeared in the Medical Repository. The true nature of the com- 
plaint had been pointed out by him as early as 1781 in a letter to Dr. Hunter, in 1809 
Dr. J. C. Warren published a valuable paper on Organic Diseases of the Heart. Dr. Na- 
than Strong, in 1810, wrote a treatise on Spotted Fever, which was followed the next year 
by papers on the same subject by Dr. North, Dr. Woodward, Dr. Bester, and Dr. Fish. Dr. 
Hugh Williamson, in 1811, published Observations on the Climate of different parts of 
America, to which he added a history of North Carolina, including an account of its dis- 
eases in 1812. ADDRESS ON MEDICAL LITERATURE. 
of Wistar.”1 His volumes contained little that was original, but the 
matter was presented in a shape highly convenient to students, and it is 
not too much to say that their publication marked an era in the history 
of American authorship. 
Of scarcely inferior popularity at the time, and of the greatest value 
to the profession of our country, was another work which proceeded 
from the same institution a few years later. The “ Elements of Surgery, 
by Dr. John Syng Dorsey, in two volumes, appeared in 1818. The au- 
thor was a young man, and could not claim to have had much personal 
experience in surgery, but that of his distinguished uncle, Physick, then, 
as long afterward, the leading surgeon of the United States, was at his 
command with which to enrich his work. It was written in a simple, 
graceful, flowing style, with special reference to the needs of students, 
and so well did the author succeed in his design that his book was at 
one time adopted in the University of Edinburgh as a text-book. That 
place it assumed at once in our schools, and maintained until latei sys- 
tems supplanted it. Nor was it less prized by the profession as a work 
of reference. It passed through four editions, two after the author’s 
death, which occurred while he was still young. Had he lived to dis- 
cipline and mature the high gifts with which he was endowed by Nature, 
he would have attained "undoubtedly to great eminence as an author. 
He indulged occasionally in poetical effusions, some of which, says Pro- 
fessor Gross, his biographer, “ embody uncommon vigor of thought and 
power of description.” Something of the glow of poetry may be de- 
tected in his professional writings. 
At all times, while acknowledging his indebtedness to foreign sur- 
geons, Dorsey does not hesitate to criticize their prejudices and prac- 
tice. Thus, in the preface to his Elements he says: “Great Britain and 
France have been foremost in the cultivation of modern surgery, but 
their deficiency in philosophical courtesy and candor has in some in- 
stances greatly retarded its progress. To illustrate this remark it will 
be sufficient to state that the doctrine of adhesion, so ably developed in 
England, has been shamefully neglected in 1 ranee; and that 1 rench 
surgery in fractures finds no advocates in Britain. Some of the best 
Writings of Desault have never been translated into the English language, 
and those of Hunter are unknown or disregarded throughout the conti- 
nent of Europe. This spirit of hostile rivalship, extending from the field 
of battle to that of science, cannot fail to exert a pernicious influence on 
practical surgery; a truth too palpable to escape the observation of any 
foreigner who visits a European hospital. An American, in walking 
their wards, sees with surprise in London a fractured thigh rudely bound 
in bundles of straw, and the patient discharged limping with a crooked 
limb. In the French capital he witnesses an amputation, and is dis- 
gusted with the officious zeal with which the surgeon crams a handful of 
lint between the stump and the flap which covers it, with an express 
design to prevent their adhesion.” 
While the University of Pennsylvania was contributing thus liberally 
to our literature, the University of Maryland was not idle. Dr. Davidge, 
its honored founder, in 1812, essayed another System of Nosology, more 
simple and therefore more eligible than that of Cullen then prevailing. 
In 1814 he republished his memoir on yellow fever, and with it his in- 
augural thesis on the Catamenia, in a volume entitled “ Physical Sketches, 
1 Gross, Introductory Lecture on American Medicine. 234 
YAISTDELL, 
or outlines of correctives applied to certain errours in Pbysick,” which, 
besides these, contains an elaborate history of the various methods of 
amputation, including one of his own. ■ The introduction to his Nosology 
contains a powerful argument against Rush’s theory of “ the unity of 
disease,” which at that time excited a good deal of interest. His thesis, 
written in Latin, and first printed at Glasgow in 1793, maintains the 
doctrine that the menstrual flux is a true secretion. Not the least 
pungent article in his sketches is the review of a case related by Cald- 
well in his paper on the vitality of the blood. The case was as fol- 
lows: The writer, after the extraction of a tooth, had some trouble with 
hemorrhage, but, keeping the blood in the alveolus by pressure, at last 
arrested its flow. The leather being warm, he examined the coagulum 
several times a day, but instead of its becoming “putrid and offensive, he 
was surprised to observe it on the fourth or fifth day after coagulation be- 
ginning to assume the appearance of flesh.” And this incarnation com- 
menced, he relates, not at the circumference, “but in the centre of the 
coagulum, at the greatest possible distance from any vessels that might, 
by elongation, have been protruded from the adjacent gums;” so that 
“what had been at first nothing but congealed blood, became a piece of 
perfect flesh, similar in texture and appearance to that of the gums.” 
Upon this remarkable case Davidge makes the following comments: 
First, that it is “ solitary of its kind; then, that the clot is singular 
“ from its transparency,” all other clots of blood being opaque ; and, 
finally, he is bold to say, that “ the asserted fact is bottomed upon the 
broad basis of human credulity.” 
As a controversialist, Davidge displayed undue acerbity, as the reader 
will conclude from the foregoing quotation. His style, at the same time, 
was stiff, involved and affected, entirely unlike that in which he lectured. 
His lectures, indeed, afforded a model of simple elegance, while the mo- 
ment he took pen in hand he seemed to forget the English idiom. Ten 
years after the appearance of his “sketches,” he issued the first number 
of a journal, The Baltimore Philosophical Journal and Review, which 
he proposed to continue, but was obliged to give up for want of 
encouragement. The number published was written almost entirely by 
himself, in his peculiar, crabbed style, and in a temper so acrimonious 
that it was hardly read at all when it came out, and might soon after 
have been bought almost as waste paper,1 
In 1816, a syllabus of the lectures of Dr. James Jackson in the Massa- 
chusetts Medical College, was published, and only increased the general 
feeling of regret that the learned and able author did not prepare a 
systematic treatise on the principles and practice of medicine. 
In 1817 was published a volume of lectures on the “ Elements of 
Therapeutics and Materia Medica,” delivered by Dr. Nathaniel Chap- 
1 Dr. J. W. Francis in 1811 published an able paper on Mercury. It was in 1813 that 
Dr. Prescott wrote his article on Ergot, which was inserted in the thirteenth volume of the 
Dictionnaire des Sciences M6dicales. The same year Dr. John Warren wrote ably on Calo- 
mel, arguing against its utility in hydrocephalus. Dr. Charles Wells, a native of South 
Carolina, also published that year, in London, his philosophical theory of dew, which was 
crowned by the Royal Society in 1814 with the Rumford medal. Dr. E. Hale, Jr., in 1814, 
published an instructive volume on spotted fever; and in that year Dr. J. Dyokman pro- 
duced an elabox-ate dissertation on the pathology of the human fluids. Dr. Joseph Gallup, 
in 1815, contributed a px-actical work on the epidemic diseases of Vermont from its first 
settlement. In the same year Dr. Job Wilson wrote an inquiry into the nature of spotted 
fever, and Dr. Exmalls Martin produced a history of the epidemics of the winter of 1813 
and 1814 in Talbot and Queen Anne’s counties, Maryland. ADDRESS ON MEDICAL LITERATURE. 
man in the University of Pennsylvania, to which a second volume suc- 
ceeded in 1819. Nothing so fresh in style, or so original in theory, had 
been contributed to our literature since the days of Push. These lec- 
tures were received by the profession with abundant favor. As “ dis- 
courses” they were characterized by some redundancy of expression, and 
a severe critic would have termed their style florid; but they were, per- 
haps, more pleasing to youthful readers on that account. The writer 
remembers well the feeling of relief, not to say delight, with which lie 
turned to them from the dry treatises on Materia Medica, and the drier 
dispensatories which they came to supplant. Chapman’s theory of the 
operation of medicines was of modern date, as he expressed it, and of 
captivating simplicity. It was this: “That all such agents act by ex- 
citing a local impression, which is extended through the medium of 
sympathy.” No article, he held, “ ever enters the circulation as a medi- 
cine.” “It cannot, indeed, be credited,” he says, “ that any substance, 
after a subjection to the digestive and assimilative process, retains in 
the slightest degree its original properties.” Besides this, everything 
that acts upon the system “is a stimulant.” Such was his philosophy 
in a few words, which one of his critics hardly ventured to controvert 
when it was announced, feeling himself tibi miles impar.l How success- 
fully it has since been opposed need not be related here. 
With this popular work came out some numbers in quarto of a treatise 
on the “ Vegetable Materia Medica of the United States,” by Dr. W. P. 
0. Barton, of the same University; and a treatise on Medical Botany, of 
much research and substantial value, in three volumes octavo, by Dr. 
Jacob Bigelow, of Harvard University. The work of Barton was sub- 
sequently issued in a form magnificently illustrated, under the name ot 
“ Flora of North America.” 
In 1817 was originated a Journal of Science, which, though not medi- 
cal in character, exerted a decided influence on medicine in the United 
States. This was the “ Journal of Science and Art,” projected at New 
Haven by Prof. Benjamin Silliman, of Yale College. The work re- 
mained under his editorial care until it reached its fiftieth volume. No 
American serial, it may be safely said, has contributed more to the fame 
of our country, and none has done so much to develop its science in the 
direction of natural history. Its volumes form a magazine of facts and 
observations indispensable to writers on any branch ot natural science, 
and contain many articles relating directly to medicine. Among the 
authors of our country it would be difficult to name a writer more 
polished and graceful, or more variously gifted and informed, than the 
elder Silliman, who devoted a long life assiduously to the advancement 
of useful knowledge among his countrymen, and who, on retiring from 
his work as editor, had the good fortune to find in his own family suc- 
cessors qualified to sustain the high reputation of his journal. Under 
the direction of Prof. B. Silliman, Jr., and Prof. James D. Dana, the 
American Journal of Science has maintained its rank as one of the lead- 
ing periodicals of the world. 
Dr. James Thacher, in 1817, published a work styled tlm “Modern 
Practice of Physic,” the reception of which by the profession was so 
favorable that a second edition was called for in a few years. Dr. 
Thacher was at the same time a scholar and a practical physician, 
equally at home in the sick-room, in writing on the nature and treat-- 
1 See Med. Recorder, vol. i. p. 189. 236 
YANDELL, 
ment of disease, or in drawing up his well-known biographical sketches 
of noted American physicians. His is one of the names which will be 
long held by the profession in grateful remembrance.1 
In 1818, Dr. Nathaniel Potter, the learned Professor of Theory and 
Practice of Medicine in the University of Maryland, published an elabo- 
rate memoir on Contagion, more especially as respects the yellow fever. 
In the same year the Medical Recorder, which for a time was the most 
influential journal of medicine in the country, was set on foot by several 
respectable physicians of Philadelphia. Drs. Eberle, McClellan, and Cal- 
houn were subsequently announced as its editors. In 1829 it was merged 
in the American Journal of the Medical Sciences. Among other inter- 
esting papers it contains a report of the famous operation of Deaderick, 
of Tennessee, for removal of the lower jaw, the first on record. Many 
other papers by the ablest medical writers of our country found their 
way into the Recorder. 
In 1819, the first American works on Chemistry appeared. Dr. John 
Gorham published his Elements of Chemical Science in two volumes; 
and Dr. Franklin Bache, of Philadelphia, prepared an elementary treatise 
on chemistry about the same time. During this year, also, was an- 
nounced a new theory of Galvanism, with an account of the calorimeter, 
a new galvanic instrument, by Dr. Robert Hare, the gifted Professor ot 
Chemistry in the University of Pennsylvania.2 
The United States Pharmacopoeia, proposed in 1808 by the Massachu- 
setts Medical Society, was issued in 1820, and having been repeatedly 
revised at intervals of ten years, retains its place among our standard 
works as a book of reference. In 1820 also was established the medical 
journal which has done more than any other of our serials to advance and 
shape the medical literature of the United States. Dr. Nathaniel Chap- 
man, Professor of Theory and Practice in the University of Pennsylva- 
nia, started that year the~Philadelphia Journal of the Medical and Physi- 
cal Sciences. In the inception of the enterprise he was alone, but in a 
short time he secured the valuable assistance of Drs. Dewees and Godman 
as associate editors. From the beginning, the Journal evinced the vigor 
to have been expected from the editorial talent engaged upon it. Its 
editor in chief was then in the prime ot his great intellectual powers, and 
Godman had already given proof of a genius rarely equalled in our pro- 
fession.3 In 1827, the name of the Philadelphia Journal was changed, 
1 Dr. James Mann, of New York, contributed an interesting History of the Campaigns of 
1812, 1813, and 1814, to which are added surgical cases, and observations on military hos- 
pital’s and flying hospitals attached to a moving army. Dr. Jabez Heustis published, in 
1817, Some Physical Observations and Medical Facts and Researches on the Topography 
and Diseases of Louisiana. In the same year, Dr. W. 0. P. Barton issued a work on the 
Internal Organization and Government of Marine Hospitals, based on his own experience 
and observation. The year following, Dr. John King published, at Norwich, a treatise on 
Extra-uterine Foetation and Retroversion of the Uterus. Dr. J. C. Shecut, of Charleston, 
the same year, produced an Essay on Contagions and Infections. Dr. A. H. Stevens pub- 
lished some cases of Fungus Hsematodes of the Eye, in 1818. 
2 This vear appeared also a work by Dr. L. Spalding, of New York, entitled Reflec- 
tions on Yellow Fever Periods; one by Dr. Felix Pascalis, on the Malignant Yellow 
Fever of New York in 1819; and one by Dr. Shecut, of Charleston, containing a history 
of Yellow Fever. 
3 The first account of that strange disease, “Milk sickness,” so far as is known, was given 
by Messrs. Lea and McCall, students of medicine from Tennessee, in one of the earlier num- 
bers of this journal, and it is proper to record that the editor was disposed to reject their 
history of this disease as apocryphal, for the reason that the facts stated seemed wholly 
irreconcilable with his hypothesis that poisons in a formal state never entered the circula- 
tion. ADDRESS ON MEDICAL LITERATURE. 
and it passed into the hands of Dr. Isaac Hays, who, with a judgment, 
perseverance, and industry, seldom witnessed in journalism, has continued 
it down to the present day, as the American Journal ot the Medical 
Sciences. 
This is the medical journal of our country to which the American 
physician abroad will point with greatest satisfaction, as reflecting the 
state of professional culture in his country. For a great many years it 
has been the medium through which our ablest writers have made known 
their discoveries and observations. 
In 1821, Dr. Hosack’s Nosology, which had been issued_ some years 
before, reached a second edition, and the Journal of Foreign Medical 
Literature was set on foot, by Drs. Emlen and Price, and afterwards con- 
tinued for a time by Drs. Godman and Littell. Dr. Donaldson, in 1821, 
published a treatise on the present system of medicine and surgery in 
Europe and America; and Dr. E. Hale, Jr., the same year issued an essay, 
which had been crowned by the Boylston prize, on the connection be- 
tween the Stomach and the Urinary Organs. 
The following year was an eventful one in the history of our medical 
literature. A work of much research was produced by Dr. John C. 
Warren, styled “A Comparative View of the Sensorial and Nervous Sys- 
tems in Man and Animals;” a treatise, by Dr. John Eberle, on Materia 
Medica, was published; and two journals appeared, the New York Medi- 
cal and Physical Journal, conducted by Drs. Dyckman, Francis, and 
John B. Beck; and the Western Quarterly Reporter, edited by Dr. John 
D. Godman, at Cincinnati, marking the rise of medical journalism in the 
Valley of the Mississippi. The Materia Medica of Eberle was a work of 
sterling merit, at once learned, practical, and judicious, and written in a 
clear, simple style. Those most partial to Chapman could hardly help 
admitting that, in all the qualities sought for by students and practi- 
tioners in a text-book or a manual, it was superior to his treatise on the 
subject. Its author, with far Jess genius, was a scholar of very much 
greater research, who had taken time to look extensively through the 
German and French literature on the subject as well as that in his own 
language, and to make his work as thorough as industry could render it. 
It was long one of the most popular text-books in our schools, as well as 
an authority in the profession. Dr. J. Bigelow, the same year, published 
a valuable treatise on Materia Medica, intended as a sequel to the Phar- 
macopoeia of the United States. An era was opened in the professional 
literature of the West by the appearance of Godman’s journal at Cincin- 
nati, which, though of short duration, was the beginning of: a most pro- 
lific series. Only six monthly numbers ot his work were issued, but as 
proof of the activity and zeal with which the editor devoted himself to 
it, it is worthy of mention that, of the matter composing them, he wrote 
more than three hundred pages.1 
The year 1828 is also memorable as having produced the classical work 
on Medical Jurisprudence by Dr. T. Romeyn Beck and Dr. John B. 
1 Dr. Godman, in 1824, published a thin octavo volume made up of anatomical researches, 
which was followed, the succeeding year, by a smaller volume, entitled Contributions to 
Physiological and Pathological Anatomy, founded on his own dissections. His American 
Natural History, in three volumes, appeared in 1826, and gave him standing with the natu- 
ralists of his time. A small volume, composed of Addresses delivered on various occasions, 
followed in 1829. The “ Rambles of a Naturalist,” written for a weekly magazine in Phila- 
delphia, and published in a small volume after the author’s death, was the last of his labors, 
all of which bore evidence of a passionate devotion to, and ot a genius capable of the 
highest achievements in, science. 238 
YANDELL, 
Beck. This admirable treatise has rather gained in reputation than 
declined during the many years that have elapsed since its publication; 
nor is there any reason why it should not maintain its enviable position 
among the works of its class, since the changes which, under a rapid suc- 
cession of systems, are inevitable in other departments of medicine, are 
not met with in medical jurisprudence. Besides this learned work, which 
has conferred so much fame upon our authorship, others of note were 
written in 1823. One of these was on Diseases of the Eye, by Dr. George 
Frick, of Baltimore; and a larger one on Fevers, from the pen of Dr. 
Thomas Miner and Dr. ¥m, Tully, two eminent physicians of New Eng- 
land, had the recommendation of being founded on the observation and 
experience of its authors at the bedside.1 
Dr. William P. Dewees, who had become eminent in Philadelphia as 
an accoucheur, and was known in all parts of his country as a writer on 
obstetrics, appeared in 18 242 as author of a System of Midwifery, which 
not only gave new dignity to the art in the New World, but may be said 
to have created an American School of Obstetrics. The popularity of 
this work was very great, and in thirteen years it had passed through a 
dozen editions. The author wrote from his own experience, and ex- 
jmessed himself as one having a right to speak. If he was dogmatic, it 
must be remembered that he was almost without a rival near him to 
question his authority, and if his pages betray haste and carelessness, the 
defect must be set down to the incessant press of business which left him 
little leisure for correcting what he wrote. There is something painful 
in the thought that a work once so much read, and held in such high 
esteem, should now be entirely neglected. But the march of science 
renders such a fate inevitable. Other systems more advanced have long 
since taken its place. 
A treatise on the Diseases of Females, and one on the Physical and 
Medical Management of Children, followed Dr. Dewees’s Midwifery in 
1826, and extended his fame as an author. It was many years before 
either work was superseded, and while they stood their ground they 
were to be found in nearly every medical library of the country. In 
1830 he entered a new field, sending forth a “ Practice of Physic,” com- 
prising most of the diseases not treated of in his “Diseases of Females” 
and his work on Children ; but this proved a failure. The writer had 
undertaken too much. Of all subjects pertaining to obstetrics, he was 
master, but his medical philosophy was tainted by the declining system 
of Broussais, and his therapeutics proved unpopular. As a specimen of 
his practice, it may be mentioned that he reports having bled one of his 
patients six times for a fever, brought back, after she was convalescent, 
by a single plate of soup. 
Few more remarkable men have appeared in the American profession 
than Dr. Nathan Smith, author of a treatise on typhus fever written in 
1 The following works were also issued in 1823 : An Essay on Suspended Animation, by 
Dr. Samuel Calhoun; a Guide for Practising Physicians in Visiting the Sick, by Dr. J. 
Lobstein ; a Treatise on Oynanche trachealis, by Dr. W. Sweetzer, of Poston, who also wrote 
on Consumption and on Indigestion in 1836 and 1837 ; an Account of Yellow Fever in New 
York, in 1822, by Dr. T. S. Townsend; and a History of Yellow Fever as it appeared in 
Natchez, in 1822, by Dr. Henry Tooley. 
2 A work on the Philosophy of Epidemics was contributed in 1824 by Dr. Joseph M. 
Smith, and also three volumes of Essays on various medical subjects by Dr. David Hosack. 
The Medical Intelligencer, a monthly in quarto form, was started in the winter of 1823-4 
by Dr. J. V. C. Smith, at Boston; and the Medical Review and Analytical Journal by Dr. 
Eberle and Dr. George McClellan, in Philadelphia, in 1824. ADDRESS ON MEDICAL LITERATURE. 
1824. He was a great surgeon, an able teacher, and a judicious author. 
In independence of thought, and in sturdy, common sense, he had few 
equals in his day, and has never had many superiors in the profession. 
When his little volume appeared, the distinction between typhus and 
typhoid fever had not been recognized, and it was evidently the latter 
that he had under consideration. “ I have never been satisfied,” he de- 
clares, “ that I have cut short a single case of typhus fever that I know 
to be such. Typhus has a natural termination like other diseases which 
arise from specific causes.” His readers, fresh from the work of Arm- 
strong, on typhus fever, recommending a vigorous treatment by the 
lancet and purgatives, were not a little disappointed when they came to 
his concluding words as to its cure: “All that is required is simple de- 
mulcent drinks, a very small quantity of farinaceous food, and avoidance 
of all causes of irritation.” Another work on surgery was produced in 
1824, by a professor in the University of Pennsylvania, Hr. William Gib- 
son. It was a heavy work, compared with that of Horsey, aiffi in com- 
parison with later systems it was greatly wanting in but 
the author made amends for these early detects in succeeding editions, 
and his surgery acquired at last a just claim to the position given it by 
his official connections. It was not long in supplanting the treatise of 
Horsey as a text-book in the American schools.1 
In 1826, the Forth American Journal of Medicine and Surgery was 
established at Philadelphia, under the auspices of the “Kappa Lambda 
Society of Hippocrates.” Its corps of editors embraced some of the best 
medical talent of the country. It included the names of H. L. Hodge, 
C. H. Meigs, B. H. Coates, P. Bache, and R. Laßoche, to which, after 
two years, those of John Bell, George B. Wood, and H. F. Condie, were 
added. The aim of the Society was to promote harmony in the ranks of 
the profession, and with its patronage the journal wTas expected to have 
wide circulation. It assumed at once a high rank among the periodicals 
of the day, but, notwithstanding its acknowledged ability, and the 
favorable circumstances attending its origin, it was discontinued at the 
end of the twelfth volume for want of adequate pecuniary support. A 
systematic treatise on anatomy was added to the list of American books 
in 1826, by Professor William E. Horner, of the University of Pennsyl- 
vania, one of the most pains-taking and assiduous of modern authors; 
but though fuller and more accurate than the volumes of Wistar,it failed 
to secure the footing in the schools so long maintained by our earliest 
work on anatomy. 
Hr. James Bush produced, in 1827, a work on the Philosophy of the 
Human Voice, which for originality and depth of research has been pro- 
nounced by competent judges one of the most creditable of the produc- 
tions of our country relating to medicine. The same year, the Monthly 
Journal of Medicine originated in Philadelphia, and Hr. Hrake took 
charge of the WFstern Journal of the Medical and Physical Sciences, at 
Cincinnati. When he projected his periodical, he assumed as its motto, 
E sylvis nuncius ; to which, no readers being secured east of the moun- 
tains, he added subsequently the words, ceque atque ad sylvas nuncius. 
' Dr. Thomas Miner gave an interesting account of typhus syncoyjalis in 1825, and an 
epitome of chemical philosophy was published the same year by Dr. James D. Dana. In 
1825 also appeared a Manual of Chemistry by Dr. John W. Webster, Professor of 
Chemistry in Harvard University, who was executed at Boston in 1850 for the murder of 
Dr. George Parkman. 240 
YANDELL, 
He conducted it with great energy for twelve years, when it was merged 
in a journal at Louisville.1 
In 1828, Dr. John E. Cooke produced a work in two volumes of decided 
originality. It was entitled a Treatise of Pathology and Therapeutics, 
and proposed a new theory of disease. The theory was one of the most 
compendious ever framed. It referred all fevers, with cholera, dysentery, 
and a host of other varying affections, to congestion of the vena cava. 
And his therapeutics were no less simple. All his remedial measures 
had reference to unlocking the liver by purgatives, at the head of which, 
in point of efficacy, he reckoned calomel. The aim being to secure bilious 
purging, cathartics were to be repeated, in increasing doses, until the 
effect was produced. In the end, this led to an abuse of calomel which 
brought it into great disrepute; and with its popularity the writings and 
the system of one of the most learned and conscientious of American 
authors have passed away. With this work, Dr. Cooke, in conjunction 
with his colleague, Dr. C. W. Short, started the Transylvania Journal 
of Medicine, which was edited by them for four years. At the close of the 
fourth volume it passed into the hands of Dr. L. P. Yandell. Dr. Pobert 
Peter became its editor in 1887. Among its more valuable papers are 
the reports by Dr. B. W. Dudley of his operations for stone in the 
bladder, and his cure of chronic epilepsy by removing portions of the 
skull bone depressed by mechanical injuries. 
The Boston Medical and Surgical Journal was also set on foot in 1828, 
by Dr. J. Y. C. Smith, author of a work on the Fishes of Massachusetts. 
In that year, too, the Medical Biography of Dr. Thacher, a work not 
likely to be superseded, was contributed to our literature. A year later 
Dr. Horner produced his System of Pathological Anatomy, founded on 
original observations.2 
In 1830, an elaborate work on Chemistry, by Prof. Silliman, was an- 
nounced. Its arrangement was regarded as defective, and, added to 
this, its size unfitted it for the use of students, so that it never attained 
general currency ; but as a repository of chemical knowledge interesting 
to all readers, nothing superior to it has been produced in the English 
language. Dr. Samuel D. Gross, who has since contributed so largely 
to the literature of the profession, appeared this year as author of a 
modest volume on the Anatomy, Physiology, and Diseases of the Bones 
and Joints, which, it is interesting to remark, contains the first account 
of adhesive plaster as a surgical appliance in fractures.3 
In 1881, the classical work of Dr. John Bell on Baths and Mineral 
Waters appeared. The same author, in 1842, produced another work, 
1 Dr. Gay W. Wright and Dr. James M. Mason had started a semi-monthly, the year 
before, under the name of the Ohio Medical Repository. In 1832 the Western Medical 
Gazette was set on foot by the Faculty of the Medical College of Ohio, but at the end of 
nine months was suspended. It was revived five months afterwards by Dr. Silas Reed and 
Dr. Samuel I). Gross, who continued it until two volumes were completed. In 1842 the 
Western Lancet was projected at Cincinnati by Dr. Leonidas M. Lawson ; and in 1847 the 
Dental Register of the West was started at the same place by Dr. James Taylor, of the 
Ohio College of Dental Surgery. 
2 In 1829 the Journal of Health was projected by Drs. John Bell and D. Francis Condie, 
at Philadelphia. A Formulary, which was greatly useful to the profession, was published 
by Dr. Benjamin Ellis ; a System of Dental Surgery was contributed by Dr. Samuel Fitch ; 
a Journal of Pharmacy was started by Dr. B. Ellis ; and a treatise on the Distinct and 
Confluent Smallpox was produced by Dr. John D. Fisher. 
3 Dr. S. W. Avery, in 1830, issued a work, meant especially for the people, entitled 
“ The Dyspeptic’s Monitor.” ADDRESS ON MEDICAL LITERATURE. 
241 
written in the same elevated style, on Regimen and Longevity. The 
kindred topics of Alcohol in its Relations to Medicine, and the Import- 
ance and Economy of Sanitary Measures to Cities, were treated of in 
works issued in 1859 and 1869, and discussed with marked ability. Dr. 
John Eberle, in 1831, enriched our literature by two works of the highest 
merit—his treatise on the Diseases and Physical Education of Children, 
and his treatise on the Practice of Medicine. Nothing equal to them, in 
every respect, had been produced by an American writer. Rot only 
were they admirable in style, but they were full, accurate, and practical 
in matter. Both were adopted as text-books in our schools, and passed 
through many editions before they were superseded.1 
Dr. Rat ban R. Smith issued a volume of great interest, in 1831, con- 
sisting of memoirs, medical and surgical, by his honored father, with 
additions from his own pen. In 1832 the same author contributed a 
Work on the Anatomy of the Arteries, which was of value to the pro- 
fession. 
Dr. Araariah Brigham also, in 1832, commenced a series of publica- 
tions which excited much interest among students of psychological 
medicine. The first treated of the influence of mental culture on health. 
It was republished in Glasgow, with notes by Dr. Robert Mcßish, and 
was followed, in 1836, by a treatise on the Influence of Religion on 
Health and the Physical Welfare of Mankind, which involved the author 
in an embittered controversy. With these a small volume was brought 
out by Dr. Brigham, in 1833, on Epidemic Cholera; and, in 1840, one of 
much more note and significance on the Diseases and Functions of the 
Brain, the Spinal Cord, and the Rervous System. 
The leading production, however, of 1832, was the treatise of Dr. 
Samuel Jackson, on the Principles of Medicine. This volume came out 
with a heraldry before unknown in the literary history of our country. 
“ Knowing the anxiety of the profession in regard to the forthcoming 
Work of Dr. Jackson,” said the leading journal of the Union, “ we applied 
fo its publishers for an early copy,” which was duly noticed in terms 
°f the strongest commendation. “ Its publication,” declared the re- 
viewer, “will constitute an epoch in the history of American medical 
literature.” For years before it was published it had been understood 
that the author was at work on a treatise in which justice should be 
done to the merits of physiological medicine; but, unfortunately for it, 
l»hysiological medicine was about to vanish away when it appeared, and 
ks interest declined with the system. One edition of it was sold, and 
the publishers proposed To issue a second ; but the author would not con- 
sent to the labor of remodelling it in a way to make it conform to the 
medical science of the period, and no other was ever issued. It has been 
often repeated, without truth, that the work fell still-born from the press, 
and much has been credited to unfriendly criticism as the explanation of 
this defeat, but with only a show of reason. Certainly, it it was re- 
viewed harshly in some quarters, in others it received, as has been shown, 
2 full meed of praise. And the most formidable of its critics, a writer 
in the Transylvania Journal of Medicine, at Lexington, assailed it with 
1 The following works also appeared in 1831: Drawings of the Anatomy of the Groin, 
t>y Dr. William Darrach; a Treatise on Malaria, by Dr. U. Parsons ; a small volume, by 
tT. John AVare, on Delirium Tremens; a work on Chemistry, by Dr. Lewis C. Deck; a 
modest little volume of Essays on Materia Medica, by Mr. Geo. W. Carpenter; and a sin- 
gular treatise on Dyspepsia, by Mr. O. Halsted, proposing to cure the complaint by shaking 
and kneading the digestive organs after eating. 
16 242 
YAISTDELL, 
arguments which rather recommended than injured it with most readers. 
The chief objections urged against it by this reviewer were that it leaned 
to humoralism in pathology, and ignored the claims of phrenology. 
The book failed, so far as it was a failure, because its philosophy was de- 
fective. It perished with the narrow and fanciful system which the 
author himself lived to renounce as unfounded. 
The treatise of Dr, Robley Dunglison on Physiology also appeared in 
1882, and formed a contribution to our literature which all readers 
hailed as of true value. It was such a compend of physiological science 
as was. before nowhere extant in the English language; incomparably 
superior to the works of Bostock, Richerand, and Blumenbach, which 
had previously been the dependence of our students of medicine. Avail- 
ing himself freely of the labors of others, the author’s aim was to present 
a view of the existing state of physiology, without any straining after 
originality; so that his volumes are marked by learning rather than 
novelty of doctrine, but are none the less valuable to students on that 
account. The style in which they are written is unambitious, simple, 
clear, and pleasing. That many of his views were not accepted at the 
time, and that not a few have since been set aside, is what was to have 
been expected in a science advancing like physiology; but his work, the 
most advanced of its day, forms a rich treasury of facts and learning 
which the student may still consult with advantage,1 
A work in some respects the most fortunate that has been produced 
in America, appeared the next year in Philadelphia. In 1838, the United 
States Dispensatory, the joint production of Dr. George B. Wood and Dr. 
Franklin Bache, two of the ablest medical scholars of our country, was 
published, and at once took the foremost place among American works of 
its class. Nearly half a century has been completed since it was brought 
before the profession, but it may be doubted whether its standing was 
ever higher than it is at the present day. Its authors commenced life in 
Philadelphia about the same time, and were early friends. When they 
rose to distinction they were called to teach in rival institutions, but the 
jealousies of the schools, if any ever arose, never entered their studies, 
nor for an hour disturbed their fraternal relations. Laboring: on together 
as edition after edition of their great work was called for, one on the 
chemical, the other on its botanical department, their cordial intercourse 
ceased only when one of the laborers was called away by death. Dr. 
Wood, who survives to enjoy the fruits of his honorable industry, may 
well recount this enduring friendship as among the greatest blessings of 
a fortunate life. 
In 1833 the profession was enriched by a work which may be said to 
have enlarged our knowledge on some points in physiology more than 
all that had preceded it—a work that resulted from an accident. Dr. 
William Beaumont, a surgeon in the United States Army, had the rare 
opportunity of observing how digestion is accomplished in the human 
stomach. A Canadian soldier received a wound from the discharge of a 
gun, that exposed the interior of his stomach to view. An orifice re- 
mained after his recovery, through which food could be introduced, and 
1 In 1832, Dr. Thomas D. Mitchell brought out a treatise on Chemistry, on the basis of 
that of Reid, his chief additions to which consisted in an argument to show that alcohol 
might be dispensed with not only in medicine, but in pharmacy. Dr. I. Hays originated, in 
this year, the Cyclopaedia of Practical Medicine, to which some of the best writers in our 
country contributed articles. Dr. James Jackson, Jr., published also, in 1832, a small 
volume on Cholera, made up of cases which he had witnessed in the Paris hospitals. ADDRESS ON MEDICAL LITERATURE. 
243 
the action of the gastric juice upon it noted. The results of his nume- 
rous experiments and observations, in many of which he had the aid of 
Dr. Dunglison, are given by Beaumont in a volume which must remain 
in all coming time an authority on the subject of digestion. Some of 
the facts first established in the case of his patient will find a place in 
every treatise on physiology. 
With this valuable monograph, another work appeared in 1888, most 
creditable to the literature of medicine in our country. This was the 
medical dictionary of Dr. Dunglison, which has gone on increasing in 
popularity with the profession from year to year. It was at first issued in 
two volumes, and contained biographical notices of many of the most emi- 
nent medical men of the world, but this feature disappeared in the second 
edition, the author finding that the biography would swell his work to 
an inconvenient size. Each successive edition has increased the value 
as much as the bulk of the dictionary, which it is safe to say stands now 
unrivalled in the English language. Dr. Dunglison’s son, fortunately for 
the profession, has inherited the gifts which rendered his father the first 
of medical lexicographers, and promises to maintain the work in its 
present high position during at least another generation. 
Dr.- E. Geddings, of the University of Maryland, set on foot another 
periodical, the same year, the Baltimore Medical and Surgical Journal 
and Review, but though among its correspondents it numbered such 
Writers as T. R. Beck, JST. Potter, and JST. R. Smith, it fell through after 
a few months. Dr. Samuel Metcalf, this year also, added something to 
our literature in the shape of a small volume presenting a new theory of 
terrestrial magnetism. Magnetism, he held, was but another form of 
caloric, which, passing from south to north, gave the directive force to 
the needle. Ten years later, and after much investigation of the subject 
abroad, he published, in London, a second and much larger edition of his 
book. It cost the author, indeed, a vast amount of labor, which was but 
poorly requited either in fame or money, while the advancing years of 
his life were embittered by disputes with contemporary scientists about 
bis claims to priority of discovery. 
In 1834 numerous works were contributed. Dr. J. R. Coxe started an 
“Inquiry into the Claims of Harvey to the discovery of the Circulation 
of the Blood,” in which he succeeded in showing that in this memorable 
instance, as in all cases before and since, the truth was not reached at 
°nce by the intuition of a single mind, but by the efforts of a succession 
°f inquirers. Dr. Frost, of the University of South Carolina, published 
a volume of lectures on Materia Medica. Dr. Vm, W. Gerhard made a 
valuable publication on the cerebral affections of children, which lie fol- 
lowed, in 4836, by a volume of lectures on the diseases of the chest, and, 
in 1837, by a clinical guide for students.1 A work of much merit on 
Dulmonary Consumption was produced, in 1834, by Dr. Samuel George 
Thorton, whose labors in other fields subsequently made his name illus- 
trious in science. In 1849, he brought out a work on human anatomy, 
but, in 1839, he had published his great work, entitled “Crania Arneri- 
1 Dr. Gerhard’s treatises were founded on clinical observations, from which they derived 
unusual interest. He did much for the education of his young countrymen in physical diag- 
nosis of diseases of the chest; and was the first, or among the first, to point out the distinc- 
tion between typhus and typhoid fever. He made the diagnosis unequivocal. He also 
nailed attention to the relation of hydrocephalus, in infants, to tubercular meningitis. Few 
111 ore successful investigators than Dr. Gerhard have labored in our country to advance 
niedicine. YANDELL, 
cana.” His “ Crania YEgyptica” followed in 1844. His collection of 
crania enabled him to compare the cerebral capacity of most of the 
nations of the earth, thus furnishing data from which physiologists are 
able to draw interesting conclusions.1 
Hr. James Jackson, in 1835, published a memoir of his lamented son, 
Hr. James Jackson, Jr., who gave promise of great distinction in his pro- 
fession ; and, in 1888, he reported a number of cases of typhoid fever, 
which occurred in the Massachusetts hospital; a paper which Hr. Bart- 
lett found of the greatest service in the preparation of his work on fevers. 
In 1835, Hr. Hunglison published his scholarly work on Hygiene; Hr. 
John P, Harrison collected and published a volume of Lectures and 
Essays on Medical Subjects, which had previously appeared in another 
form; and Hr. John B. Beck issued a volume of Researches in Medicine 
and Medical Jurisprudence. A volume consisting of papers read before 
various learned bodies was also issued, by Hr. Richard Harlan, entitled 
Medical and Physical Researches, or Original Memoirs; it embraced 
valuable contributions to Zoology and Comparative Anatomy. But the 
most original work of this year, and, in its effects, far the most import- 
ant, was the paper read before the Massachusetts Medical Society, by Hr. 
Jacob Bigelow', on Self-limited Hiseases. The conception of such a class 
of affections did not originate with the author, but its existence was never 
so fully recognized before he wrote. The recognition lias effected a revo- 
lution in the treatment of many complaints, while the class in which the 
principle obtains has been steadily extending since he called professional 
attention to it. Another work of this year, which, though a compilation, 
claims a favorable notice, is the First Lines of Physiology, by Professor 
Haniel Oliver, of Hartmouth College. It is an admirable digest of the 
facts of the Science. The Author was in advance of the Physiologists of 
his day in ignoring the pretensions of Phrenology, and in admitting the 
truth of certain phenomena in animal magnetism which rest, as Sir W. 
Hamilton expresses it, “ upon a tenfold superfluous evidence.” 
From Hr. Hunglison’s prolific pen another work appeared the following 
year; his General Therapeutics, or Principles of Medical Practice, with 
tables of the chief remedial agents and their preparations, and of the dif- 
ferent Poisons and their Antidotes, But as it was a production of the 
closet, and not the result of clinical observation, though it was written 
by a profound and judicious scholar, it never took rank with his Physio- 
logy, or his Hictionary. Hr. John C. Warren this year published an 
elaborate treatise on tumors. Huring the year, an interesting prize essay, 
on the Physical Signs in Hiseases of the Abdomen and Thorax, was pub- 
lished by Hr. R. W. Haxall, of Richmond.2 
1 Dr. Tog-no, in 1834. published a work on the Anatomy and Physiology of the Ear. Dr. 
Casanova published some observations on cholera morbus. Drs. Ogier and Logan issued a 
compend of operative surgery, and Dr. Edward Barton, who had appeared as an author in 
1828, wrote a treatise on yellow fever. 
2 Dr. Caleb Ticknor, of New York, published, this year, a popular volume in Harper’s 
Family Library, on the Philosophy of Living, taking for his motto the wise saying of 
Bacon, that “A man’s own observation, what he finds good of, and what he finds hurt of, is 
the best physic to preserve health.” And a volume was issued by Dr. Parrish, of Philadel- 
phia, entitled Practical Observations on Strangulated Hernia, based on a large experience. 
Two new journals also appeared this year—the Blectic Journal of Medicine, afterwards the 
Bulletin of Medical Science, projected by that indefatigable writer, Dr. John Bell, and the 
Southern Medical and Surgical Journal, at Augusta, Ga., edited by Dr. M. Anthony and 
Dr. Joseph A. Eve. Dr. Luther Y. Bell, of New Hampshire, published this year some 
Observations on certain obscure and undecided Doctrines in relation to Smallpox, Yaria- 
loid, and Yaccination. Dr. George Bushe, of New York, in 1837, wrote a treatise on the ADDRESS ON MEDICAL LITERATURE. 
lii 1838, also, a large number of works was issued, first among which, 
in ability and in the impression it produced, was the Philadelphia Prac- 
tice of Midwifery, by Dr. Charles D. Meigs. Another was the Medical 
Jurisprudence of Insanity, by Dr. Isaac Ray, which treats ably of a sub- 
ject too little understood by physicians. The lectures of Dr. Hosack on 
the Theory and Practice of Physic, edited by Dr. Henry W. Ducachet, 
were published this year, as were also Lectures on Lithotomy, by Dr. A. 
H. Stevens. Dr. Charles Hooker, too, produced a well written Essay on 
the Relations between the Respiratory and Circulatory Functions, while 
Dr. Tripler wrote on Recruiting, and Dr. J. W. Monette on Yellow 
Fever in New Orleans and Natchez; and the Philadelphia Medical 
Examiner, edited by Drs. Biddle and Clymer, was originated. 
Dr. Henry I. Bowditch, the succeeding year, made an important com- 
munication in reference to thoracentesis in chronic pleurisy; an opera- 
tion much opposed at first, but now generally conceded to be legitimate. 
It has been performed by Dr. Bowditch 825 times, and on 204 patients. 
To this valuable contribution to our literature, that author has added 
some interesting statistics relating to the influence of a wet soil on pul- 
monary consumption. Dr. Dunglison came out this year with still 
another book, entitled New Remedies, which, like all the productions of 
his pen, was marked by industry, sound judgment, and a clear English 
style. Dr. Samuel D. G-ross, then a professor in the Cincinnati Medical 
College, produced a work of much labor on Pathological Anatomy, the 
first in our language to present a systematic view of the science, and 
useful in directing the attention of students more generally to that im- 
portant study. 
In 1840 the following works appeared; Dr. B. B. Shober, of Charles- 
ton, issued an Essay on Yellow Fever, designed to prove the transmissi- 
bility of the disease; and Dr. Upham wrote on Disorders of the Mind; 
but the great work of the year was from a professor in the University of 
New York, Dr. Martyn Paine, entitled Medical and Physiological Com- 
mentaries. Hardly a work issued from the medical press of America 
will compare with these ponderous volumes in the learning or in the 
tedious prolixity with which they are composed. Holding resolutely to 
an exploded medical philosophy, the author was born too late to com- 
mand the reverence which his great erudition would have excited in an 
earlier age. His elaborate and exhaustive commentaries were followed, 
some years later, by a volume on Materia Medica, characterized by all 
their merits and all their defects. His volumes are works for teachers 
and writers, rather than for practitioners or students of medicine. Dr. 
Edward .Warren published, this year, two Boylston Prize Essays, on 
Scrofula, Rheumatism, and Erysipelatous Inflammation. The Western 
Journal of Medicine and Surgery was started at Louisville. It suc- 
eeeded to the Louisville Journal of Medicine, edited by Drs. Miller, 
Yandell, and Bell, two numbers of which were issued in 1838, and to 
the Western Journal of the Medical and Physical Sciences, thirteen vol- 
umes of which had been completed by Dr. Drake at Cincinnati. It was 
edited Dr. Daniel Drake and Dr. L. P, Yandell, with whom, after the 
second year, Dr. T. W. Colescott was associated, and on the retirement 
Malformations, Injuries, and Diseases of the Rectum. The American Intelligencer and 
Medical Library was set on foot the same year, by Dr. Dunglison. In it were republished 
many valuable English works on medicine. Dr. Doane also issued this year an illustrated 
Surgery, and Dr. Dunglison added his Medical Student or aids to the Study of Medicine. YANDELL, 
of Drs. Drake and Colescott, some years later, Dr. T. S. Bell became one 
of its editors. 
The only publications in 1841, of which I have been able to find any 
account, were a volume of Essays on Fevers, by Drs. Davidson and 
Hudson, and a Practical Dictionary of Materia Medica, by Dr. John 
Bell. 
The following year, Dr. Elisha Bartlett, who had made himself 
known as one of the most elegant of our writers by his papers in the 
medical journals of the day, published his well-known work on Fevers. 
It was succeeded in 1844 by his Philosophy of Medical Science, and in 
1848 he added his Inquiry into the degree of certainty in Medicine; 
three volumes which, for grace of manner and philosophical breadth of 
view, will not sutler by comparison with any medical works in our lan- 
guage. Dr. Samuel Forry also contributed to our literature, in 1842, a 
volume which attracted the attention and elicited the praise of the great 
Humboldt—his work on the Climate of the United States and its endemic 
influences. It will remain a lasting monument to the genius and industry 
of the lamented author. While preparing this treatise for the press, he 
also set on foot the Hew York Journal of Medicine and the Collateral 
Sciences, to which he continued to contribute largely, though with fail- 
ing powers, until removed by death. The name of this young physician 
ought not to be passed over without at least a word of respectful com- 
memoration. He was “learned, without any fondness for display; a 
lover of exact detail, but always searching for principles in the facts he 
accumulated so largely ; a statistician, and yet a fluent writer. How 
entirely his devotion to his pursuits prevailed over the common weak- 
nesses and interests by which most men are influenced, was shown by the 
fearless readiness with which he threw himself into the focus of a pesti- 
lential disease for the sake of studying its nature and causes, as a mere 
episode in a pleasure trip which he had undertaken to recruit his ex- 
hausted forces.”1 
In 1843, a work was produced at Louisville by Dr. W. A. M’Dowell, 
styled a “Demonstration of the Curability of Consumption in all its 
stages;” and the same year the St. Louis Medical and Surgical Journal 
was established by Dr. M. L. Linton. A work of great merit was also 
published by Dr. Gross, of the University of Louisville, entitled “An 
Experimental and Critical Inquiry into the Nature and Treatment of 
Wounds of the Intestines,” the result of a series of experiments which 
he had performed on dogs. 
In 1844, numerous works of real value appeared. The following is a 
list: A Treatise on the Diseases of Children, by Dr. D. Francis Condie; 
a quarto volume on Operative Surgery, by Dr. Joseph Pancoast; an 
Atlas illustrative of the structure of the human body, prepared with 
great care by Dr. Henry H. Smith ; a treatise on the Teeth, by Dr. Paul 
B. Goddard and Joseph E. Parker, a practical Dentist of Philadelphia; 
an ingenious essay by Dr. John Harrison, of the University of Louisiana, 
towards a correct Theory of the Nervous System; two volumes of 
lectures, by the veteran teacher Dr. Nathaniel Chapman ; and the 
American Journal of Insanity. Few physicians in our country have 
used their pens more industriously or more profitably than Condie, whose 
work on Diseases of Children was accounted, when written, the most 
learned and judicious that had appeared on the subject in the English 
1 0. W. Holmes, Eeport Med. Literature, Trans. Am. Med. Assoc., 1848. ADDRESS ON MEDICAL LITERATURE. 
language. The great fame of Chapman as a writer and teacher gave 
currency to his volumes. Dentistry, which was already making rapid 
progress, both as a science and an art, in our country, received a favor- 
able impetus from the work of Goddard and Parker. The splendid 
work of Pancoast secured him a reputation wherever surgery was culti- 
vated. As a guide to the practical surgeon, it was of the highest value, 
each operation being illustrated by drawings representing the anatomy 
involved. 
The first work by an American, on Diseases of the Skin, appeared in 
1845, and was written by Dr. FL Worcester, of the Cleveland Medical 
College. Other valuable works were issued at the same time, one of 
which was a volume of essays on Pathology and Therapeutics, by Dr. 
Samuel H. Dickson of the Medical College of South Carolina, one of the 
most accomplished of American authors.1 Another addition was also 
made this year by a western teacher of medicine to our works on Materia 
Medica ; Dr. John P. Harrison, of the Medical College of Ohio, wrote a 
treatise on that subject in two volumes, earnestly inculcating “ Solidism.” 
‘•ln the discussion of the action of medicines, we have endeavored,” he 
says, “to place the whole question on a footing conclusively vital,” He 
discusses blood-letting at great length. His classification is recommended 
by its simplicity, alt his remedies being embraced in six classes. The 
work is written in a diffuse style, and was recommended more by its 
judicious therapeutics than by its scientific teachings. 
A volume of Lectures, by Dr. Chapman ; a work on Fevers, by Dr. 
Meredith Clymer; a treatise on Scrofula, by Dr. Phillips; the Young 
Stethoscopist, by Dr, H. I. Bowditch ; an Epitome of the writings of Hip- 
pocrates and Galen, prepared by Dr. John Redman Coxe; a valuable 
memoir by Prof. Robert Peter, containing an analysis of the calculi in 
the museum of Transylvania University, with remarks on the relative 
frequency of calculous affections at Lexington, and the probable causes; 
and First Principles of Chemistry, by Prof. Benjamin Silliman, Jr., who 
Was fast succeeding to the fame of his father, were some of the contri- 
butions to our literature in 1846.2 Dr. Lewis C. Beck, in 1846, wrote on 
the Adulteration of various substances used in Medicine and the Arts, 
with the means of detection; and a practical Treatise on Ventilation 
was also published by Dr. Morrill Wyman. 
The discovery of anaesthesia renders this year memorable in the history 
of our profession. Towards its close, Dr. Henry J. Bigelow read before 
the Boston Medical Improvement Society, a paper in which he detailed 
the facts concerning the great event that had fallen under his observation, 
and vouching for the efficacy of sulphuric ether in annulling pain in 
surgical operations. This first communication on the subject appeared 
in the Boston Medical and Surgical Journal, Hov. 18, 1846, and is^note- 
worthy as announcing to the world one of the noblest discoveries in 
Medicine. 
1 Dr. Gr. R. B, Horner added an interesting volume on the Medical Topography of Brazil 
and Uruguay, and Dr. Stephen W. Williams contributed one on the Medical Biography of 
the United States. The Buffalo Medical and Surgical Journal, under the able editorial 
direction of Dr. Austin Flint, was established. Dr. Horner had in 1839 published a work 
on the Mediterranean, and in 1854 he contributed one on the diseases and injuries of sea- 
men. Dr. J. H. Griscom published in 1845 an instructive little work on the Sanitary con- 
dition of the laboring Population of New York. 
2 Dr. Peter also contributed to Medical Science by his Analysis of the Mineral Springs 
of Kentucky, contained in the geological reports of that State. 248 
YANDELL, 
The meeting of physicians at Kew York, which resulted in the organi- 
zation of the American Medical Association, is another event of this 
year, which marks an era in the history of Medicine in the western 
hemisphere. The effect of the Association upon the profession has been 
in every way beneficent, elevating its tone, promoting harmony among 
its members, and stimulating and improving its literature. Few move- 
ments of the century to which these papers refer have contributed so 
much to the advancement of American Medicine. 
Dr. Horace Green, in 1846, startled the profession by a work on the 
Diseases of the Throat and Air-passages, proposing to introduce reme- 
dies into the larynx; but his bold practice has been justified by subse- 
quent experience, and he is now admitted to have been a pioneer in this 
department of medicine, and to have led the way to what others with 
better instruments have accomplished. 
Numerous works apeared in 1847, conspicuous among which was the 
learned treatise of Dr. George B. Wood on the Practice of Medicine. It 
had the advantage over all its predecessors in that department, of being 
founded on clinical observation, and as a consequence was soon adopted 
as the text-book in our schools, and became the popular work of reference 
with practitioners. Dr. Charles D. Meigs issued another of his works, 
written in his peculiar, somewhat fantastic style—his “Woman; her 
Diseases and Remedies,” with the effect of increasing the growing in- 
terest of the profession in Gynaecology. Dr. Joseph Carson commenced 
the issue of a series of colored “Illustrations of Medical Botany,” and 
Dr, R. Eglesfeld Griffith produced a practical volume on the same sub- 
ject. A most valuable contribution was made to pathological anatomy 
by Dr. J. B, S. Jackson, in his Descriptive Catalogue of the Anatomical 
Museum of the Boston Society for Medical Improvement. In 1847 Dr. 
David H. Tucker produced a small volume entitled Elements of the 
Principles and Practice of Midwifery.1 
In 1848, a volume of Transactions was issued at Baltimore by the 
American Medical Association, which had been organized at Philadel- 
phia the year before, A volume has been sent out by the Association 
annually since, and while it would be easy to point out defects in them 
all, it will not be denied by any unprejudiced reader that they form a 
valuable body of medical literature. All that comes before each meet- 
ing, or nearly all, appears in the Transactions, and it follows that much 
is published which if submitted to a rigid criticism would never see the 
light. But the series embraces many strong, original, and truly valuable 
papers from the best minds in the profession, and, apart from the diffu- 
sion of knowledge thence directly resulting, the effect of inviting physi- 
cians everywhere to write for the Association has been to develop and 
improve professional talent in a way that nothing but such a society 
could have done. 
The following works also came out in 1848: A volume by Dr. Alfred 
Stille, on General Pathology, which possessed great merit, both as to its 
1 Dr. H. H. Smith also published this year a Minor Surgery ; and Dr. Edward Jarvis 
contributed a treatise on Physiology for the Use of Schools and Families. Dr. J. W. 
Francis delivered an admirable anniversary address before the New York Academy of 
Medicine, which was published; Dr. John Ware published an able address on Medical 
Education. “ Water versus Hydropathy” appeared, a practical essay on Water in its rela- 
tions to Medicine, by Dr. Henry Hartshorne. Dr. John Neill published Outlines of the 
Veins and Lymphatics; and Dr. J. J. Reese a small work on Physiology. The Dental 
Register of the West also came out this year. ADDRESS ON MEDICAL LITERATURE. 
249 
matter and the style of its execution; a practical and excellent Treatise 
on the Diseases of Children, by Dr. J. Forsyth Meigs; the learned lec- 
tures on the Theory and Practice of Physic, of Drs. Bell and btokes; a 
treatise on Etherization, by Dr. Walter Channing, embodying his expe- 
rience of anaesthesia in midwifery ; a work of much originality on Croup, 
by Dr. Horace Green ; the ingenious essay on the Cryptogarnous Origin 
of Diseases, by Dr. J. K. Mitchell, a man of genius as well as ot learning 
and large experience; a posthumous volume on Surgery, by the gifted 
Dr. George McClellan, of the Jefferson Medical College, edited by his son, 
Dr. J. 11. B. McClellan; Observations on Diseases of the Chesty and on 
Auscultation, by Dr. Blakiston ; Dr. Pliny Earle’s interesting history of 
the Bloomingdale Asylum for the insane; and two new journals of 
Medicine, the Charleston Medical Journal and the Northwestern Medi- 
cal and Surgical Journal.1 
The additions to our literature in 1849 were hardly less numerous than 
those of the preceding year. Dr. Meigs produced a treatise on Obstet- 
rics ; and one on the same subject appeared from the pen of Dr. Henry 
Miller, of the University of Louisville. Both works possessed great 
merit, as the productions of independent, vigorous minds long turned 
upon that branch of medicine. Dr. E. D. Fenner issued a volume of 
Southern Medical Reports, full of original observations on the diseases 
of the Southern States, which was followed by a second volume in 1851. 
Dr. Worthington Hooker produced his “Physician and Patient,” pre- 
senting a sensible view of the mutual duties, relations, and interests of 
the medical profession and the community; and Dr. J. W. Powell con- 
tributed a work on the eye and its diseases. Equal in merit to any ot 
these, and superior to most, was a volume of Essays, by Dr. John B. Beck, 
on Infantile Therapeutics, to which are added observations on ergot, and 
an interesting account of the origin of the use of mercury in inflammatory 
complaints.2 
The contributions of 1850 embrace some of the ablest made to our 
literature by the American medical profession. They are the following: 
a Treatise on the Diseases of the Great Interior Valley of North America, 
by Dr. Daniel Drake; Observations on certain of the Diseases of Young 
Children, by Dr. C. D. Meigs; a work on Materia Medica and Therapeu- 
tics, by Dr. Thomas D. Mitchell; the Principles of Medical Jurisprudence, 
by Amos Dean, Esq,, of the Albany Medical College; a work on the 
Diagnosis and Pathology of Renal diseases, by Dr. Charles P rick, a 
History of Medical Education and Institutions in the United States, by 
1 A small volume on Etherization, with surgical remarks, by Dr. John 0. Warren, was 
contributed to the literature of that subject: and an absurd work, by Dr. J. W. Hood. ot 
Kentucky, was issued setting forth a theory that all abdominal diseases are caused by dis- 
placement of the abdominal organs, and curable by pads, trusses, and supporters. In addi- 
tion to these, the following also appeared that year; a small volume on bandaging and 
other operations in Minor Surgery, by Dr. F. W. Sargent ; a Compendium ot the various 
branches of medical science, by Drs. .1. Neill and F. G. Smith; a Handbook ot Surgery, by 
Dr. J. Neill; Lectures on Yellow Fever, by Dr. John Hastings. U. S. A.; a Medical Chem- 
istry for the use of Students, by Dr. D. P. Gardner ; an essay on epidemic meningitis, by Dr. 
S. Ames; and a dictionary of dental surgery and medical terminology, by Dr. Chapin 
Harris. . 
2 The following also appeared in 1849: a small volume on Epidemic C holera, by Dr. C. 
B. Coventry; a Treatise on the Diseases of the South, by Dr. G. McGowan ; Surgical 
Essays and Cases, by Dr. D. L. Rogers; and an Essay on Respiration and its effects, by 
Dr. E. AVillard. The Transylvania Journal of Medicine, which had been discontinued, was 
revived by Dr. Ethelbert L. Dudley for a short time. A paper on Aneurism, by his illus- 
trious uncle, Dr. B. W. Dudley, enriched one of the early numbers of the journal. 250 
Y ANDELL, 
Dr. N. S. Davis; a work on the Practice of Surgery, by Dr. J. Hastings ; 
a work on Mental Hygiene, by Dr. Win. Sweetzer; a Practical Treatise 
on the Diseases and Injuries of the Urinary Bladder, by Dr. Samuel D. 
Gross; and a work on Sleep, psychologically considered, with reference 
to Sensation and Memory, by Dr. B. Posgate. To this long list must be 
added a history of Typhoid Fever, as it appeared in Georgetown, Ken- 
tucky, by Dr. AV. L. Sutton; the American Medical Formulary, by Dr. J. 
J. Reese; an Encyclopaedia of Chemistry, by Dr. Jas. C. Booth ; and a 
treatise by Dr. Thomas E. Bond, on Dental Medicine, which is a com- 
pendium of Medical Science as connected with the study of Dental Sur- 
gery. In the same year four medical journals were started ; the New 
Hampshire Journal of Medicine, at Concord, edited by Dr. H. Parker ; 
the Western Medico-Chirurgical Journal, at Keokuk, edited by Drs. J. 
F. Sandford and S. G. Armor; the Stethoscope and Virginia Medical 
Gazette, at Richmond, edited by Dr. F. C. Gooch ; and the Nashville 
Journal of Medicine and Surgery, edited by Dr. W. K. Bowling. 
This list embraces several works of great labor and uncommon merit. 
The Observations of Meigs, like all his other contributions to Medical 
Science, abound in original views, at the same time practical and judi- 
cious. The work of Sweetzer is suggestive and ingenious ; that of Gross, 
elaborate and exhaustive; but foremost among them all, in research, in 
breadth of scientific view, and in the wide scope of observations recorded, 
is the treatise of Drake. The author had planned his work when a 
young physician, even before taking his degree in Medicine, and had 
been collecting materials for its composition during the term of an ordi- 
nary lifetime. It is not made up, as so many books in all ages have been, 
of matter borrowed from other books, but of facts collected by himself, 
in a long experience, during protracted journeys, and from original ob- 
servers. In the accomplishment of his design he traversed the whole 
Mississippi Valley, tracing the causes of its diseases from the Northern 
Lakes to Gape Sable. He sought to indicate in his treatise whatever 
there was that was distinctive in the complaints of the region of which 
he was writing, as induced by climate, race, mode of living, and the other 
agencies that modify disease. The result of his extended researches was 
given in two ample volumes, the second of which was published in 1854, 
two years after his death. That in every sense the production is a great 
one, has been conceded by all writers who have noticed the work ; and 
yet it never acquired general popularity, and is now comparatively dis- 
regarded. A quarter of a century has passed away since it appeared, and 
no3 second edition has been called for by the profession. It is not of a 
form to be used as a text-book by students, and it must be owned that it 
is not quite suited to the practitioner as a book of reference. But it is a 
vast repository of facts, upon which all future writers must hereafter 
draw who would give an account of the climate, topography, and dis- 
eases of the great valley to which it relates. It can hardly be doubted 
that it belongs to a class of works, once described by Dr. Drake himself, 
that “lie embalmed in the truths with which they are penetrated, and 
cannot decay: but like the bodies of kings and philosophers steeped in 
spices, and deposited in the catacombs, are found only in unfrequented 
closets and alcoves of libraries.” 
The most important works published in 1851 were a volume of lec- 
tures on Materia Medica, by Dr. John B. Beck, prepared for the press 
after his death, by his friend, Dr. R. C. Gilman; and a system ot Opera- 
tive Surgery, by Dr. H. H. Smith, based on the practice of the surgeons of ADDRESS ON MEDICAL LITERATURE. 
251 
the United States, and comprising a bibliographical index and historical 
record of many of their operations during a period ot two hundred yeais. 
Besides these, a history of the Massachusetts General Hospital was con- 
tributed by Dr. R. 0. Bowditch.1 Dr. M. L. Linton, ot the University 
of St. Louis, also made this year a contribution which is worthy ot 
notice, his Outlines of General Pathology ; an unpretending little volume, 
but abounding in sound medical philosophy, and written in a lucid, 
vigorous style. # . 
Dr. Austin Flint, in 1852, commenced a series of publications, the 
result of his observations of disease in hospitals and private practice, 
which have placed him at the head of American writers on practical 
medicine. That year he issued a volume ot Clinical Reports on Con- 
tinued fever, based on an analysis ot 164 cases. Ibe same year, Di. R. 
U. Piper published an elaborate work on Operative Surgery, containing 
more than 1900 engravings, with explanatory text; to which is appended 
an interesting chapter on the use of Ether in Surgery, written by Di. 
Henry J. Bigelow. This year, too, was produced a volume of essays 
written in a charming style, by Dr. S. H. Dickson, on Life, Sleep, and 
Pain.2 
Dr. William 11. Boling, of Alabama, wdiose various articles on mala- 
rious fevers in the periodicals ot the day had given him a wide reputa- 
tion, published, in 1858, an instructive essay on the mechanism and 
management in Parturition of shoulder presentment. In the same year 
Dr. Joseph Warrington contributed an Obstetric Catechism, containing 
2847 questions and answers on obstetrics proper. Dr. G. E. Brown- 
Sfquard commenced in 1853 a series of publications of great interest to 
physiologists and practitioners. The first was a small volume of expeii- 
mental researches applied to physiology and pathology. A smaller 
volume followed in 1855, on the physiology and pathology of the spinal 
cord ; and in 1857 another thin volume appeared, entitled Researches on 
Epilepsy. In 1860 he published a volume of Lectures on the Physiology 
and Pathology of the Central Rervous System, delivered at the Royal 
College of Surgeons of England; and in 1868 this was followed by 
another volume of Lectures on the Diagnosis and treatment of func- 
tional nervous affections. _ 
In 1854, a volume of substantial merit was produced by Dr. Rene La 
Roche, the title of which describes its character: Pneumonia, its sup- 
posed connection, pathological and etiological, with autumnal levels, 
including an inquiry into the existence and morbid agency of malana. 
It is a monograph of enduring interest. Other works that enriched our 
literature also appeared in that year, among which the following aie 
* 
1 Dr. Charles Delevy wrote De la Fifevre perniciense de la Nouvelle Orleans, toUowing 
this history, in 1859, with a Precis historique de la Fihvre. Dr. F. B. Hagg published a 
work on Ether and Chloroform. n, , , 
2 The following works were also published; A 'treatise on Diseases ot the Ohest, by Dr. 
John A. Swett; Records of Maculated Typhus, or Ship Fever, by Dr. J. B. Upham; a 
Treatise on Uterine Displacements, by Dr, W. E. Cole; Analysis of Physiology, by Dr. J 
J. Reese; Outlines of the Arteries, by Dr. John Neill; and a description of a skeleton of 
the mastodon giganteus, by the veteran anatomist and surgeon, Dr. John O. anen. Dr. 
A. Clapp, of New Albany, a man of great attainments in general science as well as in niedi- 
cine, contributed a valuable synopsis or systematic catalogue of the medicinal plants of the 
United States, to the American Medical Association, which appeared in its transactions 
for that year, and was afterwards issued in a separate volume of more than 200 pages. 
In 1852 two periodicals were published in New Orleans the New Orleans Medical 
Journal, and the Monthly Medical Register. Since the war, the former has been revived, 
and is ably conducted by Dr. Samuel M. Bemiss. 252 
YANDELL, 
conspicuous: a treatise, by Dr. Gross, full and exhaustive, on Foreign 
Bodies in the Air Passages; Dr. T. G. Richardson’s Elements of Human 
Anatomy, in which the author, as far as he could, has substituted English 
for the Latin terminology—a manual admirably adapted to the dissecting 
room; Dr. Bennett Dowler’s “ Tableau of Yellow Fever” as it prevailed 
in Yew Orleans in 1853, with topographical, chronological, and historical 
sketches of the epidemics of that city since their origin in 1796; and a 
history of the yellow fever of 1853, in Yew Orleans, by Dr. E. D. Fenner.1 
Dr. Meigs also added to his other valuable works, this year, a volume 
written with great force, on the nature, signs, and treatment of childbed 
fevers, contending against their transmission by contact. And Dr. Jacob 
Bigelow laid the profession under additional obligation by a volume 
entitled “Yature in Disease, illustrated in various discourses and 
Essays,” recommending by conclusive arguments the conservative medi- 
cine, toward which the professional mind of the age is so strongly tend- 
ing. A volume was published in 1854, by Dr. A. S. Piggott, entitled 
Dental Chemistry and Metallurgy, which was of much use to practition- 
ers of Dentistry. 
The publications of 1855 were, many of them, of very great excellence 
and interest. The Letters of Dr, James Jackson to a Young Physician, 
in a small volume, to which he added a second series in 1860, are adapted 
to the wants of the inexperienced of every age, and may be read with profit 
by all young practitioners. A small work, by Dr. Hugh L. Hodge, on 
criminal abortion, discusses a subject, the interest of which is likely to 
increase with time. The treatise on Medical Jurisprudence, by Francis 
Wharton, Esq., and Dr. Moreton Stille, stands on a level with the great 
work of Beck. The joint production of a learned jurist and an able 
physician, it possesses merits not likely to be found in a work by a single 
hand. It is a noble monument to the memory of its medical contributor, 
who died almost at the moment when the last sheets of his work were 
issuing from the press. Gifted, cultivated, and laborious, Stille, in his 
short life, accomplished a work of which his profession is justly proud, 
and which only increases the regret at his early death. The monograph 
on the Diseases affecting the Respiratory Organs, by Dr. Flint, was in the 
line of his work on Continued Fever, and worthy of it. The tract of 
Dr. 0. W. Holmes, entitled Puerperal Fever as a Private Pestilence, pre- 
sents strong reasons for believing in the contagiousness of the disease. 
It was pronounced by Rarnsbotham, when it came out, “a masterly per- 
formance.” Dr. Zina Pitcher, in a paper on the Induction of Puerperal 
Fever by Inoculation, so called, takes the opposite side of the question, 
which he supports by a great arraj7 of facts. An Army Meteorological 
Register, for twelve years, originating from an office suggested by Hon. 
J. C. Calhoun, while Secretary of War, and prepared under the direction 
of Surgeon-General Thomas Lawson, is of value. Dr. E. R. Peaslee wrote 
this year a valuable work on Croup, and a work for students on Chemis- 
try was issued by Dr. B, Howard Rand. 
But the great work of this year was that on Yellow Fever, by Dr, La 
Roche. The American press has given birth to no original work supe- 
rior to it in research or learning. As a monograph on one of the most 
1 To this list must be added a text-book of Anatomy, for the use especially of students of 
Dental Surgery, by Dr. R. Handy, of the Dental College of Baltimore; a volume of Lec- 
tui’es on pulmonary consumption, by Dr. T. Thompson ; Letters on Yellow Fever, Cholera, 
and Quarantine, by A. F. Yach6; and a work on Human Physiology, by Dr. Worthington 
Hooker, designed for Colleges and general reading. ADDRESS ON MEDICAL LITERATURE. 
253 
formidable of the epidemics that afflict our race, it may be doubted 
whether anything more exhaustive is contained in any language. It 
was the production of a laborious student, a thorough medical scholar, and 
an amiable and accomplished gentleman. 
In 1855, the Atlanta Medical and Surgical Journal, under the care of 
Drs. Westmoreland and Batty, was set on foot, and in the same year a 
History of the American Medical Association was written by Dr. R. S. 
Davis.1 
The following year was also productive of valuable additions to the 
stock of our literature. Professor Edward Parrish, ot the Philadelphia 
College of Pharmacy, wrote an introduction to practical pharmacy, which 
was useful in that department ot medicine; an original and most able 
work on Human Physiology, statistical and dynamical, was contributed 
by Dr. John W. Draper, who before had written a remarkable treatise on 
the forces which produce the organization ot plants, in which he proposed 
a simple and ingenious theory of the capillary circulation. Dr. George 
H. JCood communicated the results of his matured researches concerning 
medicines, in his able treatise on Therapeutics and Pharmacology, or 
Materia Medica, which has long been an authority in the profession. A 
prize essay of great interest was published by Dr. George 11. Lyman, 
giving the history and statistics of Ovariotomy, and the circumstances 
underswhich the operation may he regarded as safe and expedient. A 
Treatise on Surgery, the result of much labor, by Dr. 11. H. Smith, was 
added to our literature on that subject. A history of the medical pro- 
fession in ancient times was contributed by Dr. John Watson. Dr. 
James Stewart produced a practical treatise on the Diseases of Children. 
Dr. Isaac Taylor, in a short paper, called the attention of the profession to 
the sun-burnt appearance ot the skin as an early diagnostic symptom ot 
supra-renal capsule disease. Dr. J. M. Allen added another to the list of 
our anatomical works, in his Practical Anatomist. The Rorth Ameri- 
can Medico-Chirurgical Review, which originated in Louisville, but was 
shortly afterward transferred to Philadelphia, was added by Drs. Gross 
and Richardson to our long list ot medical journals.2 
The question of the original unity of the human race has been a good 
deal discussed in our countiy since the appearance ot Dr. S. S. Smith s 
work on the subject, and in 1857 a treatise of much bulk and labor was 
contributed by Drs. Rott and Gliddon, On the Indigenous Races of the 
Earth, of the merits of which various opinions have been expressed, ac- 
cording to the preconceived notions of the writers. Dr. E. in 
this year published a work on Human Histology, to which, in 1872, he 
added one of great interest, on Ovarian Tumors. Dr. Paul F. Eve did 
the profession a service by collecting into a volume many Remaikable 
Cases in Surgery, showing into what errors surgeons ot expeiience and 
1 An Essay on Malignant Cholera, by Dr. B. M. Byrne ; the Practitionei s 1 haimaco- 
poeia, by Dr. J. Foote ; a Discourse, by Dr. J. H. Griscom, on the relation between the 
people and the Science of Medicine ; and a volume, by Drs. Comstock and Comings, on 
Physiology, chiefly taken without acknowledgment from the writings ot Carpenter, were 
also among the publications of 1855. 
2 Dr. Joseph Jones published in this year some investigations relative to American v er- 
tebrata; and Dr. M. L. Knapp wrote an interesting inquiry into the cause of Nurse’s Sore 
Mouth, and in the following year produced a rambling treatise, styled Researches as to the 
Pathology and Origin of Epidemics, tracing all to the existence of a scorbutic taint. Dr. 
Benjamin Haskell also published this year some ingenious Essays on the physiology of the 
nervous system, with an appendix on hydrophobia, and the Medical and Surgical Reporter, 
under the editorial care of Dr. S. W. Butler, took its place among our periodicals. 254 
YANDELL, 
skill may fall, and under what extremities patients may sometimes 
recover. This year, also, was published an interesting Catalogue of 
Crania, by Dr. j. Aitken Meigs. But a more important contribution to 
our literature was made by Dr. H. F. Campbell, in an essay to which a 
prize was awarded by the American Medical Association, On the Excito- 
Secretory System of Nerves. In the views advanced on this subject, Dr. 
Marshall Hall admitted that Dr. C. had anticipated him, as well as 
M. Claude Bernard. 
The succeeding year two large octavo volumes on Materia Medica, full 
of useful matter, were issued by Dr. William Tully; a text-book on 
vegetable and animal physiology was produced by Dr. H. Goadby, and 
an interesting monograph on Scarlatina, by Dr. Caspar Morris, appeared 
in a new dress, having been first issued some years before; a work, too, 
on the diseases of the urinary organs, wTnch was followed by one, in 
1861, on the effects of the retention of the elements of urine in the 
blood, was published by Dr. W. W. Morland.1 A volume of lectures on 
Surgery, delivered by Prof. E. Geddings, of the Medical College of 
Charleston, was published in 1858. It is to be regretted that the learned 
and able author has not followed up his work. 
In 1859, the treatise of Dr. John C. Dalton, on Physiology, which still 
maintains its place as a text-book in our schools, was published, and is 
not likely to be soon superseded. It is a work which has advanced 
physiological science, and in which the student finds a condensed but 
lucid summary of its truths, communicated in a pleasing style. With it 
appeared another work which has conferred lustre upon the medical lit- 
erature of our country, the learned and able System of Surgery, by 
Dr. Samuel D. Gross, With an industry truly indefatigable, the author 
has continued to add to its successive editions, until he has made it one of 
the most thorough systems of surgery to be found in any language. Dr. 
Austin Flint, the same year, produced a practical treatise on the Diseases 
of the Heart, which ranks among the high authorities on that subject. 
A volume of essays, written by his gifted father, was published this 
year by Dr. S. Weir Mitchell. In these essays, the author appears as a 
chemist and philosopher, and shows that, if he had continued his labors, 
so successfully begun in that direction, he might have attained a high 
rank among the scientific men of his time. His researches concerning 
the diffusion of gases gave him a glimpse of some of the most interest- 
ing discoveries of which modern chemistry can boast.2 
In 1860 a number of excellent books were produced, foremost of which 
in research and learning, as well as in size, is the treatise of Dr. Alfred 
Stifle, on Therapeutics and Materia Medica. Of the progress of our medi- 
1 Valuable contributions to operative surgery and surgical pathology were made this 
year by Dr. J. M. Carnochan, and Dr. Horace Green published selections from favorite pre- 
scriptions of living American practitioners. The following journals were set on foot in 
1858 : The Chicago Medical Journal, by Dr. J. Adams Allen ; the Cincinnati Lancet and 
Observer, by Dr B. B. Stevens; and the Cincinnati Medical New'S, by Dr. J. A. Thacker, 
A little work was also published by Dr. Jacob Bigelow, entitled Brief Expositions of Prac- 
tical Midwifery, to which is prefixed the Paradise of Doctors. 
2 Dr. E. J. Coxe wrote, this year, on the Yellow Fever of New Orleans; Dr. V. M. Fran- 
cis published a Thesis on Hospital Hygiene, and a work styled Contributions to Midwifery ; 
the Diseases of Children was issued by Drs. Noeggerath and Jacobi; Dr. J. J. Moorman 
wrote an account of the Virginia Springs and the Springs of the South-West, which was of 
great value to invalids in search of watering-places. A small treatise was published by Dr. 
John M. Watson, of the University of Nashville, on trismus nascentium, which he traces to 
irritation of the umbilicus in the young child. Dr. James E. Reeves, the same year, pub- 
lished a Practical Treatise on Enteric Fever. ADDRESS ON MEDICAL LITERATURE. 
255 
cal literature during the century, we could hardly point to any evidence 
more conclusive than that afforded by a comparison ot this scientific work 
with the elementary treatises on the same subject written forty years be- 
fore. We are quite willing that by it the world shall judge ot American 
Medical authorship. The “Practical Treatise on Fractures and Disloca- 
tions,” by Dr. Frank Hastings Hamilton, has become a standard authority 
on the subject.1 An Elementary Treatise on Anatomy was prepared by 
the learned Professor of Anatomy in the University ot Pennsylvania, Dr. 
Joseph Deidy. Dr. Henry Hartshorne published “Memoranda Medica, 
or note-book of medical principles. A very instructive work was issued 
by Dr. Hugh L. Hodge, on the diseases peculiar to females, including 
displacements of the uterus. And among the “Contributions ot the 
Smithsonian Institution appeared an original paper of much interest, by 
Dr. S. Weir Mitchell, on the venom of the rattlesnake.2 
Of the publications of 1861, the most important was a work on the 
principles and practice of Obstetrics, by Dr, Gunning S. Bedford, of the 
University of Hew York. But the American Medical Biography, edited 
by Dr. Samuel D. Gross, has also high claims upon the profession, and 
ought to be extended. It is a work which must be of interest to every 
American physician, as a record of the lives of men who have done 
honor to the profession. Dr. Gross, the same year, produced an excellent 
manual of military surgery. A “ Manual of Military Surgery,” was also 
produced by Dr. j. Julian Chisholm, at Columbia, South Carolina, and 
was the text-book of the surgeons of the Confederate army during the 
civil war. And one on the same subject was contributed by Drs. Black- 
man and Tripler.3 _ 
The effect of the civil war in repressing our literature, was manifest 
in 1862, in the course of which very few original books were published. 
One of these was the Medical History of the Philadelphia Almshouse, by 
Dr. D. Hayes Agnew; a second was a treatise, by Dr. A. Jacobi, on den- 
tition and its derangements ; and a third was a practical guide to diseases 
of the eye, by Dr. 11. "W. Williams. Dr. Stephen Smith added an oppoi- 
tune hand-book on surgical operations. 
In 1863, the number was also small. They were a Manual of the 
institutes of military surgery, by Dr. J. Ordronaux; a manual of minor 
surgery, by Dr. J. 11. Packard, and the practice of surgery for field and 
hospital, by Dr. E. Warren. Dr. J. J. Whodward made a practical and 
substantial contribution to military medicine, in a volume on the chief 
1 A useful medico-legal treatise on Malpractice was written by Dr. John J. El well. Dr. 
Samuel W. Francis presented to the profession a report of the Clinical Lectures ot Dr. 
Valentine Mott in the University of New York. .„ , , 
2 A Catalogue of the Pathological Cabinet of New York Hospital, classified and 
arranged, was published this year by Dr. Robert Ray, Jr., and also an epitome ot medicine 
and surgery, by Dr. W. S. Wells. Dr. Edward Warren, in 1860, published an interesting 
biography of Dr. John 0. Warren. Two new medical journals were also projected: the 
Pacific Medical and Surgical Journal, edited by Dr. Henry Gibbons, and the Chicago 
Medical Examiner, edited by Drs. N. S. and F. H. Davis. m 
3 Besides these, the following works also appeared in 1861; A Practical i realise on 
Phthisis Pulmonalis, by Dr. L. M. Lawson, of Cincinnati; a work by Dr. R. M. Hodges, 
on Excision of the Joints; one by C. H. Jackson, on Etherization ; a sprightly paper on 
Currents and Counter-currents in Medical Science, by Dr. 0. W. Holmes; a work on 
Placenta Prsevia, by Dr. William Reid; and two valuable Essays, by Dr. Fordyce Barker, 
one on an Effort to shorten the first stage of Labor; the other on the use of anaesthetics 
in Midwifery. Dr. Edwin R. Maxson also published this year a volume on the Practice 
of Medicine, and, in 1868, he published an account of Hospitals, British, French, and 
American. 256 
YANDELL, 
camp diseases of the U. S. armies as observed during the war of the 
rebellion. 
In 1864, an important work on Gunshot Wounds and Injuries of Nerves 
was contributed by Dr. S. Weir Mitchell and Drs. Morehouse and Keen ; 
and in this year the following works also appeared: Lectures on Vene- 
real Diseases, by Dr. William A. Hammond ; a Medical Dictionary, by 
Dr. J. Thomas ; a paper on the puerperal disease, by Dr. B. F. Barker ; a 
work by Dr. Bartholow on disinfection, which was followed in 1867 by a 
manual on enlisting and discharging Soldiers, and in 1868 by a work on 
spermatorrhoea ; a prize-essay by Dr. H. F, Damon, on leucocythsemia ; a 
volume of Medical and Surgical Essays, by Dr. W. A. Hammond; a 
“ Memoire sur la fibvre paludienne,” by Dr. J. C. Faget; and an ac- 
count, by Dr. J. O’Reilly, of the Nervous and venous connection 
between the Mother and the Foetus. 
The following is a list of the publications in 1865: a Monograph 
on glycerin, by" Dr. H. Hartshorne; the Book of Prescriptions, by Dr. 
Henry Beasley ; a Treatise on Military Surgery and Hygiene, by Dr. F. 
IT. Hamilton; a Vest-pocket Medical Lexicon, by Dr. D. B. St. John 
Roosa ; a Treatise on the Diseases and Accidents incident to Women, by 
Dr. W. H. Byford ; and Elements of Materia Medica for the use of stu- 
dents, by Dr. John B. Biddle. The last two are substantial additions to 
our practical medical literature. No more eligible text-book than Dr. 
Biddle’s has yet been written ; and the volume by Dr. Byford illustrates 
a class of affections which he has studied with success. To this list we 
have to add the able work of Dr. W. H. Van Buren on the Surgical Dis- 
eases of the Genito-Urinary Organs, and his contributions to Practical 
Surgery ; and the Lectures of Dr. J. H. Packard on inflammation.1 
Cholera prevailed in the United States in 1866, and a number of works 
were written concerning the epidemic; but besides these, that year was 
productive of some of the best contributions made by American writers to 
medical science. The work of Dr. Austin Flint, on the Principles and 
Practice of Medicine, is entitled to the first place among our treatises on 
that subject. It is the production of a practical, able, and patient ob- 
server, who speaks from long clinical experience, and is written in a clear, 
direct, concise style, and with a fulness that leaves nothing to be desired. 
And by the side of this admirable work deserves to stand the treatise of 
Dr. Austin Flint, Jr., on Physiology, the first volume of which appeared 
about the same time, and which has since been completed in five volumes. 
Few works of equal merit to these, the productions of father and son, have 
proceeded from American authors. Another publication of that year 
possessing great value was the treatise of Dr. J. M. Da Costa, on Medi- 
cal Diagnosis, a work with which our students of medicine can hardly 
dispense; and one of equal value to the practitioner was that of Dr. J. 
Marion Sims, entitled Clinical Notes on Uterine Surgery, with special 
reference to the sterile condition ; the first treatise written in our lan- 
guage on the surgery of the uterus.2 
’ In this year the following works too appeared : A Sanitary Code for Cities, by Dr. H. 
G. Clarke; a volume on Hypodermic Injections, by Dr. Antoine Ruppauer ; and the New 
York Medical Journal, edited at first by Dr. W. A. Hammond, and subsequently by Drs. J. 
B. Hunter and W. T. Lusk. 
2 A treatise appeared, this year, by Dr. J. W. Wright, on Psychology, and one by Dr. S. 
G. Webber, on cerebro-spinal meningitis. Dr. A. 0. Garratt also contributed one on electro- 
therapeutics, and three new journals of medicine were projected—the Detroit Review of 
Medicine, by Drs. Conner and Lyons ; the New York Medical Record, by Dr. Geo. F. Shrady, ADDRESS ON MEDICAL LITERATURE. 
257 
Dr. Henry Hartshorne in 1867 produced a volume which has met with 
much professional approbation, entitled Essentials of the Principles and 
Practice of Medicine. A very able work of an original character, on the 
micro-chemistry of poisons, was produced by Dr. Theo. G. Wormley. Dr. 
J. Solis Cohen contributed a valuable volume on Inhalation, its_ thera- 
peutics and practice. One was produced on injuries of the Spine, by 
Dr. John Ashhurst, Jr., containing an analysis of nearly four hundred 
cases. Drs. Francis Minot and "Charles Homans, Secretaries of the 
Society, published a volume of Extracts from the Transactions of the 
Poston Society for Medical Improvement, with Papers read before the 
Society. The lamented Dr. J. Mason "Warren contributed a valuable 
volume of Surgical Observations, with Cases and Operations. Dr. A. 
P. Smith wrote on the treatment of fractures of the lower extremi- 
ties, by the use of the anterior suspensory apparatus; and Dr. John 
H. Packard published Rotes on Fractures of the Upper Extremity. A 
volume of Researches upon Spurious Vaccination was contributed by Dr. 
Joseph E. Jones. Dr. Henry J. Bigelow published a practical paper on 
Ununited Fractures successfully treated ; and Dr. B. Howard Rand con- 
tributed an elementary work on Chemistry. A work of much labor was 
issued under the editorial supervision of Dr. A. Flint, entitled Contribu- 
tions relating to the Causation and Prevention of Disease, and Camp 
Diseases, together with a report of the diseases, etc., among the prisoners 
at Andersouville. A large volume, entitled Mechanical Therapeutics, a 
treatise on surgical appliances, was produced by Dr. Philip S. Wales, at 
Philadelphia. A Monograph on Cerebro-Spinal Meningitis, treating ably 
of the subject, was issued by Dr. Alfred Stifle. Dr. S. 11. Dickson made 
a valuable contribution to Studies in Pathology and Therapeutics ; and 
an interesting work on the Medical Use of Electricity was produced by 
Drs. George M. Beard and A. D. Rockwell. To which long catalogue 
of publications for that year we have to add the Leavenworth Medi- 
cal Herald, by Dr. Tiffen Sinks, and the Medical Archives, by Dr. J. C. 
Whitehill, published at St. Louis.1 
In 1868 three important works were produced on the diseases and acci- 
dents incident to females; an Obstetric Clinic, by Dr. George T. Elliot; 
a Practical Treatise on the Diseases of Women, by Dr. T. Gail lard 
Thomas; and a work on Vesico-vaginal Fistula, by Dr. Thomas Addis 
Emmet. Dr. Dalton wrote a Treatise on Physiology and Hygiene, for 
schools, families, and colleges; a volume of Reports of the Pennsylvania 
Hospital, was edited and issued by Dr. Da Costa and Dr. W. Hunt; and 
a work on Physical Diagnosis was published by Dr. Alfred Loomis.2 
and the Richmond (now Richmond and Louisville) Medical Journal, by Dr. L. S. Gaillard, 
editor and proprietor. This year the following works also were published: Contributions to 
hone and nerve Surgery, by Dr. J. 0. Nott; a small treatise on food and digestion, by Dr. 
Howard Townsend; Lectures on Orthopedic Surgery, by Dr. L. Bauer ; a small treatise on 
Orthopedics, by Dr. D. Prince, followed, in 1871, by one on Plastics ; and works of greater 
°l' less length on Cholera, by Drs. J. C. Peters, R. Nelson, E. Whitney, 1. A. Burrall, 
Palmer, Fletcher, and Henry Hartshorne. 1 
1 Two works on conservative surgery, one by Dr. H. 0. Davis, and another by Dr. A. 
C. Walter, appeared in 1867, and with them a Manual of Examinations, by Dr. J. L. Lud- 
kw; a paper on Epidemic Cholera, by Dr. G. Hurt; a Treatise on Polypus ol the Ear, by 
Hr. Edward H. Clark; a work by Dr. D. Wooster, on Diseases of the Heart, and a Thesis 
011 Aneurism of the Aorta, by Dr. E. Souchong. 
2 Beside these the following also appeared: The Law of Human Increase, or Population 
based on Physiology and Psychology, by Dr. Nathan Allen; a Practical Anatomy, by Dr. 
H• H. Agnew, who followed it in 1873 by a work on laceration ot the perineum ; a Trea- 
tise, by Dr. W. Bodenhamer, ou Diseases of the Rectum; a Dissertation, by Drs. Edes, 
17 258 
YANDELL, 
The following list comprises the most noted publications of 1869. A 
Treatise on the Diseases of Infancy and Childhood, by Dr. J. Lewis 
Smith; a Conspectus of the Medical Sciences,'by Dr. H. Hartshorne; 
Outlines of Comparative Anatomy and Medical Zoology, by Dr. Harrison 
Allen; a History of the Medical Department of the University of Penn- 
sylvania, by Dr. Joseph Carson; the Intermarriage of Relations, by Dr. 
Hath an Allen; a treatise, by Dr. J. S. Lambert, on Longevity; Con- 
tribution to the Medical History of the United States, by Dr. J. M. 
Toner; the Mechanism of Dislocation and Fracture of the Hip, by Dr. 
11. J. Bigelow; an essay on External Perineal Urethrotomy,_ by Dr. J. 
W. S. Glouley; a volume on the Jurisprudence of Medicine, in its rela- 
tions to the law of contracts, by Dr. Ordronaux; a work, in quarto, on 
Amputation of the Cervix Uteri in certain cases, by Dr. Isaac E. Taylor; 
a compend of Materia Medica, by Dr. John C. Riley, and a volume on 
the physiology and pathology of the sympathetic nervous system, by Dr. 
Robert T. Edes. In addition to these, a small treatise was written on 
Yeratrum Yiride, by Dr. R. Amory ; one on physical culture in Amherst 
College, was contributed by Dr. H. Allen; and one, of much greater size, 
on the Principles of Haval Staff Rank and its History for over halt a 
century, by a Surgeon in the U. S. Havy. The Archives ot Ophthalmo- 
logy, edited by Profs. Knapp and Moos, and the Oregon Medical and 
Surgical Journal were projected this year. 
The most important contributions in 1870, were the Surgical Memoirs 
of the War of the Rebellion, which when completed will form the most 
magnificent work pertaining to medicine that our country has produced; 
an if the Treatise on the Theory and Practice of Obstetrics, by Dr. \\ .H. 
Byford, which stands on a level with the best of a class of works in 
which the profession of America is conceded to have excelled. The Lec- 
tures on the Diseases of the Rectum, by Dr. W. H. Yan Luren, and the 
Hand-book of Operative Surgery, by Dr. J. H. Packard are valuable 
contributions to practical surgery; as are also the Bellevue and Charity 
Hospital Reports; the Medical and Surgical Reports of the Boston City 
Hospital, and the work of Dr. J. A. Lidell on wounds of the bloodves- 
se]s>i 
The publications of the Surgeon General’s Office were continued in 
1871, and some very able works appeared with them, at the head ot 
which professional opinion ranks the Principles and Practice of Surgery, 
Hibbard, and Spare, on Nature and Time in Disease; a posthumous work on Electro- 
Phvsioloor, by Dr. Morgan, edited by Dr. Hammond; and the Principles and 1 ractice ot 
Laryngoscopy, by Dr. A. Ruppaner. The American Journal of Obstetrics, edited by Dr. 
B P Dawson, was also added to the list of our serials. 
1 An excellent little Manual of the Urine was published by Dr. A. Flint, Jr.; and an 
interesting tract styled “ New Facts and Remarks concerning Idiocy” was issued by Dr- 
Edward Be«’uin. The Microscopical Anatomy of the Liver was illustrated by Dr. H. p. 
Schmidt, in*an article in the New Orleans Medical Journal, which was afterwards issued m 
n sonar ate form ; and a useful treatise was produced, on naval hygiene, by Dr. Joseph G- 
Wilson and Dr Albert C. Gorgas ; in addition to which Dr. M. Clymer published valuable 
notes on the physiology and pathology of the nervous system; J.C. Hutchison com 
tributed a small treatise on physiology and hygiene; and Dr. L, H. Morgan published a 
system of consanguinity of the human family. The new journals set on foot in 18 <0 were 
the Clinic, at Cincinnati, by Dr. J. T. Whittaker; the Philadelphia Medical limes, edited 
by Dr. H. C. Wood; the Michigan University Medical Review, by Drs. Cheever, Rose, 
Prescott, and Frothingharn ; the American Journal of Syphilography, by Dr. M. H. Henry , 
and the American Practitioner, by Dr. David W. Yandell and Dr. iheophilus Parvin- a 
continuation of the Western. Journal of Medicine, which was for some years conducted oy 
Prof. Parvin at Indianapolis. The Photographic Review ot Medicine and burgery w 
also set on foot. ADDRESS ON MEDICAL LITERATURE. 
259 
by Dr. John Ashhurst, Jr, The treatise of Dr. W. A. Hammond, on 
Hervous Diseases, is also a graceful addition to our professional litera- 
ture, albeit his readers may not always obtain the gratifying results 
from remedies reported as occurring in his practice. The Report to the 
Surgeon General’s Office of the surgical cases in the army of the United 
States from 1865 to 1871, is an invaluable storehouse of facts; and emi- 
nently useful also, for its statistics, is the first annual Report of the Board 
of Health Department of Hew York.1 
In 1872, a volume was produced by Dr, S. Weir Mitchell on Injuries 
to the Herves, and their consequences, which is esteemed one of the most 
valuable contributions to surgical science made by an American writer. 
An elaborate work on ovarian tumors was issued by Dr. B. R. Peaslee. 
Hr. Gurdon Buck illustrated lithotomy and lithotrity by a number of 
cases in a brief memoir on the subject. Dr. Thomas M. Markoe wrote 
an able treatise on diseases of the bones, and Dr. J. W. S. Gouley con- 
tributed one on the diseases of the genito-urinary organs, which has been 
much commended. The little volume of Dr. H. C. Wood, Jr., on Thermic 
Uever or Sunstroke, is scientific and practical, the production of a-mind 
trained and adapted to philosophical investigation. With it appeared 
his Year Book of Therapeutics, Pharmacy, and the allied sciences. A 
volume of clinical lectures on various important diseases, possessing 
uncommon excellence, was contributed by Dr. H. S. Davis.2 In this year 
also appeared the last work of the learned and indefatigable Dunglison, 
who had been called away from his earthly labors, leaving his History of 
Medicine to be completed by his son Dr. Richard J. Dunglison. This 
posthumous work of the great medical scholar is a fit companion of his 
dictionary, by which his name is destined to be transmitted to the latest 
! A Handbook of Medical Microscopy was a seasonable contribution by Dr. Joseph G. 
Richardson. Three new journals appeared during the year, viz.: New Remedies, by Dr. 
H. 0. Wood, Jr., at New York; the Kansas City Medical Journal, by B. W. Shauffler; 
and the Southern Medical Record, at Atlanta, by Drs. Powell and Goldsmith. Dr. B. Joy 
Jeffries wrote a treatise on the eye in health and disease: Dr. M. L. Holbrook produced one on 
parturition without pain; Dr. A. L. Gihon wrote on surgery and naval hygiene; and Dr. 
Joseph Jones appeared in one. of his laborious memoirs, giving an account of the clinics at 
the Charity Hospital in New Orleans. Emergencies, and how to treat them, is the title 
°f a manual by Dr. Joseph W. Howe, of the University of New York, which affords know- 
ledge useful to all; and the work on Bromides, by Dr. Bartholow, was read with interest 
at a time when the action of these medicines was so much discussed. Internal urethrotomy 
Was discussed in a short paper by Dr. C. H. Mastin ; Dr. Allen produced another treatise 
bearing on vital statistics, entitled Lessons on Population, suggested by Grecian and Roman 
History. Dr. B. W. Neftel added one on Galvano-Therapeutics, and Drs. Beard and Rock- 
well brought out their work on the Medical and Surgical uses of Electricity in an enlarged 
form, rendering it complete as to the present state of that branch of therapeutics. The 
tenth edition of the Medical Students’ Yade mecum, by Dr. George Mendenhall, was issued; 
that year. 
2 The little works of Drs. Clarke and Araory on the Bromides of potassium and sodium,, 
Dr. Morrill Wyman on Catarrh or hay fever, are both admirable in their way. A 
hand-book of post-mortem examinations and of morbid anatomy, by Dr. Francis Delafield,. 
ajso appeared. The attention of the profession was directed to Earth as a topical applica- 
tion in Surgery, by Dr. Addinell Hewson, in a work on that subject. A Clinical Manual of 
the Diseases of the Ear was prepared by Dr. Lawrence Turnbull. A brief account of the 
treatment of the Venereal Disease in the Vienna Hospitals was published by Dr. M. H.. 
Henry. Two excellent little monographs on Diseases of the Skin, and Animal and Vege- 
table Parasites of the Human Skin, were issued by Dr. B. J. Jeffries ; the 'fen Laws of Health 
were illustrated by Dr. J. R. Black ; and Dr. J. S. Cohen contributed a practical work on 
Diseases of the Throat. Dr. J. W. Richardson read a judicious paper on puerperal convul- 
sions to the Medical Society of Tennessee ; and Dr. Stephen Smith produced a volume styled 
Doctor in Medicine, with other papers. The Charleston Medical Journal, which for some 
time had been suspended, was revived this year by Drs. Porcher and Kinloch. YANDELL, 
ages. The medical journals originated in 1872 were the Western Lancet, 
at San Francisco, by Drs. Trenor and Babcock; and the Sanitarian, edited 
by Dr. A. FT. Bell, at New York.1 
" In 1873 a number of valuable works were published, prominent among 
which was Contributions to Surgery, by that faithful worker and accom- 
plished medical scholar, Dr. George W. Norris. A handsome volume of 
superior merit on ovarian tumors was brought out by Dr. Washington 
L. Atlee, and Dr. John A. Lidell produced one on apolexy. A volume 
of clinical lectures on diseases of the nervous system swelled the con- 
tributions of Dr. W. A. Hammond to medical science. A volume of 
huge proportions was written by Dr. James E. Garretson on the somewhat 
limited subject of oral surgery, and Dr. Isaac Hay published one entitled 
Contributions to Mental Pathology. 
In 1874, a work possessing some novel and attractive features was 
issued by Dr. Horatio 0. Wood, Jr., on Therapeutics, Materia Medica, 
and Toxicology. The author devotes much more space than any previous 
writer has done to the physiological action of medicines, facts bearing 
upon which he has collected with great industry from every accessible 
■source. This departure of Dr. Wood from the old beaten track of writers 
,ou materia medica imparts unusual interest to his pages. The other 
works of this year were a treatise by Dr. R. A. Gunn, on the Venereal 
Disease, and a-small volume on Croup, by Dr. J. Solis Cohen.2 
In 1875, an exhaustive volume was issued on the Epidemic Cholera of 
1878. It was the joint production of Drs. Ely M’Clellaip J. C. Peters, 
J. M. Woodworth, and J. S. Billings, prepared by order of the General 
Government, No more thorough discussion ot the etiology of cholera is 
to be found in any American work, and, as a whole, it will take its place 
with the foremost of the many volumes called forth in our country by 
that pestilence. The work of Dr. Loomis on the Diseases of the Respi- 
ratory Organs, notwithstanding the fulness with which the subject had 
been treated in earlier works, was an acceptable contribution. A volume 
was published by Dr. R. W. Taylor on Syphilitic Lesions of the Osseous 
System. Dr. C. S. Fenner contributed a work on Vision, its optical de- 
fects, and the adaptation of Spectacles. A work on pulmonary tubercu- 
losis was brought out by Dr. Addison P. Dutcher. Dr. W. B. Atkinson 
issued a small but practical volume, entitled Hints in the Obstetric Pro- 
cedure. Dr. James E. Reeves established, at Wheeling, a journal styled 
the West Virginia Medical Student. Two volumes of immense labor, 
made up of Statistics, medical and anthropological, of the Provost-Mar- 
fibal-General’s Bureau, were prepared by Dr. J. K, Baxter; and Dr. B. J. 
Getting produced a volume of medical addresses. 
The works issued in the first months of 1876 belong to the century we 
are commemorating. Of these, one was a characteristic volume of medi- 
cal and surgical memoirs, by Dr, Joseph Jones, the first of an elaborate 
aeries which the author contemplates. This treats of many subjects, and 
1 Dr. H. Y. W. Sweringen also added a pharmaceutical lexicon ; Dr. M. A. Milland 
wrote a work on civil mat-practice; Dr. D. B. St. J. Roosa produced a treatise on diseases 
of the ear; Dr. Prince published a report on galvano-therapeutics, and Dr. Henry G- 
Piffard wrote a little work on urinary analysis. 
2 Besides these the following were contributed ; A treatise by Dr. A. D. Williamson on 
diseases of the ear ; one on the “ breath and fetid odors,” by Dr. J. W. Howe ; one by Di- 
pl Holden on the Sphygraograph ; a manual of toxicology, by Dr. J. J. Reese, and a small 
volume by Dr. Thomas C. Minor on erysipelas and childbed fever. A new journal, the 
Virginia Monthly, was also started by Dr. L. B. Edwards, at Richmond, and one, the Medica 
Times, at Louisville, by Dr. E. S. Gaillard. ADDRESS ON MEDICAL LITERATURE. 
261 
with a patient industry seldom shown by native writers. Dr. Austin 
Flint, Jr., issued a splendid volume, comprising; the substance of his live 
volumes on physiology, intended as a text-book for students. A work 
on extra-uterine pregnancy was produced by Dr. John S. Parry, whose 
early death the profession was called on to deplore soon after the appear- 
ance of his work, giving so much proof of his ability to enrich his pro- 
fession. Two works were contributed by Dr. Austin Flint, a monograph 
on Phthisis, and a small volume of essays on Medicine, 
works worthy of the fame of their admired author. Dr. Lewis A. Sayre 
added to the productions of the century a volume, abundantly illustrated, 
on orthopaedic surgery and diseases ot the joints, which has already 
been translated into more than one foreign language. _ A new journal, too, 
was added to our long list of periodicals, the Louisville Medical News, a 
weekly publication, edited by Dr. Richard 0. Cowling and Dr. "Whlliam 
H. Galt, writers of wit as well as learning, whose keen satire of abuses 
in medical schools will cause their work to be remembered as one of the 
most useful of its period. 
This retrospect of our literature ought not to be concluded without a 
reference to the publications ot the various medical societies of our coun- 
try. The Transactions of the great National Association have been 
mentioned; but there are societies in nearly all the States of the Union 
which annually send forth volumes ot greater or less bulk, containing 
papers of lasting interest. They began as tar back as 1/88, when the 
Medical Society of New Haven County, Conn., issued a volume of “ Cases 
and Observations.” This was followed, in 1/93, by a volume from the 
Philadelphia College of Physicians. Massachusetts has been for seventy 
years sending out valuable communications through her societies. Ihe 
Medical Society of the State of New Aork, too, has tor more than halt a 
century been making contributions to medical science. The effect ot 
these societies, not only upon the literature, but upon the tone ot the 
profession, is everywhere felt to have been most salutary. 
The reports of the lunatic asyldms, now founded in all but a few of the 
States, are also to be mentioned as works which have enriched our pro- 
fessional literature. It was a sagacious remark of the Governor ot Ken- 
tucky, General Adair, in his message urging upon the legislature the 
establishment of an asylum at Lexington, that “ the hospital would help 
the medical school, which would return the obligation by improving the 
hospital system, making discoveries in treatment.” Since the day that 
medical men were first placed over these institutions, it is a fact conceded 
by all that a steady improvement has been going on, as well in the thera- 
peutic treatment of their inmates as in their whole administration. Ihe 
annual communications of Earle, Kirkbride, and others who have labored 
so successfully in psychological medicine, have received their full mea- 
•sure of applause. _ . 
As forming a voluminous branch of our literature, the intioductoiy lec- 
tures published at the opening of the numerous schools of the country 
each autumn, deserve a passing notice. Many ot these efforts are worthy 
of preservation, as the offspring of the best minds in the American pro- 
fession ; but others are “ open to severe comment,” as was remarked by 
Dr. Holmes thirty years ago, who then added that “turgid and extrava- 
gant attempts at eloquence, a fondness for effete Latin quotations, a 
parade of scholastic terms where simple ones only are called lor, are the 
common faults of these productions.” 262 
YANDELL, 
In reviewing the literature of medicine in the United States, the first 
fact that will strike the mind of the reader, perhaps, is the very large 
proportion of the works that have emanated from the medical schools. 
Another that must occur to every reader is the disproportion between 
monographs and the manuals written for the use of students. Teachers 
have both greater leisure and greater facilities than others of the pro- 
fession for making books, as they are also more likely to find sale for 
them; and they write text-books rather than monographs, because stu- 
dents demand them. But, in the nature of things, such productions 
are short lived. The manual that gives a fair view of its subject to-day, 
must fall short of representing it to-morrow, and yields of necessity to a 
later system. Mundinus, when medical science stood still, held his place 
as a text-book on anatomy in the medical schools of Italy two hundred 
years. Wistar, who stood his ground longer than any of our text- 
books, hardly kept his place thirty years; and as to those that have 
succeeded him, “clouds that rake the mountain summit” scarcely follow 
each other faster than they have followed one another as popular 
favorites. 
The growth of our periodical literature has been unprecedented. In 
1848, the committee on medical literature reported to the Medical Asso- 
ciation, that the number of journals in the United States was about 
twenty. They had been fifty years reaching that number; but in a little 
more than half that time their number has been doubled. Since the ori- 
gin of the first, in 1797, one hundred and ninety-five, including reprints 
of foreign journals, have been set on foot, of which more than fifty, 
counting those that relate to pharmacy and dentistry, are still in pro- 
gress. In all, they have made one thousand six hundred and thirty- 
seven volumes, a bulk which exceeds that of our monographs and 
manuals. Hardly any other country in the world has projected so many 
in the same period, or is now sustaining so large a number. Germany 
and Austria together have only fifty-seven; France has but fifty-two; 
Great Britain has but twenty-nine; Italy thirty-one; Holland six; and 
Spain the same number. Most of our journals have subscribers enough 
to justify their publication, and to support them in a state of comparative 
ease, though one is dropped, from time to time, for want of patronage. 
They have, collectively, a large circle of readers, and tend to a wide diffu- 
sion of medical knowledge. The discoveries in any branch of medicine 
are at once announced by them, and carried in a little while to the door 
of every reading physician, by which the profession in country and city 
is placed on comparative equality. And besides these benefits, they 
increase a taste for reading, and stimulate practitioners to become writers; 
so that the admitted superfluity of our journalism has been beneficial to 
the profession, promoting activity among its members, bringing to light 
much useful matter, exciting greater and more general exertion. 
But it cannot be denied that these benefits are secured at the expense 
of many countervailing evils. To the excess of this literature we are to 
attribute its deficiencies, which all admit to be greater than those that 
attach to our books. The aliment that would keep a dozen journals 
vigorous, divided between four times that number, is barely sufficient to 
keep many of them alive. The support of too many of them, mental, 
pecuniary, and literary, is flagrantly inadequate. Hot only is their list 
of subscribers insufficient for anything beyond a feeble existence, but the 
corps of contributors is too limited to give the necessary variety to their 
pages. The editor in the hour of pressing need is often obliged to admit ADDRESS ON MEDICAL LITERATURE. 
263 
articles which he would not hesitate to reject if he had anything better 
on hand. But no choice is left him. The inevitable day is coming 
round when the number must appear; the printer is waiting, and copy 
must be forthcoming. . . 
Hor is this the only fault of our journalism attributable to its excess. 
The editors in too many cases devote only such odds and ends of then 
time to their publications as they can spare from more profitable engage- 
ments. Deriving hardly any pecuniary emolument from their journals, 
they are compelled to look to other employment foi subsistence. cai y 
all their time and thoughts are engrossed by other duties, and their edi- 
torial functions are necessarily performed in a hurried and slovenly man- 
ner. They cannot take the time to “ edit” their publications in any true 
sense of that term. They have no leisure for correcting the papers sent 
them, and for putting them into a shape suitable for the public eye. 
These contributions, it is safe to say, are for the most part hurriedly 
written, very often by young, unpractised writers, and while presenting 
many trains of valuable truth, contain mixed up with them no small 
amount of chaff which calls for the winnowing hand of the editor. 
Wanting this friendly office, they appear before a critical public witli 
all their imperfections on their heads. . . „ , . 
Editors are not responsible for either the facts or the opinions of their 
contributors, but the public has undoubtedly the right to expect that the 
matter composing their pages shall be free from glaring literary blunders. 
It has a right to insist, at least, that their own papers shall be written 
carefully, and with a moderate show of accuracy. 
But the department in which our periodical literature stands most in 
need of improvement is that of critical reviews. In only a few of our 
journals has this office—one of the most important pertaining to journal- 
ism— been properly performed. It is not too much to say that it has 
been generally neglected. The articles that appear in the critical depart- 
ment rarely aspire to the dignity of reviews, but are, as a rule, mere 
bibliographical notices, written after the most cursory examination ot 
the books in hand, and often with slight knowledge ot their contents. 
The notices, therefore, are too generally made up of commonplace stric- 
tures or indiscriminate praise—mere vague generalities which leave the 
reader as much as ever in the dark as to the true chaiactei and va ue o 
the book reviewed. . , , 
Still, with all these deficiencies, and others that might be pointed out, 
our journalism is of a character to commend it to the respect of the pro- 
fession. Ho one who has carefully observed its progress in the last tit y 
years can have a doubt that it is fast outgrowing its defects, blot only 
are the journals appearing in a mechanical dress more neat and p easing 
to the eye, and with fewer typographical errors, but in point of style they 
are more scholarly than those of half a century ago. The articles are more 
generally practical,and the selections are almost always made from original 
sources. If many of them were started in the interest of medical schools 
(which will hardly be denied), it must be owned that their conductors 
have generally been observant enough of public opinion to keep that 
object in the background. Few of them have betrayed a naiiow, partisan 
temper. Hardly an editor has availed himself of his station to defame 
his professional brethren. While many articles find their way into the 
journals that are not instructive—many that are carelessly written and 
marred by many literary blemishes—it is seldom that we meet with one 
that offends against decency or the proprieties of social life. Personal!- 264 
YANDELL, ADDRESS ON MEDICAL LITERATURE. 
ties, as they are discountenanced by the profession, are almost univer- 
sally eschewed. 
It is easy to see that the rivulet which represented our literature at 
the beginning of the century just closed, “ has swollen into a torrent, 
augmented into a river, expanded into a sea.” When we assumed our 
position among the sovereignties of the earth, we could hardly point to 
a single original volume on medicine. We were dependent as a profes- 
sion almost wholly upon our brethren of the old world for instruction. 
All our books were the production of foreigners; but we may now claim 
to be independent of the world. If by any chance we could be cut off 
from all intercourse with other nations, the authors of America would 
supply the text-books required by its students, and guides to its practi- 
tioners, in every department.of the profession. Nor am I assuming too 
much when I assert that, as lucid exponents of the existing art and sci- 
ence of medicine, as trustworthy companions in the sick-room, as lights 
in everything relating to the practice of physic, using that term in its 
widest scope, the works of American physicians are up with the times, 
and equal to the books which come to us from abroad. And this is said 
in full view of the fact that in some branches of medical science we have 
not done our part towards its advancement, while in others we have 
hardly done anything at all. But whether we compare the later issues 
of our medical press with its earlier productions, or with analogous works 
by physicians of the old countries, we find cause for congratulation as 
to the past, and for high expectations in regard to the future. 265 
ADDRESS ON THE PROGRESS OF MEDICAL EDUCATION IN 
THE UNITED STATES OF AMERICA, 
DURING THE CENTURY COMMENCING IN 1716. 
BY 
K S. DAYIS, A.M., M.D., 
OF CHICAGO, ILLINOIS 
From the date of the first English settlement in America, which was 
in 1607, to the Declaration of Independence in 1776, thirteen separate 
colonies had been established, embracing the Atlantic Coast from Massa- 
chusetts to Georgia inclusive, and all acknowledging allegiance to the 
government of Great Britain. Distributed over this wide extent of ter- 
ritory, there had accumulated about three millions of people, among 
whom there were between three and four thousand engaged in the prac- 
tice of medicine. Of these, it has been estimated that not more than 
four hundred had received the degree of Doctor in Medicine from any 
medical college ; and these, with but few exceptions, had received their 
collegiate education and honors in the medical schools of Europe. Only 
two medical schools had been organized in the colonies, namely, the 
Medical Department of the College of Philadelphia (now the Medical De- 
partment of the University of Pennsylvania), in 1765, and the Medical 
Department of King’s (now Columbia) College, in New York, in 1768. 
Only fifty-one medical degrees had been conferred by both of these insti- 
tutions prior to 1776, when active operations in them were suspended by 
the progress of war. In all the colonies there were not more than twelve 
or fifteen cities and towns having over five thousand inhabitants, and 
these were so widely separated from each other, and possessed of such 
limited means of communication, that attendance on a medical college, 
or on the meetings of medical, societies, was hindered by delays and diffi- 
culties bnt little thought of at the present day. 
The same condition of the country compelled many of those practising 
in the smaller and more remote settlements to unite other occupations 
with their practice. In the New* England Colonies, the offices of physi- 
cian and clergyman were often united in the same person, and in all the 
colonies it was common for the physician to occupy a part ot his time 
and increase his income by agricultural labor. 
Notwithstanding all the obstacles presented by the sparseness of the 
population, and the want of roads and means of communication, a large 
proportion of those engaged in practice had attended one course of medi- 
cal college instruction, and had served a regular apprenticeship with 
some practitioner of note, before entering upon the active duties of the 
profession. Only three medical societies are known to have been organ- 
ized during the colonial period of our history. The most important of 
these was the Medical Society of the State of New Jersey, which wras 
organized in July, 1766. It appears that a fewr months previous to this, 
a societj7 called the Philadelphia Medical Society w7as formed in that 266 
DAYIS, 
city, chiefly through the influence of Dr. John Morgan, who had returned 
from Europe the year previous. It did not probably survive the wai 
for Independence, and is not known to have left any permanent iccoid 
of its doings. The Delaware State Medical Society was organized in 
1776, and hence has a history parallel with that ot the independence of 
the States. 
In nearly all of the colonies, laws had been enacted concermngsome 
topics of interest to the profession. Most of these laws were designed 
either to protect the people of the colonies from the introduction and 
spread of contagious diseases, from injury by ignorant and reckless mid- 
wives, or from exorbitant charges by physicians; or tor the establish- 
ment of hospitals for the sick and insane. In only two of the colonies 
had laws been enacted to define the qualifications of physicians and 
surgeons, with provisions for enforcing an observance of the same. The 
General Assembly of Hew York, in 1760, ordained that “ no person what- 
soever shall practise as Physician or Surgeon in the City of Hew York 
before he shall have been examined in Physic and Surgery, and approved 
of and admitted by one of His Majesty’s Council, the Judges of the Su- 
perior Court, the King’s Attorney-General, and the Mayor of the City of 
Hew York for the time being, or by any three or more of them, taking to 
their assistance for such examination such proper person or persons as 
they in their discretion shall see fit.” Such candidates as were approved 
received certificates conferring the right to practise physic or surgery, or 
both, throughout the whole province; and a penalty of five pounds was 
prescribed for all violations of this law.1 A similar act was passed by 
the General Assembly of Hew Jersey in 1772. 
Although most of the colonies had provided temporary hospitals for 
seamen, emigrants, and the victims of smallpox and other epidemic dis- 
eases. the only permanent general hospital tor the sick was established 
in Philadelphia, in 1752, and was aided by a grant of two thousand 
pounds from the Colonial Assembly. Dr. Thomas Pond was appointed 
superintendent, with Drs. Lloyd Zachary, Thomas Cadwaladei, Sam lie 
P. Moore, John Redman and Phineas Bond, as associates. 
Dr. Thomas Bond, from the opening of the institution, introduced his 
class of students for bedside instruction, and thereby became the first 
regular clinical lecturer in America. In 1767, the colonial government 
of"Hew York was induced to grant a charter for a general hospital, and 
an organization was effected, and the work commenced. But the build- 
ing when nearly completed was destroyed by tire, in 1772, and owing to 
the supervention of the Revolutionary war was not rebuilt until 1791. 
From this very brief glance at the condition of medical matters in the 
colonies, more especially in relation to educational facilities, it will be 
seen that at the commencement of our history as an independent nation, 
in 1776 there were between three and four thousand practitioners of 
medicine, supplying about three millions of people, their field of duty 
occupying thirteen States, embracing the whole Atlantic coast from 
Maine to Florida, and containing two medical colleges, two organized 
medical societies, and one permanent general hospital. Small as were 
these beginnings, they nevertheless constituted the germs from which 
have since developed all the educational institutions belonging to the 
profession in our country. 
1 See History of Medical Education and Institutions in the United States, by N. S. 
Davis, M.D., p. 22. ADDRESS ON MEDICAL EDUCATION. 
267 
The Medical Department of the College of Philadelphia, which had 
been organized in 1765, with Dr. William Shippen, Jr., as Professor of 
Anatomy and Surgery, and Dr. John Morgan, as Professor of Medi- 
cine, had continued regular annual courses of medical instruction until 
1776, when the session was broken up by the vicissitudes of war, and 
the most valuable movable materials of the college were privately re- 
moved to places of safety by the provost and members of the faculty. 
Previous to this time, Drs. Adam Kuhn and Benjamin Rush had been 
added to the medical faculty of the college—the first, as Professor of 
Materia Medica and Botany, and the second, as Professor of Chemistry. 
During the same time, Dr. Thomas Bond had been lecturing on clinical 
medicine in the Pennsylvania Hospital. On an attempt being made to 
resume the courses of medical instruction in the College, in 1/79, politi- 
cal differences and suspicions caused the State Legislature to pass an act 
abrogating the charter of the college, removing its officers, and transfer- 
ring its property to a new institution, called the “ University of the State 
of Pennsylvania.” 
The new University was granted a very liberal charter and consider- 
able endowments. The Rev. John Ewing, D.D., was appointed Provost, 
and an effort immediately made to organize a medical department, by- 
offering those who had held professorships in the College, the same posi- 
tions in connection with the University. Regarding the act of the Legis- 
lature abrogating the charter of the College and confiscating its property 
as unjust, all but Dr. William Shippen, Jr., refused the offer and con- 
tinued their annual courses of instruction independently, but without 
legal authority to confer degrees. The Trustees of the University, find- 
ing themselves unable to till the several medical chairs satisfactorily, 
agreed to confer degrees on such students as should be examined and 
recommended by the several professors of the College whose charter had 
been abrogated. By this arrangement, at the first public commencement 
of the University, held in Philadelphia, June 27, 1780, the degree of 
Bachelor of Medicine was conferred on William W. Smith and Ebehezer 
Crossly, and that of Doctor of Medicine on David Ramsey, who was in 
the service of the American Army, and at the time a prisoner in the 
hands of the British. These were the first medical degrees conferred 
by any institution created under the auspices of one of the independent 
States of America. This state of antagonism between the professors in 
the College of Philadelphia and the trustees of the University, con- 
tinued until 1789, when, aided by the influence of Benjamin Eranklin, 
after his return from Europe as foreign minister, the former succeeded 
in inducing the State Legislature to repeal the act of abrogation, and to 
restore College all its rights and privileges. This was done in 
March, 1789, but it left the University in existence, with its endowments 
from confiscated estates the same as before. The officers and faculty of 
the College of Philadelphia were immediately reinstated, with Dr. Ben- 
jamin Franklin himself as president of the Board of Trustees. 
In October of the same year, Dr. John Morgan died, and Dr. Adam 
Kuhn resigned, leaving the chairs of Practice of Medicine, and Materia 
Medica and Botany, vacant. The vacancies were immediately filled, 
and the Medical faculty of the College as reorganized for the session of 
1789-90, was composed of William Shippen, Jr., M.D., Professor of 
Anatomy, Surgery, and Midwifery ; Benjamin Rush, M.D., Professor of 
the Theory and Practice of Physic; Caspar Wistar, M.D., Professor of 
Chemistry and of Institutes of Medicine ; Samuel P. Griffiths, M.D.,Pro- 268 
DAVIS, 
fessor of Materia Medica and Pharmacy; Benjamin Smith Barton, M.8., 
Professor of Natural History and Botany. At the same time Hr. Shippen 
continued to occupy the same chair in the University ot the State ot 
Pennsylvania, and was joined in that faculty by Hr. Adam Ivuhn, in the 
Chair of Theory and Practice ot Medicine, and by Hr. James Hutchin- 
son, in that of Chemistry. 
The trustees of the College of Philadelphia not only reinstated a full 
corps of medical professors, but they revised their former rules in regaid 
to medical requirements for graduation. These rules, as adopted hi 1 (67, 
provided for the conferring of the degrees of Bachelor of Medicine and 
Hoctor of Medicine. The student was permitted to apply few the first 
after a a sufficient apprenticeship to some repiutable practitioner in 
Physic,” attendance on u at least one course ot Lectures on Anatomy, 
Materia Medica, Chemistry, the Theory and Practice of Physic, one 
course of Clinical Lectures, and attendance on the practice ot the Penn- 
sylvania Hospital one year.” It was expected by the founders of the 
College, that those who took the Bachelor’s degree would return after 
three^years of study and practice, and take the higher degree of Hoctor. 
Experience, however, had proved this expectation fallacious, as very few 
of those who entered into practice after receiving the first degree, ever 
returned for the second. For this reason the Bachelor’s Hegree was 
abolished, and the revised regulations adopted for the College by the 
trustees, November 17, 1789, and published in the Pennsylvania Gazette 
were as follows: 
«I. No person shall be received as a candidate for the degree of Doctor of 
Medicine until he has arrived at the age of twenty-one years, and has applied 
himself to the study of medicine in the College tor at least two years, those 
students, candidates, who may reside in the city of Philadelphia or within five 
miles thereof, must have been the pupils of some respectable piactitionei foi 
the space of three years, and those who may come from the country, and from 
any greater distance than five miles, must have studied with some respectable 
physician there, for at least two years. 
11. Every candidate shall have regularly attended the Lectures of the follow- 
ing professors, viz.: of Anatomy and Surgery ;ot Chemistry and the Institutes 
of Medicine ; of Materia Medica and Pharmacy ; ot the I heory and 1 ractice 
of Medicine ; the Botanical Lectures of the Professor of Natural History and 
Botany ; and a course of Lectures on Natural and Experimental Philosophy. 
Hl.' Each candidate shall signify his intention of graduating to the Dean of 
the Medical Faculty, at least two months before the time of graduation, after 
which he shall be examined privately by the professors of the different branches 
of medicine. 
If remitted to his studies, the professors shall hold themselves bound not to 
divulge the same; but if he is judged to be properly qualified, a medical ques- 
tion and a case shall be proposed to him, the answer and treatment of which he 
shall submit to the medical professors. If these performances are approved, 
the candidate shall then be admitted to a public examination before the Trus- 
tees the Provost, Vice Provost, Professors and Students of the College; after 
which he shall offer to the inspection of each of the Medical Professors a 
Thesis, written in the Latin or English Language (at his own option) on a 
medical subject. This Thesis, if approved of, is to be printed at the expense 
of the candidate, and defended from such objections as may be made to it by 
the Medical Professors at a commencement to be held for the purpose of con- 
ferring degrees, on the first Wednesday in June every year. 
Bachelors in Medicine who wish to be admitted to the degree of Doctor in 
Medicine, shall publish and defend a Thesis agreeably to the rules above men- 
tioned. ADDRESS ON MEDICAL EDUCATION. 
269 
The different Medical Lectures shall commence annually on the first Monday 
in November, the lectures in Natural and Experimental Philosophy about 
the same time, and the lectures on Botany on the first Monday in April. 
Benjamin Franklin, President of the Board of Trustees. 
William Smith, Provost of the College and Secretary of 
the Board of Trustees.”1 
The Trustees of the University of the State of Pennsylvania adopted 
very similar regulations regarding courses of lectures and time ot study 
for the degree of Doctor in Medicine, but they continued also to confer 
the degree of Bachelor, as before. One hundred and four medical stu- 
dents attended the Lectures in Philadelphia during the College teim o 
1790-1, and appear to have been nearly equally divided between the 
two schools. The disadvantages arising from this division of patronage 
were too apparent to be overlooked, and the friends of both schools soon 
instituted measures for an amicable union. These measures result Min 
the passage of an Act of the Legislature of the State, Septernbei 30, ( , 
uniting the College and the University on the terms which had been 
mutually agreed to by both the parties in interest, the adoptee 
for the united institution was the “University of Pennsylvania. Dr. 
John Ewing was elected Provost and Professor of Natural and Lxptn- 
inental Philosophy, and all the professors in the medical department of 
the two previous institutions were elected professors in the new one. 
The full medical faculty of the University, as thus constituted, was ar- 
ranged as follows: William Shippen, M.D., Professor of Anatomy, 
Surgery, and Midwifery ; Caspar Wistar, M.D., Adjunct; Adam Kuhn, 
M.D., Professor of Theory and Practice of Medicine p Benjamin Push, 
M.D.’ Professor of Institutes of Medicine and of Clinical Medicine ; 
James Hutchinson, M.D., Professor of Chemistry; Samuel P. Gnmithb, 
M.D., Professor of Materia Medica and Pharmacy; Benjamin Smith 
Barton, M.D., Professor of Botany and Natural History. 
The University, as thus reorganized, ceased to confer the degree ot 
Bachelor of Medicine, and left it optional with the medical students 
whether they should attend the lectures on Natural History and Botany, 
but in all other respects adopted the “Pules respecting a medical educa- 
tion and the conferring of Degrees in Medicine,” which have been already 
given as having been adopted by the Trustees of the College of I hiladei- 
phia in 1789. f 
We have thus sketched briefly the progress of medical instruction trom 
its incipient beginnings in Philadelphia, to the complete establishment 
of the University of Pennsylvania by the formal election of the faculty 
above named, in January, 1792, not merely because it was the pioneer 
school, and one which still continues to exercise an important influence 
over the educational interests of our profession, but because it has »ei ved 
as the type or pattern for nearly all the medical schools subsequently 
organized in this country. While the cause of medical education was 
progressing, as we have detailed, in Philadelphia, the profession in -Mew 
York was not idle. We have stated that, as early as 1767, a charter was 
granted by the Colonial government of New York for the establishment 
ot a General Hospital in that city; that, chiefly through the efforts of 
Drs. Samuel Bard and Peter Middleton, a society was organized, and a 
hospital building nearly completed, which was destroyed by fire in 1(72; 
and that the enterprise received liberal pecuniary aid from Sir Henry 
1 See History of the University of Pennsylvania, by Joseph Carson, M.D., pp. 95-6. 270 
DAVIS, 
Moore, the provincial Governor, from the Legislature, from the City 
Corporation of New York, and from many private individuals. The 
loss of the building by fire, and the speedy supervention of the war for 
Independence, prevented all further efforts in that direction until after the 
close of that war. Soon after this latter event, the corporation known 
as the Society of the New York Hospital was revived, its work re- 
sumed, and adequate hospital buildings completed ready for occupation 
in 1791. The same persons who had been influential in the primary 
effort to establish the New York Hospital, also induced the trustees or 
governors of King’s College, located in New York City, to establish a 
Medical Department of that institution, and to appoint a full medical 
faculty in 1768. This faculty was composed of Samuel Clossy, M.D., 
Professor of Anatomy; John Jones, M.D., Professor of Surgery ; Peter 
Middleton, M.D., Professor of Physiology and Pathology ; James Smith, 
M.D., Professor of Chemistry and Materia Medica; John Y. B. Tennent, 
M.D., Professor of Midwifery; and Samuel Bard, M.D., Professor of 
Theory and Practice of Physic. 
Some important differences will he noticed in comparing this faculty 
organization with that of the faculty just previously organized in Phila- 
delphia. First, it makes a more complete division of labor, and at once 
gives a full recognition to the departments of Surgery and Midwifery, 
assigning to each a separate professorship on an equality with all other 
departments, instead of making them appendages to the more prominent 
departments of Anatomy and Theory and Practice of Medicine. In this 
respect the New York faculty was in advance, not only of that of the 
Philadelphia College, but also of that of the University of Edinburgh. 
Second, it makes no mention of the departments of Botany and of Natural 
and Experimental Philosophy. Third, as the number of chairs and the 
consequent division of labor was greater, tiie annual college term was 
made shorter b}7 one month ; the term closing in May instead of June in 
each year. In all other respects the regulations were very similar to those 
adopted by the school in Philadelphia. The first courses of lectures 
were given in the autumn and winter of 1768-9, at the close of which, 
in May, 1769, the degree of Bachelor in Medicine was conferred by the 
Trustees of the College on Samuel Kissam and Kobert Tucker. And at 
the close of the succeeding college term, in May, 1770, the degree of 
Doctor in Medicine was conferred "on one or both of the same persons. 
These are stated by Dr. J. B. Beck, and several other writers, to have 
been the first medical degrees conferred by any college in America. This 
is true, howmver, only as it relates to the degree of Doctor in Medicine. 
For, as a matter of fact, the College of Philadelphia conferred the degree 
of Bachelor in Medicine on ten students in June, 1768, but did not con- 
fer the decree of Doctor in Medicine until June, 1771. 
The regular annual courses of medical instruction were continued, and 
attended!)}7 small classes of students, until they were interrupted by the 
war. During the war, the name of King’s College was changed to that 
of Columbia College, which it still retains. Soon after the close of the 
war an effort was made to re-establish the medical department connected 
therewith. By some misfortune connected with the procuring of sub- 
jects for dissection, a violent popular outbreak, called the “ Doctors’ 
Mob,” was induced, during which the dissecting-room of the college was 
broken up, and for three days law and order were trampled under foot. 
To counteract, as far as possible, the evil influences thus brought to bear 
upon the profession, and to improve medical science, several of the more ADDRESS ON MEDICAL EDUCATION. 
271 
enterprising and younger members of the profession formed a private 
society, and in 1787 succeeded in inducing the magistrates of the city to 
establish a public free dispensary for the sick poor. Among the more 
prominent of those engaged in this enterprise were Drs. William Moore, 
Nicholas Roraaine, Benjamin Kissara, Wright Post, and Valentine Sea- 
man. They not only gave gratuitous attendance on the poor in the dis- 
pensary, hut in connection therewith gave lectures on most of the 
branches of medicine; thereby making it the first institution connected 
with practical Instruction in medicine under the corporation of the Pity 
of New York. . , , , 
So o-reat was their success that, in 1790, more than fifty students 
attended their instruction, and an unsuccessful attempt was made to 
organize an independent school under the name of the College of Physi- 
cians and Surgeons. In the autumn of 1791, the private association intro- 
duced not less than sixty students into Columbia Col%e, and thereby 
induced the Legislature of the State to make a grant of $30,000 to the 
trustees, for the purpose of enabling them to enlarge their buildings, etc. 
In the following year the medical faculty was reorganized by the appoint- 
ment of Drs. Bailey, Post, Rogers, Hammersly, Nicol, and Kissam, as 
professors, and of Dr. Samuel Bard, as Dean of the Faculty. Some of 
these appointments were very unsatisfactory to the students, and were 
followed by such a degree of opposition as to greatly interfere with the 
prosperity of the College, and to lead many members of the profession in 
the city to use their influence in favor of the establishment of another 
and independent medical school. „ T 
In accordance with their wishes, the regents of the University of the 
State of New York granted a charter for a new college in 1807, to be 
located in the city, and called the College of Physicians and Surgeons 
of New York. It was placed under the control of a board of tiustees, 
consisting of the whole Medical Society of the city and county of New 
York, and the degree of Doctor of Medicine was to be conferred by the 
reo-ents of the University of the State, on the recommendation of the trus- 
tees and faculty of the College. The first course of lectures was given in 
the winter of 1807-8, to a class of fifty-three students. In 1810 the 
medical department of Columbia College was finally discontinued, leav- 
ing the College of Physicians and Surgeons the only one in the State, 
with a class of students numbering eighty-two, and the following very 
able faculty, viz.: Samuel Bard, M.D., President; David Hosack, M.D., 
Vice President and Professor of the Theory and Practice of Medicine and 
of Clinical Medicine ; William James Macnevm, M.D., Professor of Chem- 
istry ; Samuel L. Mitchill, M.D., Professor of Materia Medica and Bot- 
any; Valentine Mott, M.D., Professor of Surgery; John V. liancis, 
M.D., Professor of Obstetrics and Diseases of Women and Children ; 
Wright Post, M.D., Professor of Anatomy. ... 
But instead of that rapid prosperity which the friends of the institu- 
tion and the regents of the University now anticipated, the very numer- 
ous board of trustees, being mostly medical practitioners in ie imme- 
diate vicinity of the College, soon became distracted by opposing councils, 
and jealousies arose between them and the members of the faculty, which 
caused much difficulty and greatly retarded the prosperity of the college. 
These defects were corrected in subsequent years, and the institution has 
maintained a good reputation and leading influence down to the piesent 
time- . ~ . 
In 1783, the medical department of Harvard College, in Cambridge, 272 
DAVIS, 
near Boston, was organized by the appointment of John Warren, M.T)., 
Professor of Anatomy and Surgery; Aaron Dexter, M.8., Professor of 
Chemistry and Materia Medina ; and Benjamin Waterhouse, M.D., Pro- 
fessor of the Theory and Practice of Medicine. The medical department 
of Dartmouth College, at Hanover, Hew Hampshire, was organized in 
1797, chiefly through the influence of Dr. Nathan Smith, who was ap- 
pointed Professor of Medicine, and for ten or twelve years taught all the 
branches of medicine with signal ability. The medical department of 
the University of Maryland, at Baltimore, was incorporated in 1807, and 
was supplied with an able faculty, consisting of John B. Davidge, M.D., 
Professor of the Principles and Practice of Surgery, and Nathaniel Pot- 
ter, M.D., Professor of the Theory and Practice of Medicine, assisted by 
Drs. Shaw, of Maryland, and Cooke, of Virginia. 
By the foregoing brief historical statements it will be seen that during 
the first thirty years after the close of the war for Independence, which 
included the first decade of the present century, seven medical schools 
had been organized, namely, two in Philadelphia, two in New York City, 
one in Boston, one in Hanover, and one in Baltimore. The two in Phila- 
delphia had been speedily united into one, and one of those in New York 
had been discontinued. We find, therefore, only five medical schools in 
existence in the United States in 1810, with an aggregate number of 
medical students in attendance of about 650, of whom about 100 received 
in that year the degree of either Bachelor or Doctor of Medicine. Two- 
thirds of this whole number were in the University of Pennsylvania. 
Only two public general hospitals had been established, namely, the 
Pennsylvania Hospital in Philadelphia, and the New York Hospital in 
New York City.1 The former was a very important aid to the Univer- 
sity in attracting students to Philadelphia, by the clinical instruction 
which it afforded, as inaugurated by Dr. Thomas Bond soon after it was 
opened for the reception of patients. 
All but one of these medical schools were organized as departments of 
colleges or universities of literature and science, already established, and 
all but the one began with a small number of professors, making it neces- 
sary that one man should teach two, and sometimes three, branches of 
medicine during each annual college term. For this reason more than 
any other, the medical college terms were made to commence generally 
on the first of October, and to continue until the following May or June. 
All these schools adopted, at first, the policy of conferring the degree of 
Bachelor of Medicine on students who had studied medicine with some 
reputable practitioner not less than two years, and had attended the 
medical instruction in the college one year, or rather one college term ; 
and the degree of Doctor of Medicine after three years of study and two 
annual college terms. It must be remembered that, during the colo- 
nial period of our history, and for thirty or forty years subsequent to 
the achievement of our National Independence, it was the universal cus- 
tom for young men who entered upon the study of medicine to become 
regularly apprenticed to some practitioner for a term of three or four 
years, during which time the preceptor was entitled to the student’s ser- 
1 Since the above was written, we have learned that, in 1784, Don Andras Almonaster 
commenced the erection of a public or general hospital in the city of New Orleans, on the 
site of the one blown down in the great storm of 1779. It was called the New Charity 
Hospital, and cost $114,000. As Louisiana became one of the States of our Union, by pur- 
chase, in 1803, this Charity Hospital should have been included with those of Philadelphia 
and New York mentioned above. ADDRESS ON MEDICAL EDUCATION. 
273 
vices in preparing and dispensing medicines, extracting teeth, bleeding, 
and other minor surgical operations, and, when more advanced in studies, 
in attending on the sick ; and, in return, the preceptor became obligated 
to give the student detailed and thorough instruction in all the branches 
of medicine. Many of the more eminent practitioners often had several 
students in their offices at one time, constituting a small class who were 
drilled almost as regularly in their studies as they would be in a college. 
In some instances the term of apprenticeship was extended to six and 
even seven years, and was made to commence at the early age of fifteen 
or sixteen years. All these customs were brought by the emigrants from 
the parent country, and their perpetuation here was rendered more neces- 
sary by the sparseness of the population and the difficulty of access to 
medical schools.1 
In the midst of such customs, and at a period in the world’s history 
when railroads, steamboats, and other means of speedy transit were un- 
known, and even post-coaches were rare, it was entirely reasonable that 
the first idea of a medical college should be to furnish the means for a 
rapid review of the several branches of medical science, aided by such 
experiments and appliances for illustration as could be commanded, and 
the whole concentrated into as small a part of the year as possible. The 
idea of the founders of medical schools, both in Great Britain and in this 
country, was to make them supplement but not supersede the work of the 
preceptor and the medical apprentice. The study of anatomy by dissec- 
tions, the illustration of chemistry by experiments, the clinical observa- 
tion of disease at the bedside, were capable of being carried on in the 
offices of preceptors, only to a very limited extent. But by combining 
several preceptors, each eminently qualified in some one department, in 
a college faculty, with access to anatomical rooms, chemical laboratory, 
and hospitals for the sick, all the branches of medicine then recognized 
could be very well reviewed in the form of didactic instruction, in five 
or six months of the year. It was expressly to supply the wants here 
indicated, with the greatest economy of time and labor, that the medical 
department of the University of Edinburgh was founded in the beginning 
of the eighteenth century, and conferred its first degree of Doctor of 
Medicine in 1705. It rose rapidly to distinction among the schools of 
Europe, and furnished the model after which the first medical schools in 
this country were organized ; as it was the Alma Mater of nearly all their 
first professors. 
Assuming that the student would serve from two to four years of his 
apprenticeship to his preceptor, before resorting to a medical school, the 
several professors very naturally arranged their courses of instruction to 
begin nearly at the same time, generally in September or October, and to 
be completed in time for the public commencement and conferring of de- 
grees in the following May or June. And as the Bachelor’s degree was 
generally conferred after attendance on one full course of college instruc- 
tion in the several branches taught, no gradation or consecutive order of 
studies could be incorporated into the college course. The addition of 
one or two years more of study, including a second course of college in- 
struction, entitled the applicant to an examination for the degree of Doc- 
tor of Medicine. At the first organization of all the medical schools to 
which we have thus far alluded, provision was made for conferring the 
degrees of both Bachelor and Doctor of Medicine. But, as already men- 
1 See Contributions to the Annals of Medical Progress, etc., by J. M. Toner, M.D. 
18 274 
dayis, 
tioned, the degree of Bachelor was abandoned by the College of Phila- 
delphia in 1789, and by the University of Pennsylvania in 1791, and by 
all the medical colleges in the country after 1813. The whole number 
of medical degrees conferred by the seven medical schools whose origin 
we have traced, prior to 1810, did not exceed six hundred. Very many, 
however, served their regular apprenticeship with the preceptor, attended 
one course of college instruction, and entered upon practice without a 
college degree; and there were not a few who entered upon the respon- 
sible duties of practice with simple certificates from their preceptors, 
without ever having seen the inside of a college building. 
We shall not fully appreciate the relations of the medical schools to 
the needs of the profession at that time, unless we consider also the coin- 
cident condition of the different branches of medical science. To the 
active workers of the present generation, a medical college with only 
three or four professors, or one professor attempting to teach anatomy, 
surgery, and midwifery, all in one college terra of five or six months, 
would appear hardly less than absurd. If we remember, however, that 
down to the commencement of the present century, the principal medical 
works in use were the writings of Sydenham, Boerhaave, and Cullen, 
the Physiology of Haller, the Anatomy of Cheselden or Monro, the Sur- 
gery of Sharp, Pott, or Jones, the Midwifery of Smellie or Hunter, and 
the Materia Medina of Lewis, we shall readily see that the field of med- 
ical study was limited in comparison to that which now opens before the 
student. 
At that time, surgery had only begun to be recognized as a distinct 
branch from anatomy. We learn from an introductory lecture by James 
Spence, E.R.C.S.E., Professor in the University of Edinburgh, that “so 
late as 1777, when the College of Surgeons petitioned the patrons to in- 
stitute a separate professorship of surgery in the University, they were 
opposed by Monro, then Professor of Anatomy, as interfering with his 
branch ; and he succeeded in getting his commission altered so as to_ in- 
clude surgery, which was thus made a mere adjunct of the anatomical 
course, and continued to be so taught (if it could be said to be taught) 
until the institution of the chair of Surgery in 1831.” It was not until 
June 4, 1805, that Surgery was separated from the chair of Anatomy 
by the appointment of Hr. Philip Syng Physick as Professor of Surgery, 
on an equality with the other professors in the University of Pennsylva- 
nia. The department of Midwifery was still later in gaining recognition 
as a distinct branch of medicine. At the request of Hr, Caspar Wistar, 
who had succeeded to the professorship of Anatomy and Midwifery in 
the University on the death of Hr. Shippen, in 1808, the trustees sepa- 
rated the chairs, and in 1810 appointed Hr. Thomas Chalkly James the 
first Professor of Midwifery in that College. And yet it was not until 
three years later, October 11,1813, that he was formally recognized as 
a member of the faculty, and attendance on his lectures rendered obliga- 
tory upon the students who applied for graduation. In New York, how- 
ever, midwifery was recognized as a distinct branch at a much earlier 
period than in any of the other cities in which medical schools had been 
organized; for in the first medical faculty appointed in connection with 
King’s College, in 1768, Hr. John Y. B. Tennent was made Professor of 
Midwifery, apparently on an equal footing with all the other professors. 
The foregoing facts are sufficient to show the limited field of medical 
science at the beginning of the present century, compared with the same 
field at the present time. If this is borne in mind, it will be seen that ADDRESS ON MEDICAL EDUCATION. 
275 
the five medical schools, embracing the medical departments of the 
University of Pennsylvania, Harvard College, near Boston, Dartmouth 
College, at Hanover, the University of Maryland, at Baltimore, and the 
College of Physicians and Surgeons, at New York, which were either re- 
organized or founded de novo during the first thirty years of our history 
as an independent nation, were established on as liberal a basis, and were 
as well adapted to the then existing wants of the profession and the peo- 
ple, as any that have been organized since. As a general rule, they com- 
menced with a small number of professors, but as the different depart- 
ments of professional knowledge became better developed, and the work 
of instruction better systematized, there was manifested that tendency to 
make divisions of labor by the creation of new chairs, which has con- 
tinued to the present time. In this respect the University of Pennsyl- 
vania, as the leading school, may be taken as a representative of all the 
rest. Commencing with only two professors, Drs. Morgan and Shippen, 
aided by the clinical instruction of Dr. Bond in the Hospital, in 1765, 
the number was increased by the addition of the chairs of Chemistry and 
Materia Medica, in 1768-9; and on the merging of the College of Phila- 
delphia with the University of the State*of Pennsylvania, in 1791-2, the 
number of chairs was increased to six, by the addition of professorships 
of Institutes of Medicine, and of Botany and Natural History. A fur- 
ther addition took place by the creation of a separate chair of Surgery, 
in 1805, and one of Midwifery, in 1810. From the year just named the 
number of medical schools began to increase with great rapidity. 
A medical department was established in connection with Yale Col- 
lege, in New Haven, in 1810, but the first course of instruction was not 
commenced until 1813. In 1812, the Regents of the University of the 
State of New York incorporated the College of Physicians and Surgeons 
of the Western District, located in Fairfield, Herkimer County. The 
Vermont Academy of Medicine, located at Castleton, Vermont, received 
a charter from the Legislature of that State in 1818. The same year, a 
medical school was organized as a department of Transylvania Univer- 
sity, at Lexington, Kentucky, chiefly through the influence of Drs. Dud- 
ley, Richardson, and Blythe. In January, 1819, the Legislature of Ohio 
passed an act incorporating the Medical College of Ohio, in Cincinnati. 
In 1820, the Medical School of Maine was organized as a department of 
Bowdoin College, at Brunswick, Maine, with a faculty consisting of Drs. 
Vathau Smith, John D. Wells, and Parker Cleaveland. In 1821, a rnedi- 
eal school was organized in connection with Brown University, at Provi- 
dence, Rhode Island, but was soon after discontinued. The medical 
school of the University of Vermont was established in Burlington, in 
1822. A school called the Berkshire Medical Institute, was organized 
in Pittsfield, Massachusetts, under the charter of Williams College, in 
1823. The Medical College of South Carolina was established in Charles- 
ton, in 1824, and supplied with a full corps of professors, including the 
well-known names of Drs. Ramsey, Holbrook, Dickson, Prioleau, Frost, 
Bavenal,and Elliot. The Medical Department of Columbian College, in 
the District of Columbia, was organized in 1825, chiefly through the in- 
fluence of Drs. Thomas Sewall and Frederick May, of Washington. 
In the winter of 1825, the Legislature of the State of Pennsylvania 
passed an act under which a new medical school was organized in Phila- 
delphia, in connection with a literary institution called Jefferson College, 
nt Canonsburg ; and hence the new medical school took the name of Jef- 
ferson Medical College, and, in its progress since,has attained a prosper- 276 
DAVIS, 
ity and influence equal to that of the best medical colleges in this country. 
The Medical Department of the University of Virginia, located at Char- 
lottesville, in that State, was organized in 1825, and has continued to the 
present time, teaching the different branches of medicine in the same man- 
ner as the various branches of science are taught in other departments of 
the institution. The medical school of the Valley of Virginia was estab- 
lished at Winchester, Virginia, in 1826, on nearly the same plan as the Med- 
ical Department of the University, at Charlottesville. It attracted but a 
small number of students, and appears to have been discontinued several 
years since. In 1827, the Washington Medical College was organized in 
Baltimore, on the same plan as the majority of American medical colleges. 
The Medical College of Georgia, located at Augusta, was incorporated by 
an act of the Legislature of that State in 1880, and the first course of 
instruction was given in 1832-3. The Willoughby University, in Ohio, 
was chartered in 1834, and its first course of instruction commenced in the 
autumn of 1835. The Medical Department of the University of Louisi- 
ana, at Yew Orleans; the Medical Institution of Geneva College, at Ge- 
neva, Yew York ; the Medical Department of Cincinnati College, Cin- 
cinnati, Ohio; and the Vermont Medical School, at Woodstock, Ver- 
mont, were chartered by the Legislatures of the respective States in which 
they were located in the year 1835. 
The Medical Department of the University of Louisville, Kentucky, 
was organized in 1837, and the Medical Department of the University 
of the City of Yew York, the same year. The Medical Department of 
Hampden Sidney College, at .Richmond, Virginia, was organized in 1838. 
The Albany Medical College, at Albany, Yew York, and the Medical 
Department of Pennsylvania College, at Philadelphia, in 1839. The Mis- 
souri Medical College, at St. Louis, Missouri, was organized in 1840, and 
the St. Louis Medical College, in the same city, in 1841. The Legisla- 
ture of Illinois granted a charter for the Rush Medical College, in Chi- 
cago, in 1837, hut a faculty was not organized for instruction until 1843. 
The Cleveland Medical College was organized at Cleveland, Ohio, in 
1843. The Medical Department of the University of Buffalo was organ- 
ized in Buffalo, Yew York, in 1846. The Starling Medical College and 
Hospital was organized at Columbus, Ohio, in 1847. The Medical De- 
partment of the University of Michigan, at Ann Arbor, was instituted 
in 1849. The Medical Department of the University of Yashville, at 
Yashville, Tennessee; the College of Physicians and Surgeons, at Keo- 
kuk, lowa ; and the Woman’s Medical College of Pennsylvania, at Phila- 
delphia, were organized in 3 850. 
The Medical College of Virginia, at Richmond; the Medical Depart- 
ment of Georgetown University, at Washington; and the Cincinnati 
College of Medicine and Surgery, at Cincinnati, were created in 1851. 
The Savannah Medical College, at Savannah, Georgia, and the Miami 
Medical College, at Cincinnati, were established in 1852. The Atlanta 
Medical College was commenced at Atlanta, Georgia, in 1855. The 
Medical College of the Pacific, at San Francisco, was organized in 1858. 
The Chicago Medical College, Medical Department of the Yorthwestern 
University, was organized in 1859. The Medical College of Mobile, Ala- 
bama, and the Long Island College Hospital, in Brooklyn, Yew York, 
were organized in iB6O. The Bellevue Hospital Medical College was 
established in the city of Yew York in 1861. The Woman’s Medical 
College of the Yew York Infirmary, located in the city of Yew York, 
was created in 1864. The Medical Department of Willamette University, ADDRESS ON MEDICAL EDUCATION, 
277 
located at Salem, Oregon, was commenced in 1866. The Medical Depart- 
ment of Howard University was organized in 1867. The Medical Depart- 
ment of the University of South Carolina, at Columbia, and the Detroit 
Medical College, at Detroit, Michigan, were commenced in 1868. The 
Medical Department of the University of Wooster, at Cleveland, Ohio; 
the Kansas City College of Physicians and Surgeons, at Kansas City, 
Missouri; the Louisville Medical College, at Louisville, Kentucky ; the 
Medical Department of the lowa State University, at lowa City; and 
the Medical Department of the Indiana University, at Indianapolis, all 
had their beginning in 1869. 
The Woman’s Hospital Medical College, at Chicago, and the Medical 
Department of Lincoln University, at Oxford, Pennsylvania, were organ- 
ized in 1870. The Free Medical College for Women was organized in 
the city of New York in 1871. The Medical College of Evansville, 
Indiana, was chartered in 1846, and reorganized in 1872. The College 
of Physicians and Surgeons of Syracuse University, at Syracuse, New 
York, and the College of Physicians and Surgeons at Wilmington, North 
Carolina, were incorporated in 1872. The Medical Department ot the 
University of California, at San Francisco, was first organized under the 
name of the Toland Medical College in 1864, and became a department 
of the University in 1873. The Medical College ot the University ot the 
State of Missouri, at Columbia, Missouri, and the Texas Medical College 
and Hospital, at Galveston, Texas, were organized in 1873. Medical 
schools have recently been established in Portland, Maine, and in Balti- 
more, Maryland, the exact dates of the formations of which are not at 
hand. 
From the foregoing statistics we learn that, during the thirty years 
intervening between the close of the war tor Independence and 1810, 
seven medical schools were organized; in the thirty years intervening 
between 1810 and 1840, twenty-six new medical colleges were added to 
the list; in the thirty-five years since 1840, the number of new medical 
schools created is forty-seven ; making the whole number ot medical edu- 
cational institutions established in the United States, during the first 
century of our history as a nation, eighty. We have not included in 
these numbers five or six mere abortive attempts to form medical schools 
in different localities, but which were so transient as to leave a record 
difficult to trace. Of the eighty which have been established, seventeen 
have been discontinued or suspended, leaving, at this date, sixty-three 
medical colleges now in active operation in this country. Of these, Maine 
has two, New Hampshire one, Vermont three, Massachusetts one, Con- 
necticut one. New York nine, Pennsylvania three, Maryland three, Vir- 
ginia two, South Carolina one, Georgia three, Alabama one, Louisiana 
two, Texas one, Tennessee one, Kentucky three, Missouri three, Califor- 
nia two, Oregon one, lowa two, Illinois three, Indiana three, Ohio seven, 
Michigan two, and the District of Columbia three, leaving thirteen 
States without any medical college now in operation. Four of the 
schools included in the foregoing list, namely, two in New York City, 
one in Philadelphia, and one in Chicago, are established for the exclusive 
education of women in medicine. The whole number of students attend- 
ing the medical colleges in 1810 was about 650, of whom about 100 gradu- 
ated at the close of the college terms for that year. The population of the 
United States at that time was 7,239,881. In 1840, the whole number 
of students in the colleges was about 2500, of whom about 800 received 
the degree of Doctor of Medicine. The population of the United States 278 
DAVIS, 
in that year was 17,069,458. During the college terms for 1875-6, the 
whole number of medical students in attendance on the colleges was 
6650, of whom 2200 received the degree of Doctor of Medicine. The 
population of the States at this time is over 40,000,000. Without 
claiming absolute accuracy for the foregoing figures, they are sufficiently 
close for all the purposes of comparison. And they show clearly, notwith- 
standing all that has been said about the rapid multiplication of medical 
schools, and the increased numbers of students and graduates, that the 
colleges and the students, during the last thirty-five years, have increased 
in a ratio only about equal to the increase of the population of the country. 
The whole number of those engaged in teaching as professors in the several 
medical colleges, at this time, is about five hundred.1 
As has been already stated, the origin of medical schools in this country 
was solely from individual efforts, put forth from time to time, as the 
ambition of the individuals or the supposed wants of the country 
demanded, and not from any well-digested scheme or official plan of 
professional education adopted either by the States or hy the General 
Government. The same remark is true, not only of their origin, but 
also of their continuance and multiplication to the present time. When- 
ever and wherever the Legislature of any one of our States has been asked 
to grant a charter for a medical college, as a rule the request has been 
complied with. And in the few instances in which such requests have 
been denied, the parties interested have seldom found difficulty in forming 
a connection with some literary college or university, already having 
authority to grant degrees in medicine, as well as in general science. 
Some of the State Legislatures, in addition to liberally granting charters 
for medical colleges, have also occasionally appropriated a few thousand 
dollars to aid in the erection of suitable buildings, but rarely, if ever, to 
endow professorships, or to defray any of the current expenses of such 
institutions. In the State University of Michigan, and possibly in one or 
two other State Universities, the medical professorships, like those of the 
other departments, are sustained by the income from the general endow- 
ment, independent of the fees derived from the medical students. We 
may say, in general terms, therefore, that the whole system of medical edu- 
cation in this country, represented to-day by sixty-three medical colleges 
distributed anrong twenty-four different States, sustained by the active 
work of over five hundred professors,and annually aiding in the education 
of nearly seven thousand students, is the spontaneous outgrowth of the 
profession itself, self-reliant, and almost wholly self-sustained. Originating 
among a free people, under the cegis of various educationally independent 
States, apparently striving to keep pace in the increase of their number 
and efficiency with a population winch, in one short century, has increased 
from three millions to forty millions, and extended over a territory from 
the Atlantic to the Pacific, and from the great interior Lakes to the Gulf, 
under circumstances of the freest competition, these schools constitute a 
subject worthy of the most careful study. 
To what extent have these schools been adapted to the real wants of 
the profession and people of these States? 'Wherein have they failed to 
keep themselves adjusted to these needs or wants, as the country has 
1 In the above statistics we have not included colleges or schools for teaching exclusively 
dentistry or pharmacy, or exclusive dogmas in medicine. Of the first there are eleven ; of 
the second, thirteen ; of the third there are three, called Eclectic, and eight or nine, Homoeo- 
pathic. ADDRESS ON MEDICAL EDUCATION. 
279 
advanced to the present time? If failures in adjustment have taken 
place, in what do they consist, and how can they be remedied? Let me 
ask a continuance of your patient attention, while I answer as briefly 
and directly as possible these most important questions, and my task will 
be done. 
We have already seen that our medical colleges had their origin at a 
time when medical science and art occupied a far narrower field than 
at present. A time when obstetrics was yet mostly in the hands of 
unlettered midwives; surgery an appendage to anatomy; organic che- 
mistry, histology, and even physiology, as now recognized, hardly known. 
A time, too, when it was the universal practice for regular students of 
medicine to apprentice themselves to private preceptors of reputation, 
from whom they expected to receive the greater part of their professional 
education. The great and pressing need, at that time, was for schools in 
which, after gaining a knowledge of the text-books, the rude pharmacy 
of his preceptor’s oflice, and the individual experience of the preceptor 
himself, during two or three of the first years of his study, the student 
could review the whole in connection with such experimental demonstra- 
tions as could be given only in the laboratory, the dissecting room, and 
the clinical wards of the public hospital. It was to supplement, not 
supersede, the work of the private preceptor. 
Precisely this was what the medical schools were adjusted to do, and 
they fulfilled the object well. Hence, although originating in different 
States, wholly independent of each other, and in direct rivalry for patron- 
age on which they depended for support, they were remarkably similar 
in their organization and requirements. At first, the number of profes- 
sors was small, and the college term eight or nine months, offering the 
Bachelor’s Decree after three years’ study, and one college terra, and the 
Doctor’s Degree after one or two more years, and a second course of col- 
lege attendance. But as most of the students lived in small towns and 
country districts remote from the colleges, making attendance on the 
lectures both tedious and expensive, only a part of those engaging in the 
study of medicine ever reached a medical college,and most of these, after 
taking the Bachelor’s Degree, never returned to take a second course and 
the higher degree of Doctor. These circumstances constituted a strong 
inducement for the co,leges to concentrate the annual period of instruc- 
tion into as short a time as possible, both for the purpose of increasing 
the number of students who could afford the means of attending, and 
the number who would take the second degree. Under these influences, 
the first thirty years sufficed to cause the Bachelor’s Decree to be aban- 
doned by all the schools, the number of professors in each to be doubled, 
and the length of the annual college terra to be shortened one-third. 
And in twenty-five years more, from the same causes, aided efficiently 
By the fact that the degree conferred by the colleges became practically 
recognized everywhere as a sufficient license to practise medicine in all 
its departments, the colleges, with but one exception worth noting, had 
each from five to seven professorships occupied by as many different pro- 
lessors, and an annual college term of only from twelve to sixteen weeks, 
during which the students, in one class, listened to from five to six lec- 
tures daily, on as many different topics, besides attending to dissections 
and clinical instruction when such were accessible. 
The requirements for the Doctor’s Degree were, three years study with 
some regular practitioner of medicine, including attendance upon two 
such courses of college instruction, the one being chiefly a repetition of 280 
DAVIS, 
the other; the writing of a thesis on some medical subject; the possession 
of a good moral character; the attainment of twenty-one years of age; 
and the sustaining of a creditable examination in the several branches of 
medicine at the close of the second course of lectures. It will be seen 
that, in these requirements, there was no reference to any standard of 
preliminary education to be attained by the student before entering upon 
his professional studies, except the ability to write a thesis. The require- 
ment of a knowledge of the ancient languages, and the writing of a thesis 
in the Latin language, were abandoned on the full reorganization of the 
University of Pennsylvania, in 1792. The relinquishment of natural 
philosophy, natural history, and botany, as requirements, soon followed, 
leaving only the single indirect trace of any non-professional education, 
to which we have alluded. Under these conditions and tendencies, by 
the end of the second thirty years of our history, the number of medical 
colleges had increased from live to forty-one; the number of students 
attending them from six hundred and fifty to twenty-five hundred, and 
the ratio of those graduating, each year,from less than one in six, to one 
in three. 
Here w*e see a system of medical colleges originating spontaneously to 
supply the wants of a free and rapidly increasing people, and open to the 
most free and unrestrained rivalry, actively developing two apparently 
opposite results. In one direction, the schools justly vie-with each other 
in increasing the number of their professors in full consonance with the 
rapid advancement of medical sciences; they sagaciously seek out and 
enlist the services, as teachers, of the most learned, eloquent, and indus- 
trious men to be found in the profession ; they spend time and money 
freely in filling laboratories, anatomical rooms, and museums with all the 
means for efficient teaching and illustration. So far their free rivalry 
has reference only to their office as teaching bodies—institutions for im- 
parting instruction—and is productive only of the highest good to the 
profession and the people. But the anomaly consists in the fact that, at 
the same time, the same institutions have been rapidly shortening their 
annual courses; cutting off all collateral requirements; failing to grade 
the branches of medical study, as they have increased in number and ex- 
tent, so as to adapt them to the several years of pupilage; and even re- 
ducing the final examinations to the simple process of asking a few oral 
questions in the mysterious “green room.” This most unfortunate ten- 
dency of our experiment in permitting the freest rivalry in the estab- 
lishment of medical schools, results directly and necessarily from the 
fact that the degrees they confer, and the diplomas they give, have been 
permitted throughout the whole country, with only a few temporary ex- 
ceptions, to have all the force and effect of a license to practise medicine. 
It requires but a moderate familiarity with the motives that govern 
human actions, to see clearly that in a country where there are no entail- 
ments of estates, and where the great body of young men who seek the 
profession are without pecuniary fortune, and largely dependent on their 
own industry for the means of education, as well as reputation and for- 
tune in after life, the question “ where can I get the degree of doctor, 
which is equivalent to a license to practice, and a full admission into the 
ranks of the medical profession in the shortest time, and consequently 
with the least expenditure of time and money ?” exerts a very great, if 
not controlling influence, in determining where the student shall attend 
his college instruction. 
Hot that medical students are a whit less conscientious, in their desire ADDRESS ON MEDICAL EDUCATION. 
281 
to fully qualify themselves for the responsible duties of our profession, 
than those who seek any other calling in life. But present necessity, 01 
even convenience, easily controls when there comes with it the flatteiing 
thought that, at another time, after having earned a little money by 
practice, all deficiencies can he supplied by a season of reviewing in a 
school of the largest facilities. Just on this half-unconscious delusion, 
hundreds are induced to go where the requirements in time and money 
are least, regardless of all other advantages. The medical college in a 
country village, remote from all facilities for clinical Distinction in 
hospital or dispensary, and but scantily supplied with subjects for dissec- 
tion, can issue to its graduates just as large a diploma, couched in just 
as unintelligible Latin, and having much the same influence with the 
people, as the school in a metropolitan city, where its students can have 
the largest facilities for clinical and practical study. Hence it is not 
strange that, before the end of the seventh decade of the past century of 
our existence as a nation, about forty medical colleges had been organized, 
only sixteen of which were so located as to afloid then students any 
proper facilities for clinical instruction 5 and that these sixteen vveie 
attended by little more than one-third of the whole number of those who 
attended medical colleges. ... 
The general acceptance of the college diploma as full admission into the 
profession, thereby uniting in the hands of the same men the business of 
teaching and the power of licensing, has continued to the present day ; and 
is wholly responsible for the fact that, while we have sixty-three medical 
colleges to-day, one third of them are so located that they can afioid 
their3students no advantages,for clinical instruction worthy of mention; 
and all, except three or four, still attempt to crowd instruction in all the 
departments of medicine upon the attention of mixed or ungraded classes, 
in annual college terms of from sixteen to twenty weeks, and exact only 
two such strictly repetitional courses for graduation. This state of things, 
in regard to our medical schools, is made still worse by the fact that, 
during the century under consideration, the system of private medical 
pupilage has undergone a complete change. At the beginning of that 
period, as we have already seen, the private study, under a master, was 
a protracted and serious work, and the resort to the college was simp y 
to review and more fully illustrate that work. But steadily, as raedica 
colleges increased in number, as populations became moie dense, am as 
steamboats and railroads increased a thousand fold the facilities for travel, 
the work of private pupilage relaxed. Indentures of medical students, as 
pupils, to the more noted practitioners, long since ceased, and the relations 
of student and preceptor have become merely nominal in practice, in nine 
cases out of ten consisting in little more than the registry of the student s 
name in the doctor’s office, permission to read the books of his library or 
not as he chooses, and the giving of a certificate of time of study for the 
student to take to the medical college where he expects to graduate. 
The relative position of the private pupilage and the collegiate studies 
has undergone a complete practical reversal. The lattei, instead of 
reviewing and supplementing the former, has become the student s chief 
reliance for the acquisition of medical knowledge; and hence, to have 
maintained its adaptation or adjustment to the needs of the profession, 
should have not only increased the number of its professors and its means 
for communicating knowledge, but also the length of its annual courses, 
and the division or gradation of its classes in accordance with their period 
of study, and in proportion to the greatly enlarged field of medical know- 282 
DAVIS, 
ledge to be acquired. And such would have been, to-day, the grand 
result worked out by our experiment of self-originating, self-sustaining, 
and unrestricted competition in the establishment and jnaintenance ot 
medical schools, had they been restricted to their only appropriate func- 
tion as institutions for imparting medical instruction and advancing 
medical science, instead of being hampered and perverted from their 
natural course by assuming the office of licensing institutions. And 
could this incubus be removed to-day, another quarter of a century would 
not pass before every medical college in our country would have its annual 
course of instruction extended to six months; its curriculum and classes 
so graded that the attention of each student should be restricted to such 
branches as are adapted to his period of advancement in study ; and nine- 
tenths of all our medical students would be in attendance on those colleges 
only that could afford proper facilities for full clinical and demonstrative 
instruction. 
Let the only question presented to the mind of the student, when 
choosing the college he shall attend, be where can he most certainly 
obtain that amount and variety of medical knowledge which will enable 
him successfully to pass the examination of an independent board of 
examiners, acting under liberal and enlightened rules and modes ot 
testing the student’s knowledge, and we shall have nothing to fear either 
from the number, or the rivalry, of our medical schools. The injurious 
tendencies of our system of uniting the work of teaching and that of 
licensing to practise, in an unlimited number of independent medical 
colleges, was seen at an early period, and clearly pointed out; and by 
none more clearly and forcibly than by some of those engaged in the 
colleges themselves. 
So true is this that the Legislatures of some of the States, in organiz- 
ing and regulating their respective State Medical Societies, made some 
ineffectual attempts to lessen the evil by legislation. This was particu- 
larly true in South Carolina, Maryland, Delaware, Massachusetts, and 
Yew York. As early as 1889, at an annual meeting of the Medical So- 
ciety of the State of Yew York, the following resolution was reported 
by a committee, and, after free discussion in the Society, was adopted 
by a vote of fourteen to four: “Resolved, That the right of teaching 
ought to be separated as much as possible trorn the power of conferring 
degrees or licenses.” The following year a committee, consisting of Drs. 
James R. Manly, of Yew York City, T. Romeyn Beck, of Albany, and 
John McCall, of Utica, submitted to the same Society an able and inter- 
esting report on the whole subject of medical education, in which occurs 
the following cautious but significant language: “But in view of the 
diploma becoming depreciated by the rapid establishment of new schools, 
it may well become a question deserving serious consideration, whether 
at no distant period the rights of teaching and licensing should not be 
disjoined. An incidental difficulty to the adoption of this suggestion, is 
the fact that we are surrounded by institutions in other States, which 
might or might not follow it, and thus our students be induced to desert 
0-0 
our own colleges.”1 
In 1887, the same view was advocated by some of the ablest members 
of the profession in Philadelphia, and they proceeded so far as to organ- 
ize an institution for the purpose of examining candidates and of confer- 
ring degrees, wholly independent of the business of teaching. A petition 
1 See Transactions of the New Yoi’k State Medical Society for 1840. ADDRESS ON MEDICAL EDUCATION. 
283 
signed by one hundred and twenty-six physicians, residents of that city, 
was presented to the Legislature of the State, asking for a charter giving 
legal effect to their organization, but the charter was not granted and the 
project failed. . . , 
In 1844 the subject was again brought prominently under discussion 
in the meeting of the New York State Medical Society, by him who now 
addresses yom The discussion of the same subject was continued in the 
annual meeting of 1845, and resulted in the call issued by that society 
for a convention of delegates from all the medical colleges and societies 
in the United States, which was held in New York, m May, 1846, and 
from which originated the American Medical Association. 1 make these 
historical allusions to show that neither those engaged in medical teaching; 
nor the profession at large have been unmindful of the evil to which i 
have attached so much importance. Yet it still exists in all its force, 1 hat 
the colleges have failed to keep themselves adjusted to the needs ot the 
profession in regard to the length of their annual courses of instruction, 
the systematic classification of the branches included in their curncu- 
lums, the corresponding grading or division of their classes and the exac- 
tion of a reasonable standard of preliminary education, has been still 
more fully appreciated and acknowledged. . . , 
Not only is this appreciation indicated by the criticisms in our medical 
periodicals and the discussions in our medical societies, and by the more 
general efforts of the colleges, since 1850, to increase the number ot then 
professors, and the fulness of their curriculums, by piecing out their 
annual courses of instruction with two or three weeks of preliminary 
lectures at the beginning, and short spring courses at the end of the teg- 
ular terms—all of which the student might attend or not as he chose— 
but in a still more formal manner by the proceedings of two or three 
conventions of delegates from the various schools, in which all the detects 
here stated relating to preliminary education, inadequate length ot the 
annual courses of instruction, and the urgent need of a systematic division 
of the branches taught into groups appropriate for each year ot study, 
and the consequent grading of the classes, with annual examinations o 
each class, have been fully stated, and a thorough plan of remedying them 
devised and urgently recommended to the schools for their adoption. 
The first of the conventions to which I allude was held in Cincinnati, 
in May, 1867, and was presided over by the learned Prof. Stille, ot the 
medical faculty of the University in whose buildings we are assembled 
to-day. The second was held in the city of Washington, in May, 18W 
and was presided over by the justly distinguished head of acu y o 
the Jefferson Medical College of this city. A third convention ot less 
formal character was held in this city, in June of the present year, 
you ask me why these reasonable and highly important recommendations 
have not been adopted by the greater part of the schools, I can on y point 
you for answer to the paragraph already quoted from the repoit on med- 
ical education made to the New York State Medical Society, in 8 0, by 
that learned trio composed of P>eck, Manly, and McCall. i, nioie di- 
rectly, to the fact that while the faculty ot each school Lankly acknowl- 
edges the defects in adaptation to the present enlarged field of medical 
science and art, and the urgent needs ot the profession, each waits lor 
the other to move first, lest, by placing higher requiiements upon the 
time and resources of the student, it should cause its own halls to be de- 
serted for those of its less exacting neighbor. 
The efforts in this direction, however, have not been entirely fruitless 284 
DAVIS, 
of practical results. In 1859, the Chicago Medical College, now the 
Medical Department of the Northwestern University, was organized for 
the express purpose of testing the practicability of establishing a school 
with a thoroughly graded and consecutive system of instruction. Its 
curriculum was made to embrace thirteen professorships, arranged in three 
groups, one appropriate for each of the three years of study required. The 
students attending were correspondingly divided into three classes, 
junior, middle, and senior. Each class was required to devote its time 
thoroughly to the group of branches and lectures belonging to its year of 
advancement in study, and to be examined fully in those branches at the 
end of the college term. Each of the three courses was continued six 
months of the year, and actual attendance on hospital clinical instruction, 
and practical work in the chemical, anatomical, and microscopic, or his- 
tological laboratories, was added to the requisites for eligibility to gradu- 
ation. The very satisfactory success of tliis institution during the past 
fifteen years, and its present prosperity, certainly demonstrate the prac- 
ticability of the scheme. 
In 1871, the medical school of Harvard University, one of the oldest and 
most influential medical institutions in our country, also adopted a fully 
graded system of instruction, dividing her classes, and extending her 
courses of instruction throughout the collegiate year, and has continued 
this plan to the present time, adding annually to the perfection of its 
details, and adding also to her own prosperity and influence. The new 
medical school of Syracuse University, New York, has practically adopted 
the same scheme; and the annual announcements of several other medical 
schools, for the present year, including some of the most influential and 
important institutions in the country, give unmistakable evidence of 
their having taken initial steps in the direction of this most desirable 
change. 
But our medical schools, aided by the work of the private preceptor, 
do not constitute the whole educational force or influence operating upon 
the profession in this country. Our social or society organizations, City, 
County, District, State, and National, have exerted, throughout the whole 
period of our history, a most potent influence over the educational inter- 
ests of the profession. We had intended to sketch briefly the history of 
the more important of these organizations, but must not trespass further 
upon your time and patience on this occasion. It is sufficient to say that 
these society organizations, by their annual reunions of the profession in 
almost every State and important city in our wide domain ; by the oppor- 
tunities they afford for the presentation of papers, and comparison of 
views in free discussion, not only in relation to scientific and clinical 
matters, but in relation to every interest whether of medical science or 
medical polity, have exerted indirectly an influence over the progress, the 
education, and the general character of the profession, hardly second to 
that of the organized schools. And if the profession, as represented in 
these social organizations, would boldly move on in the exercise of its 
own most important right and duty—by fixing for itself both the stand- 
ard of preliminary and professional education necessary for young men to 
attain before admittance into its ranks, and by appointing the necessary 
tribunals for enforcing that standard, thereby leaving the colleges to their 
only legitimate work, that of imparting instruction—the latter would 
speedily adjust themselves perfectly to the actual educational needs of 
the profession. 
Because we have endeavored, in reviewing the progress of our educa- ADDRESS ON MEDICAL EDUCATION. 
285 
tional institutions during the past century, to indicate what we regaid 
as their most important defects, let no one inter that we belong to that 
class, who, in any degree, undervalue the past work or present influence 
of our medical schools. We do not agree with those who would compel 
every young man who desires to spend his life in alleviating the suftei- 
ings of the sparse populations of our mountains and prairies, to spend the 
best part of his youth in the vain endeavor to become an adept in the 
native languages of Cicero and Hippocrates; nor would we discouiage 
the laudable ambition of that large and most valuable class of our young 
men, who are largely dependent on the proceeds of their own labor for 
their education, as well as for their advancement in after life, nor foster 
the indolence of the more wealthy by copying the five, six, or seven years 
of professional collegiate study from the institutions of Europe. _ Neither 
do we agree with those who regard the establishment ot a National pi o- 
fessionaf school by our general government, or the endowment of State 
colleges, with professors salaried out of public funds, as the panacea for 
our ills. To invoke the patronage of either National or State Govern- 
ments, in this country, in the regulation and support of medical schools, 
is simply equivalent to asking that the lobbies ot every legislative body 
in the country shall be annually filled with the log-rolling satellites ot 
every “pathy” and “ism” of the day, that the professorships of our co.- 
leges shall be transformed into political sinecures, and that the colleges 
themselves shall become the foot-balls ot partisan politicians. 
On the contrary, we believe that our system of medical college instruc- 
tion, with all its defects, has developed in strict consonance with the 
spirit of a free and enlightened people, in the comparatively short period 
of one hundred years, a body of medical men as enlightened, enteipiising, 
industrious, and self-sacrificing, as faithful to the interests of the people, 
and animated by as noble an esprit de corps, as is to be found in any country 
on the globe. And not only so, but that these same schools have done 
their full share in creating and sustaining that progress in medical science 
and literature, which has been demonstrated to this Congress so fully in 
the most intersting Addresses to which we have listened, on the vaiious 
departments of medical science and art, . 
Let us, then, in the same self-reliant, independent spirit, which actuated 
those who founded, and with the same untiring zeal and generous emu- 
lation which characterized the host of others who have sustained and 
developed, the medical institutions of our country thus far, endeavor to 
manage wisely the high trust they have left us. Let us neither be blinded 
by reverence for the past, nor be fretful with impatience because c eai y 
perceived evils will not flee at our bidding, nor yet, with childish weak- 
ness, call on the Hercules of government to do our work for us; but let 
ns with boldness yet persevering steadiness of purpose, carry forward our 
educational organizations, both collegiate and social, enlarging their 
foundations, improving their adjustments, and adding to their super- 
structure; and we shall thereby most certainly enable those who come 
after us in celebrating the next centennial anniversary of our national 
progress, to review our work wTith the same pleasure and profit that we 
derive to-day, in contemplating the works and characteis ot those whose 
names are an honor to the century which has just passed. 286 
ADDRESS ON THE MEDICAL STAFF OF THE UNITED STATES 
ARMY, AND ITS SCIENTIFIC WORK. 
BY 
J. J. WOODWARD, M.D., 
SURGEON, UNITED STATES ARMY. 
Gentlemen: The Centennial Medical Commission having requested 
the Surgeon General of the Army to depute an officer of the Medical 
Staff to occupy an evening during the session of the International Medi- 
cal Congress by giving some account of the scientific work of the Medi- 
cal Department of the Army, the Surgeon General has designated me as 
the officer to undertake the task, and, in obedience to his commands, I 
am here to-night to comply with the invitation of the Commission. 
In the discharge of this duty, I wish first of all to explain, as briefly 
as possible, how it happens that a certain class of scientific work, inti- 
mately connected in its nature and results with the progress of practical 
medicine and surgery, is undertaken by the Medical Bureau, and I hope 
to make it clear to you that the kind of work to which 1 refer is of na- 
tional importance, and that it can be better and more economically done 
by the Medical Bureau of the Army than in any other way. 1 shall, 
then, endeavor to lay before you in a sketchy way, for a single evening 
will not suffice to go into any branch of my subject in detail, the charac- 
ter of the work already done, and of that actually in progress, with some 
hints as to matters which might profitably be undertaken in the future, 
did the means placed at our disposal permit. 
It is the duty of the Surgeon General to provide for the maintenance 
of the health of the Array, as well as for the humane treatment of its sick 
and wounded. The first duty is, if possible, more important and more 
delicate than the second, and both are rendered much more difficult to 
discharge efficiently than might be anticipated in view of the small num- 
ber of men in our little army, by the comparatively great number of sepa- 
rate military posts, and by the vast extent of the territory over which 
they are scattered. 
The total strength of the Army, officers and men, is, after all, less than 
twenty-eight thousand, hardly the strength of an army corps of the army 
of the great German Empire, but it is broken up into little detachments, 
so that there are nearly two hundred permanent garrisoned posts, and 
almost half as many more detached parties, of variable strength, requiring 
medical care. I think it quite safe to affirm that the actual strength of 
the army might be increased tenfold without materially increasing the 
labor of its medical administration, provided the number of posts and 
detachments remained the same as-now. 
These posts and detachments are scattered over all parts of our wide 
territory. They are most numerous in the great interior wilderness, 
remote from the comforts and facilities of more settled communities. 
Many of them on the southern coast and the Mexican frontier are exposed 
to frequent visits of epidemic yellow fever, the scourge of our southern MEDICAL STAFF OF U. S. ARMY. 
287 
seaboard, which, as late as 1867, destroyed in a single season nearly one 
per cent, of the whole strength of the array of that year. Moreover, the 
troops stationed on the Indian frontier are most of the time exposed*to 
nil the hardships and privations of a state of actual war. I know that a 
great statesman has recently declared that Indian conflicts are not war, 
and that it has been decided that gallantry in these bloody struggles 
shall no longer receive the poor reward of brevet rank ; but the bullet 
wounds that are received are none the less dangerous because they are 
inflicted a savage foe, and the privations and hardships of campaigns 
in the wilderness against a well-armed enemy who greatly out-numbers 
our little force, have precisely the same tendency to produce disease and 
death that the same conditions would exert could they exist in a war 
against a civilized foe. In a recent disaster, which is only too fresh in 
the memory of ray hearers, about one per cent, of the whole strength of 
the army, among them two medical officers,1 perished in a single day. 
Let us hope that such a catastrophe may never occur again ; but similar 
incidents, though the total loss in each case was less, have happened be- 
fore, and almost every year since the close of the civil war has had its 
share of victims fallen in obscure but bloody conflicts. 
Now, it is self-evident that the officer charged with the medical and 
surgical care of any army must keep himself informed as to its sanitary 
condition ; as to the number and character of the cases of disease actually 
occurring, and the circumstances under which they are developed ; as to 
the number and character of the wounds, and the circumstances under 
which they are sustained. This information would be indispensable to 
the intelligent action of the Surgeon General of the Army, even were he 
charged with no other duties than the assignment of the medical officers 
and the .purchase and distribution of the medical supplies required for 
the treatment of the sick and wounded ; it is still more necessary if he is 
expected to supervise the sanitary condition of the army with a view to 
the suppression, as far as jiossible, of all preventable diseases. In the 
army of every civilized nation in modern times, therefore, the medical 
officers actually serving with troops are required to keep a record of the 
cases of sickness and wounds under their care, and to report them at 
stated intervals to a central bureau. It is, furthermore, self-evident, that 
it these reports are at all numerous or voluminous, as they must be, either 
if the army is large, or if it is scattered in numerous detachments, the 
Surgeon General will be physically unable to perform the task of person- 
ally examining them with any thoroughness, and must assign this duty 
to others, distributing it among a sufficient number of competent assist- 
ants, who must analyze the reports received, and bring to the attention 
°t the Surgeon General such facts and deductions as require his official 
action. In other words, the Surgeon General of an army, to act effi- 
ciently, requires a personal staff of medical officers who enjoy his confi- 
dence, and who must be competent to analyze thoroughly the various re- 
ports assigned to them, and, if necessary, to advise intelligently on any 
matters as to which their opinions may be required by their chief. 
, I’l our own army, the system of reports established tor the purposes 
just indicated is briefly as follows: 
1 he medical officer of each post or station is required to keep a register 
°f the sick and wounded under his care, in which each patient is entered 
1 Assistant Surgeon George E. Lord, United States Army, and Acting Assistant Sur- 
geon James M. l>e' Wolf. 288 
WOODWAED, 
by name, with the date at which he is taken on sick report; the diagnosis 
of his disease or injury, and the termination of the case, being subse- 
quently entered in appropriate columns. From this register a monthly 
report of sick and wounded is prepared, and forwarded to the Surgeon 
General from each post or station. It contains a statistical statement 
of the number of cases of each kind of disease or injury under treatment 
at the commencement of the month, the number taken on sick report 
during the month, and the number of each recovered, died, discharged 
the service, or otherwise disposed of, and the number remaining under 
treatment at the close of the month. The report also includes a list of 
the deaths and discharges from the service on surgeon’s certificate of 
disability, giving in each case the name of the soldier and the cause of 
death or discharge, and has a place reserved for any necessary explanatory 
remarks. 
These reports, consolidated and analyzed at the Surgeon General’s 
Ofiice, keep the Surgeon General constantly informed as to the health of 
each individual post, of each military department, and of the whole army; 
acquainting him with the actual amount of sickness, its nature, mortality, 
and relationship to strength, with the number of wounds and injuries, 
their character, mortality, and the localities at which they have occurred. 
The deaths and discharges for disability are recorded in alphabetical 
registers for convenient reference, and subsequently serve to give neces- 
sary information to the accounting officers of the Government, and es- 
pecially to the Commissioner of Pensions, in case discharged soldiers, 
or the heirs of the deceased, make application for pensions or other 
allowances due under the laws of the land. The medical officer of each 
post or station is required, besides, to make special reports of interesting 
cases, giving the full histories of such as appear to him of sufficient 
importance, and in case of the outbreak of epidemic diseases, giving 
monthly, besides the usual statistical report, a list of all the soldiers 
attacked, with the date of attack and the date of recovery or death. In 
such epidemic outbreaks the medical officer is required to investigate the 
cause of the outbreak, to ascertain, if possible, the mode of introduction, 
if the disease is introduced from without, and to record the circumstances 
under which it has originated if it appears to have resulted from local 
causes. These investigations serve as the basis of a special report, which 
is required of the medical officer in charge of any post or detachment in 
which an epidemic outbreak may occur. 
As intimately connected with the question of the causes of disease, 
the medical officer in charge of each post is required to keep a meteoro- 
logical register, a transcript of which must be furnished to the Surgeon 
General at the close of each month. Moreover, at the close of each year 
the medical officer of each post is required to make to the Surgeon 
General a general sanitary report on the health of the post, with remarks 
on the diseases which may have prevailed, and suggestions, if any occur 
to him, as to the improvements or changes which in his opinion may be 
advantageously introduced, with the view of iihproving the health of the 
garrison. 
Injuries, wounds, and surgical operations are made the subject of 
separate special reports, giving the names of the soldiers, and the par- 
ticulars of each case. 
Medical officers examining recruits are obliged to record the name 
and physical description of each recruit examined, and in the case of MEDICAL STAFF OF U. S. ARMY. 
289 
rejected recruits, the cause of rejection. A transcript of this record is 
furnished to the Surgeon General at the close of each month. 
Now, I think, it will be understood without argument, that such a 
mass of reports as I have just indicated, embracing annually the observa- 
tions and experience of several hundred well-educated medical men, 
stationed at as many different places, must contain a great deal of 
information which, besides its administrative value, must have no little 
significance in connection with the interests of progress in scientific 
medicine and surgery. I wish, on the one hand, to insist that all these 
reports are indispensable from the mere administrative point of view. 
Without them, and especially, I may add, without their intelligent 
analysis, the Surgeon General of the Army, whatever his personal ability, 
■would be but a figure-head, powerless for any efficient interference in 
behalf of the health of the army. On the other hand, I wish also to insist 
on the fact, that by a very small additional expenditure of labor, clerical 
force, and money, beyond what would be indispensable for the intelligent 
administrative use of the facts collected, they can be made to subserve a 
much wider purpose, and the usefulness of the work, which is indispensa- 
ble to the army itself, for the sake of which primarily it is done, can 
be vastly extended so as to benefit the medical profession at large, and, 
through the medical profession, the sick and injured in every walk of life. 
These considerations would afford a sufficient motive for much of the 
scientific work that has been done by the Medical Bureau in the past, 
and for much that is still in progress; but there are other circumstances 
to he considered of equal, indeed, as I think, of even greater significance. 
A few years ago our country was convulsed by a great civil war which 
lasted for four long years. During this time about a million of men 
Were constantly under arms in defence of the national flag; about two 
hundred thousand of them died of disease, about one hundred thousand 
of wounds. The Confederate armies, though somewhat smaller, were 
numerous enough to resist effectively till the very close of the struggle. 
Their losses can hardly have been much less than those of the national 
armies. After the close of the war the national armaments were dis- 
banded ; the great general hospitals, several hundred of which were in 
operation, were closed as rapidly as the patients under treatment could 
be provided for, and it became necessary, for administrative reasons, to 
order that as each was closed its books and records should be sent 
to the Surgeon General’s Office in Washington. In that office there 
had also accumulated during the war a vast quantity of reports of sick 
and wounded, and other records which had been required for adminis- 
trative purposes during the war. The records thus accumulated em- 
braced over sixteen thousand folio volumes of manuscript record books, 
and, I suppose, several tons of manuscript reports and papers. Urgent 
administrative reasons demanded that these records should be examined, 
classified for convenient reference, and, to a certain extent, that their 
contents should be analyzed. The pension laws of the United States 
are so framed that it became necessary, in almost every one of the hun- 
dreds of thousands of applications for pensions, to apply to the Surgeon 
General for the hospital history of the soldier concerned. Subsequently, 
liberal laws were adopted granting artificial limbs and other prothetic 
apparatus to those who had lost limbs or been otherwise mutilated, and 
Busses to those who had been ruptured during the war. This bounty 
was to be dispensed under the direction of the Surgeon General, and 
again the records of his office came into requisition, both to protect the 
19 290 
WOODWARD, 
Government against fraudulent claims and to secure the rights of honest 
applicants. For all these strictly administrative purposes a vast amount 
of clerical work became necessary, and that this work might effect its 
end, it was absolutely necessary that it should be directed at every step 
by competent medical officers. 
Now, it became evident from the very first, that by the expenditure of 
a comparatively small amount of additional labor in the supervision of 
this work, by a comparatively small increase of the clerical force, and 
other expenditures absolutely required for mere administrative reasons, 
results might be attained the publication of which would be beneficial 
to mankind, and it seemed as though it would have been indeed a great 
national crime to have lost this opportunity to utilize, in the service of 
humanity, the experience which it had cost so much blood and so many 
tears to acquire. 
The work of analyzing these records for the double purpose just indi- 
cated was entrusted to the very same medical officers who have charge 
of the current work of the bureau to which I referred a little while ago. 
Even if no intention of publication had been entertained, these officers 
would have required for the efficient discharge of their duties, supposing 
them to have been limited to mere administrative ends, the use of a good 
consulting library ; and if they had simply preserved for subsequent 
comparison the pathological specimens with which special medical and 
surgical reports were frequently accompanied, and without which these 
reports would often be only partially intelligible, an Army Medical 
Museum would have gradually been built up, however slow the process 
might have been. 
At the time the war broke out nothing deserving the name of a Medi- 
cal Library existed in Washington ; and the incipient medical libraries 
in other cities, even at such great medical centres as Philadelphia, New 
York, and Boston, were exceedingly deficient in the very class of books 
which were most frequently needed for consultation. Indeed, these 
medical libraries, built up by the voluntary contributions of a generous 
profession which numbers but few wealthy men in its ranks, were defi- 
cient in every direction, and, had the best of them been situated in 
Washington, it would but imperfectly have satisfied the necessities of 
the case. There was, therefore, no hope of supplying the want unless 
the Surgeon General’s Office should be able to accumulate a library of 
its own. In like manner, the correct interpretation of many of the patho- 
logical specimens received implied the ability to compare them with 
others, such as ought to be found in a General Pathological Museum. 
But no considerable pathological museum existed in America. Small 
museums had indeed been created by the industry and liberality of the 
professors of several of the medical schools in the great northern cities, 
but these had been founded with special reference to the needs of the 
elementary instruction of medical students, and contained no wealth of 
accumulated material such as is often needed for purposes of comparison 
in arriving at the intelligent interpretation of an individual case. Such 
museums had been built up in the older civilized countries of Europe 
for the most part by Government aid, and without Government aid it 
was and still is impossible that any considerable collection of the sort 
should ever grow up in America. It was evident, therefore, that if the 
officers on duty in the Surgeon General’s Office were to enjoy the advan- 
tages of consulting such a collection, it must be created by the office 
itself. Now, here again, it was clear from the first that by a small addi- MEDICAL STAFF OF U. S. ARMY. 
291 
tional expenditure beyond what would have been necessary to create 
such a library and museum* as would be thoroughly efficient foi t 
merely practical purposes of the Medical Bureau, a National Medical 
and a G Lie ml Pathological Museum might be created, which 
would meet a want long felt by every medical man m America who has 
ventured into the domain of original resealch. t f 
The considerations hitherto presented are, let me hope, sufficien 
make it plain that it was the bounden duty ot the Surgeon Geneial s 
Office to Undertake that scientific work of _ which enough has already 
been published to enable the medical profession throughout 11 d to 
form a judgment as to its character, and as to the fatness of the medical 
officers to whom it has been intrusted to accomplish the task which t y 
have undertaken. The medical criticism of the old world has aheady 
proclaimed its verdict as to both points in an outspoken mannei, and I 
will not be deterred by any false modesty, on behalf of my colleagues or 
myself from making the statement that the verdict has been altoget mr 
favorable. As for the medical profession of our own county, my fellow- 
citizens—so many of whom I see around me to-day—how shall i find 
words to express my feelings? Your generous sympathy and encourage- 
meet have sustained us from the very first. Many ot you seived with us 
during the war, and aided in accumulating those vast stores of « 'ellen«e 
Which we are now endeavoring to utilize. ¥e were so fortunate as to 
secure your co-operation at the beginning, and your support has never 
failed us vet - I believe it never will, if we continue to deseive it. it 
largely owing to your influence that the National Legislature has been 
induced to supply us with the funds, without which our work could not 
have been carried on; and however scanty these funds have appealed to 
some of ns, when compared with the suras devoted by other civi ,zed 
governments to similar purposes, we have never forgotten how kb> a a 
appropriations have been when compared with any \nfmerelv have 
our own National Government for any medical purpose. Not mciely have 
you constantly strengthened our hands, and supported ns in our endeavors 
to accomplish our work, but, ever since the close of a 
labored with the National Legislature to secure for the officers ot the medi- 
cal staff a reasonable share of rank and pay, and these efforts were a last 
durino- the recent session of Congress, successful in securing legislation 
which, if it did not do for us all you had hoped at least placed us o 
better footing than we had ever hitherto enjoyed. It is, alto- 
gether an appropriate thing that I should explain, as I am nov doG, 
your presence, the character of the work we are endeavoring to pe • 
I ha ve now to present to yon, as briefly as possible some details with 
regard to the nature and extent of the scientific work of which I-have 
been speaking; hut first, let me remark that the observations an 1 
which form the basis of this work are due to the in exigence and industiy 
of the whole medical staff. This fact must never be lost sight ofm esti- 
mating the character and importance ot the work. It lepiesei t c mcie 
individual observations and'opinions, hot the conjoined and systematic 
labor of a considerable body of trained and trustworthy medical men 
The officers entrusted with the labor of digesting these obseivatmns and 
preparing them for the press, have constantly endeavoied in all then 
publications, to give full credit to their brother officers at the various 
military posts, whose original labors are the foundation of all the scien- 
tific work that has been done, and of all that can be done at the Surgeon 
General’s Office. I refer you confidently to any of our publications in 292 
WOODWARD, 
illustration of this statement. This work of the officers of the Medical 
Staff deserves the appreciative recognition of all who are interested in the 
progress of Medical Science. Not merely have they made with alacrity 
the observations and reports required of them in the discharge of their 
military duties, but their voluntary labors have been meritorious and 
important. Those of you who practise medicine in cities, and enjoy all 
the stimulus of converse with intelligent fellow-laborers and of competi- 
tion for success, can hardly realize the difficulties under which most of 
the work of these medical officers is done, at remote and usually isolated 
stations, or amidst the hardships and perils of campaigns in the wilder- 
ness against the Indians, with no special stimulus to investigation except 
the love of science and desire for usefulness. 
Next, I have to remind you that the work of analyzing these observa- 
ions, comparing them with each other and with similar observations 
in other lands, preparing the results of these studies for publication, and 
seeing them through the press, has been from the beginning to the 
present time, with the exception of two or three publications, to which 
I will refer specifically hereafter, performed by but three medical officers ; 
and it may be of interest to those who love to see economy in adminis- 
tration above all other things, for me to state that these three officers 
have received as remuneration for their labors during the last ten years 
nothing more than the modest emoluments belonging to the rank of 
Assistant Surgeons in the Army. One of them was, it is true, promoted 
to the grade of Surgeon a few months ago, but this was simply the 
accidental consequence of his place on the Army Register; the others 
remain as before. The three officers to whom I refer are my colleagues, 
Drs. Billings and Otis, and myself. 
Now, it would not be just to these officers if I did not state that they 
have never been, and are not now, free to devote their whole time to the 
scientific work entrusted to their care—each is also charged with certain 
administrative duties which demand a portion of his time and attention. 
Thus, my colleague, Dr. Billings, besides the charge of the Library 
and various special duties connected especially with the sanitary con- 
dition of barracks and hospitals, has always had to do a good deal of 
administrative work in connection especially with the purveying of med- 
ical supplies and the accountability of medical officers for supplies issued 
to them. 
My colleague, Dr. Otis, besides his duties as Curator of the Army 
Medical Museum, as the officer in charge of its Surgical, Anatomical, 
and Miscellaneous sections, and as the officer entrusted with the prepa- 
ration of the Surgical History of the Civil War, has had administrative 
work to do in the way of furnishing information from the Surgical 
records with regard to the numerous applications for artificial limbs and 
prothetic apparatus, and other current work connected with the Division 
of Surgical Records. 
For myself, besides the charge of the Medical, Comparative Anatomy, 
and Microscopical sections of the Museum, the Chemical Laboratory of 
the Surgeon General’s Office, and the preparation of the Medical History 
of the Civil War, I have had charge, since its organization, of the Record 
and Pension Division of the Surgeon General’s Office, a purely adminis- 
trative bureau, which for several years employed about one hundred 
clerks, and which still has thrust upon it ample work to employ the same 
number, although parsimony in legislation has reduced the force to less 
than half, so that the work is rapidly falling behindhand. Some notion MEDICAL STAFF OF U. S. ARMY. 
293 
°f the responsibility attaching to this bureau can be formed when I state 
that, since 1865, the hospital histories of about three hundred thousand 
deceased or disabled soldiers have been traced through the record books 
and furnished to accounting officers of the Government, especially to the 
Commissioner of Pensions, and the insufficiency of the clerical force 
now authorized, will be appreciated, when I state that between twelve 
and thirteen thousand such applications are lying unanswered on the 
table of my chief clerk as I speak these words. 
Now, you will readily understand that the administrative duties to 
which I refer must not merely increase the responsibilities, but must 
necessarily occupy a portion of the time of the officers concerned, with 
the inevitable effect of diminishing the amount of scientific work which 
ff is possible for them to perform. Yet my experience in the office has 
convinced me that it would not be wise to relieve these officers of this 
administrative responsibility and throw it upon a different set of officers. 
The same records are to be used both for administrative and scientific 
purposes, and the double work can best be performed under the same 
heads. The most economical, and at the same time the most efficient 
uieans of diminishing the burdens of these officers, and of increasing 
both the quantity and the value of the scientific work which it is possi- 
ble for them to perform, would be to provide them with a really ade- 
quate clerical force, and with a sufficient number of competent assistants. 
I do not speak to-night in any complaining spirit, but it would be worse 
than useless to pretend that adequate clerical and other assistance has 
ever been supplied to us. This is a naked fact, which it is my duty to 
fiaake known, and which you must constantly bear in mind in appreci- 
ating the amount of work which we have as yet published. That under 
the circumstances we should have been able to do as much as we have—■ 
that since the close of the war we should have been able to prepare for 
Publication the various works with which }*ou are acquainted—the pub- 
lications of the Surgeon General’s Office, edited by us and already issued, 
constituting over six thousand quarto pagesI—could only have been 
achieved by tireless industry and a genuine devotion to our task. 
Coming next to the details of this scientific work, I may remark that 
a portion of the reports received at the Surgeon General’s Office which 
ai'e susceptible of scientific treatment, refer to the conditions under which 
the soldier lives. Here belong the meteorological reports and a large 
portion of the annual sanitary reports. 
Trior to the civil war, the meteorological observations made by the 
piedical officers of the army were published from time to time by the 
Surgeon General’s Office, the greater portion having been edited by the 
lumen ted Coolidge. All students of the Climatology of the United 
States are familiar with these works, which long furnished the only re- 
liable information with regard to the climate of our western territories, 
aud, indeed, contain information with regard to many districts which is 
BTII the only information printed. 
During the civil war the fierce necessities of the struggle caused the 
suspension of these observations, but they were resumed after its close, 
tlud, at the present time, observations of the temperature three times a 
uuy, the rain-fall, appearance of sky, and direction and force of the winds, 
aie recorded under the direction of the medical officer of every perma- 
uent military post, and barometrical, and other special observations, at 
1 See Appendix. 294 
WOODWARD, 
selected posts. Since the Signal Service has been conducting its exten- 
sive meteorological observations in the more settled portions of the 
country, however, it has been thought by the Surgeon General that the 
interests of science, as well as of economy, would he best subserved if 
he should discontinue the publication of the meteorological observations 
made by the medical officers of the army, and accordingly an arrange- 
ment has been made by which the monthly means and other portions of 
the meteorological reports needed for reference in the Surgeon General’s 
Office are briefed in convenient books, and the original reports are then 
turned over to the Signal Office, for use in conjunction with the observa- 
tions made under the supervision of that bureau. 
The annual sanitary reports received from the several military posts, 
since the close of the war, have served as the basis for the preparation 
by my colleague, Dr. Billings, of two bulky volumes, which contain de- 
scriptions of the several military posts, their barracks and hospitals, 
embracing a good deal of new information with regard to the medical 
topography of many parts of our country, especially the western terri- 
tories, and also containing abstracts, prepared under my own supervision, 
of the sickness and mortality, and of the meteorological conditions, of 
the various posts for several years. 
Another portion of the reports contains information with regard to 
the physical characteristics of the men who become soldiers; I refer to 
the monthly reports of the officers entrusted with the physical examina- 
tion of recruits. These reports contain the name, nativity, former occu- 
pation, age, social condition, height, weight, chest measurement, com- 
plexion, and color of eyes and hair of each recruit examined, and in the 
case of rejected recruits, the nature of the disability on account of which 
enlistment is refused. These reports, if subjected to scientific treatment 
at stated intervals, say every five or ten years, would give valuable hints 
as to the improvement, deterioration, or stability of the physical char- 
acteristics of our population. I know that a very great number of these 
recruits are of foreign birth, but, as this is carefully specified in each 
case recorded, there would be no difficulty in the way of the separate 
analysis of the facts with regard to the native born, and the total number 
of observations which have accumulated since the war is large enough to 
be of considerable importance. The two splendid volumes recently pub- 
lished by Colonel J. 11. Baxter, U. S. A., recently Chief Medical Officer 
of the Provost Marshal General’s Bureau, and now Chief Medical Pur- 
veyor of the Army, contain an analysis of a vast number of similar facts 
observed by the examining surgeons in the course of the several drafts 
made during the civil war. lam clearly of the opinion that the analysis 
of the subsequent observations would possess sufficient scientific value to 
warrant the comparatively small amount of labor and expense requisite 
to do the work and publish it; but I regret to say that the office has not 
yet been able to secure enough clerical aid to assign the necessary force 
to this work, and nothing has as yet been done in this direction. I must 
hope that it may be possible in the near future to undertake the analysis 
of the reports received during the last ten years. 
Still another portion of the reports received contains information with 
regard to the diseases and injuries from which our soldiers suffer while 
in actual service. Here belong the monthly reports of sick and wounded, 
the special reports of cases, the reports relating to epidemic diseases, and 
the various reports of wounds and surgical operations. 
The monthly reports of sick and wounded are analyzed and consoli- MEDICAL STAFF OF U. S. ARMY. 
295 
dated by districts as soon after their reception as possible, and constantly 
furnish information as to the actual condition of the health of the army. 
From the statistical tables produced by their consolidation the brief 
statements made by the Surgeon General in his annual reports are pre- 
pared. They have also furnished the data for the abstracts published in 
the volumes prepared by Dr. Billings, mentioned a few moments ago. 
With these exceptions, these valuable statistical tables remain unpub- 
lished. lam decidedly of the opinion that they contain a great deal of 
information much too useful to be lost. Indeed,! think, if the Surgeon 
General’s Office could obtain the necessary force of clerks and assistants 
to make an annual publication of these reports, accompanied by the 
accounts of interesting medical and surgical cases received during each 
year, it would be an important contribution to medical science ; but with 
the means at our disposal, and the other demands made upon us, this 
lias been hitherto quite out of our power. The special reports upon 
epidemics have, however, been utilized to some extent in the publication 
of two works prepared by myself, on the Epidemic Cholera and Yellow 
Fever in the Army during the years 1866 and 1867, and my colleague, 
Dr. Otis, has prepared a large volume, published in 1871, containing a 
report of 732 surgical cases treated in the Army from the close of the 
War to the date of publication. Thus the material in question has at 
least been partially utilized, but I think that the portion which as yet 
remains unpublished fully equals in value, and certainly exceeds in 
quantity, that which has thus far been printed. In connection with the 
subject of epidemic diseases, just alluded to, I ought also here to men- 
tion the investigation of the Epidemic Cholera which in 1873 afflicted 
the civil population of the United States. By an act of Congress the 
Surgeon General was directed to detail a medical officer of the army for 
this investigation, and Assistant Surgeon (now Surgeon) Ely McClellan, 
G. S. Array, was designated for this purpose. This officer made an 
elaborate report, which was published as a Congressional document. 
With it was printed a bibliography of cholera, prepared at the Surgeon 
General’s Office by Dr. Billings, which is, I believe, the most complete 
list of the works on this subject that has yet appeared. 
Ferhaps it would be most convenient, in this connection, to say a few 
words with regard to the Chemical Laboratory of the Surgeon General’s 
Office. The creation of this Laboratory was one of the necessities of the 
pivil war. Immense purchases of medical supplies were being made, and 
!t very frequently happened that efforts of the most ingenious kind were 
employed to defraud the Government. Moreover, among the great num- 
ber of medical officers in service, there were many who were inexperi- 
euced, and some who were ignorant, and complaints were often made as 
to the quality of the medical supplies issued which were not justified by 
tbe facts. Under these circumstances it was constantly necessary that 
the Surgeon General should have the opinion of a chemical expert on 
whose advice he could rely, and it was this that let! to the organization 
°t the Chemical Laboratory, Soon other bureaus, especially the Subsis- 
tence department, began to apply to the Surgeon General for advice in 
the matter of supplies purchased or about to be purchased, and it is safe 
to affirm that the Laboratory of the Surgeon General’s Office was the 
Cleans of saving hundreds of thousands of dollars to the Government. 
The Laboratory was established on the most economical basis, its person- 
nel never having exceeded two individuals, a chemist and an assistant, 
both employed as acting assistant surgeons. Their time has been almost 296 
WOODWARD, 
exclusively occupied in the examination of supplies about to be pur- 
chased for the army, or of supplies already purchased, with regard to 
which complaints had been made. If this Laboratory could be more 
liberally provided for, it might have a much wider held of usefulness. 
Scientific questions of a chemical character constantly arise in connection 
with the medical service of the Army, which might then profitably be 
investigated. 
I have next to present a few remarks with regard to the Medical and 
Surgical History of the late Civil War. The project of such a work was 
conceived early during the struggle, suggested, no doubt, by the volumes 
published by the British Government on the Medical and Surgical His- 
tory of the War in the Crimea. As early as June 9, 1862, the intention 
to prepare such a work was announced to the Medical Staff by a circular 
from the Surgeon General’s Office, and all medical officers were requested 
'to co-operate in the undertaking by collecting details of cases, and other 
material for the work. The supervision of the work of collecting surgi- 
cal material was assigned, by the same circular, to Hr. J. H. Brinton, at 
that time Surgeon U. S. Volunteers; that of collecting medical material 
was assigned to me. Dr. Brinton was relieved from "this duty in Octo- 
ber, 1864, and his place supplied by ray present colleague, Assistant Sur- 
geon Otis, U. S. Army, then Surgeon U. S. who, for the three 
years previous, had served continuously in the field as Surgeon of the 
27th Mass. Regiment of Infantry. Both my colleagues and myself did 
our best to collect material for the work in view, and our efforts were 
constantly sustained and encouraged by the Surgeon General. 
In November, 1865, the Surgeon General issued a document, now well 
known as Circular No. 6, which was accompanied by two somewhat de- 
tailed reports, prepared by I)r. Otis and myself, “On the extent and 
nature of the materials available for the preparation of a Medical and 
Surgical History of the Rebellion.” The object of this circular was to 
acquaint the medical profession with the character of the materials col- 
lected, and to secure, if possible, favorable public opinion in behalf of 
the legislation necessary to provide means for preparing the work and 
completing its publication. This merely preliminary document was 
widely circulated, and effected the end for which it was designed, Con- 
gress, in July, 1866, making an appropriation for the preparation of 
plates and illustrations for “ A first part of the Medical and Surgical His- 
tory of the Rebellion but it was not until March 8,1869, that"Congress 
at length authorized the actual printing of five thousand copies of the 
first part of the work. 
Meanwhile, anxious that the information collected on some of the more 
important surgical points should be made public, the Surgeon General 
published, in 1867 and 1869, two important monographs prepared by Dr. 
Otis; the first on Amputations at the Hip-joint, the second on Excisions 
of the head of the Femur for shot injury. 
The labor of preparing the first part of the Medical and Surgical 
History for publication had now so far advanced that it went to press 
soon after the necessary authority was obtained, and in December, 1872, 
the first part of the Medical and Surgical History was issued from the 
Government Printing Office, This part consisted of a medical volume, 
a surgical volume, and an appendix, the whole occupying 1800 pages 
quarto. The Medical volume, edited by myself, was devoted to the 
medical statistics of the war. Some necessary explanatory remarks were 
offered in the introduction to this volume, but detailed comments on the MEDICAL STAFF OF U. S. ARMY. 
297 
statistics were reserved for the second part of the work. The appendix 
consisted of the reports of the Medical Directors of armies and depart- 
ments, and of other medical officers, which were believed to be of histori- 
cal value. The Surgical volume, edited by Dr. Otis, contained a chrono- 
logical summary of losses in battles and engagements, and a detailed 
discussion of the statistics and reports relating to special wounds and 
mjuries of the head, face, neck, spine, and chest. 
ft was not until June, 1872, that legislation was obtained for continu- 
lng the publication of the work. Congress then passed an act for its com- 
pletion and publication, in two parts, of eighteen hundred pages each, in 
addition to the parts already published. 
In accordance with this legislation the publication of the second part 
of the work was commenced, and the Surgical volume of my colleague, 
treating of special wounds and injuries of the abdomen, the pelvis, the 
back, and the upper extremities, has, as you know, been brought success- 
tally to its completion, and was issued from the Government Printing 
Office during the present summer. This volume contains 1024 pages 
Oaarto. I had hoped that its companion Medical volume, which will 
embrace a discussion of the symptoms, pathology, and treatment of those 
diseases which were the chief causes of the sickness and mortality among 
°Ur soldiers during the war, would have appeared simultaneously. In 
this hope I was doomed to disappointment. In the winter of 1873 and 
1874 my health unexpectedly gave way, and for several months I was 
lncapacitated for any literary work. For a long time subsequently, I 
JTas obliged in accordance with the counsel of my medical advisers, to 
bniit my hours of labor to a minimum, so that, with all my other duties, 
I made during the two years which followed my first illness but little 
progress on the Medical History. lam thankful to say, however, that 
health appears at length fully restored, and I trust, when my labors 
ln connection with the Centennial come to a close, that I will be able to 
lesurne the printing of the volume and to bring it to a conclusion in a 
reasonable time. 
The third part of the History is expected to consist, like the others, of 
w° volumes. The Surgical volume will treat of the wounds and injuries 
v- the lower extremities; of luxations and fractures from other causes 
han gunshot; of burns, scalds, and frost-bites; of generalities on gunshot 
'Wounds, amputations, etc.; of the use of anaesthetics; of the materia chi- 
-1 Urgica, and of the transportation of the wounded. The Medical volume 
wdl treat of the hospital system inaugurated during the war, the system 
supplies, and other kindred matters. 
Defore passing to another topic, I desire to say a word with regard to 
ie work of my colleague, Dr, Otis, on the Surgical History. How pains- 
aking and accurate it has been, how laboriously he has collected the 
°rrner experience of other lands to throw light on our own, and to aid 
its interpretation, is well known to all of you who have looked into 
118 volumes. But I wish to remind you, in connection with the state- 
ments I have made, as to the time required for the preparation of this 
Woi’k, of the extent of the data to be handled as compared with those of 
aily former war. The previous surgical histories of wars, published under 
government auspices, were that prepared by Dr, T. P. Matthew, on the 
uigery of the English Army in the Crimean War, and those of M. 
nenu on the Surgery of the French Army in the Crimea, and during 
io Italian War. Dr. Matthew had to deal with 12,166 surgical cases; 
ienu with 40,586 for the Crimean, and 19,590 for the Italian war. 298 
WOODWARD, 
The reporter for the American war had to deal with the reports of over 
270,000 cases of wounds. Moreover, my colleague undertook a task 
comparatively new in military surgery, which certainly appears to me of 
the greatest importance. In the British and French reports, when a 
wounded man was invalided or pensioned his history was terminated. 
Dr. Otis attempted to trace all the more important cases down to the 
date of publication, and this the organization of the Pension Bureau 
enabled him to do successfully in the majority of instances. At the time 
this plan was determined upon, it was believed to he altogether new. It 
is now known, however, that Professor Hannover, of Copenhagen, had 
conceived a similar plan, and applied it in the case of the invalids of the 
war of 1864. 
Similar investigations have since been made by Loeffler, Mossakowsky, 
and Berthold, though in connection with a much smaller number of cases 
than occupied my colleague. 
I cannot dwell longer to-night on the Medical and Surgical History 
of the War of the Rebellion. I pass to a few remarks concerning the 
Library of the Surgeon General’s Office. I have already indicated the 
reasons for the commencement of this Library. The first appropriation 
of money for the purpose was made by Congress not long after the close 
of the war. For two or three years ten thousand dollars, subsequently, 
however, only five thousand, were appropriated annually. This has been 
expended with great economy and discretion, under the supervision of 
my colleague, Hr. Billings. A great many books have also been acquired 
by exchange, or have been presented to the library. As a result, this 
library now contains about 40,500 bound volumes and 41,000 pamphlets. 
Although, for obvious reasons, under the charge of the Surgeon General, 
this library is essentially the Medical Section of the Library of Congress. 
For several years the Librarian of Congress has not purchased medical 
books, leaving that branch of the subject to the Surgeon General’s Office. 
In 1874, the Government Printing Office issued a small edition of a 
Catalogue of Authors, prepared by Hr. Billings, which formed three 
quarto volumes of about 2000 pages, similar in style to the Catalogue 
of the Congressional Library. This Catalogue is in the possession of 
every public medical library in the country, and is very useful, as far as 
it goes, to students who desire to avail themselves of the resources of 
the library in connection with medical researches of any kind. The 
library itself is thrown open to all medical men who choose to use it. 
Although far from complete, this library is now one of the great medi- 
cal libraries of the world ; and right here I wish to say, that even double 
the money expended upon it would not have made it as valuable as it 
now is but for the generous assistance of the profession of this country. 
Many of our physicians have ransacked their own libraries to supply us 
with works which, in many instances, we could not otherwise have ob- 
tained, especially the older American books and journals. The extent to 
which this has been done is the best proof of the general desire of the 
medical profession of the United States that this library should speedily 
become a complete library of reference on medical subjects. 
I know that a few individuals have objected that Washington is not 
the best place for a great medical library, and seem to think it a pity that 
it cannot be established in Philadelphia or Hew York, where the number 
of physicians is so much larger; but the usefulness of such a library is 
not to be measured by the number of casual readers, but by the number 
of original investigators who consult it in connection with their own work. MEDICAL STAFF OF U. S. ARMY. 
299 
It is only through the work of these men that a great library becomes 
generally useful to the whole profession. These original investigators 
are comparatively few in any city, but almost every city has some of 
them. Wherever the National Medical Library might be, the majority 
°f the medical investigators of the country would have to travel to con- 
-Bult it. Until very lately, such men had to travel to Europe for tlie 
same purpose. It is important that this should no longer be necessary. 
It is important that there should be in at least one place in our country 
a complete medical library, and this we will make at the Surgeon Gene- 
ral’s Office, if we can get the means. There is no probability that such a 
library will ever be built up in the United States except by Government 
Rid. This is also what has happened in all other countries. If we conld 
secure for the purposes of the library exclusive!}" an annual appropriation 
°f ten thousand dollars, we could in a very few years make this library 
tbe most complete in the world. 
One point further I desire to mention. To give the library already 
collected the highest degree of usefulness, a subject catalogue is now im- 
peratively demanded. Dr. Billings has undertaken such a work. With 
dauntless industry he has not merely arranged the cards representing the 
separate treatises in the library according to their subjects, but he has 
undertaken to make separate cards for all the original essays contained 
|u all the medical periodicals in the library. About 275,000 such cards 
Rave already been prepared, lie now desires to obtain the authority to 
have the Government Printing Office publish a Subject Catalogue pre- 
pared from these cards. A specimen fasciculus of this catalogue has 
already been issued, and most of you who are specially interested in med- 
lcal bibliography have already seen it. Dr. Billings estimates that the 
catalogue, if completed on the plan of this fasciculus, would make about 
hve volumes of a thousand pages each. He is abundantly willing to un- 
dertake the labor if Congress can be induced to authorize the printing of 
the work. An appeal will be made to Congress on this subject at its 
uext session, and if the medical profession of the country agree with me, 
that the publication of such a catalogue would be a work useful to every 
Medical investigator in the land, I feel sure that by an expression of their 
Vlews they can secure the success of the undertaking. 
Lastly, I have to say a few words with regard to the Army Medical 
Museum. I have already indicated the circumstances under which it 
°ngmated. It has now acquired very considerable extent, containing 
Ve,7 nearly 19,000 specimens. The specimens collected during the civil 
War were almost all illustrations of military surgery and of camp dis- 
uses. But, since the war, it has begun to acquire a broader scope, and 
We now aim to make it a National Medical Museum. The collection now 
Mu braces, besides the Medical and Surgical sections, a Microscopical sec- 
lolb sections of Human and Comparative Anatomy, and a Miscellaneous 
section. 
Ihe section of Comparative Anatomy is yet in its infancy,and almost 
ad the specimens have been collected by medical officers of the army, so 
pat it has cost altogether but a few hundred dollars. There are about 
°9O skeletons and crania, almost all of American vertebrates, in this 
section. A check list of them,prepared by Dr. 11. C. Yarrow,has recently 
. 00,1 published in pamphlet form. Those interested in this special sub- 
ject can obtain copies of it at the Hospital of the Medical Department 
° rn 10 ArmJ at the Centennial grounds. 
I be section of Human Anatomy is chiefly remarkable for its collection WOODWARD, 
of human crania, which now number about 1600. These chiefly repre- 
sent the native American races, including the prehistoric mound-builders, 
and the various modern tribes, from the Esquimaux at the North to the 
Patagonians at the southern extremity of South America. The careful 
measurement of these crania, under the supervision of Dr. Otis, consti- 
tutes a genuine addition to the science of ethnology. An abstract of 
these measurements has been prepared by him, and recently published 
in pamphlet form. Ethnologists can obtain copies at our hospital on 
the Centennial grounds, or of the Surgeon General. 
Catalogues of the Medical, Surgical, and Microscopical sections were 
published in 1867. That of the Surgical section was prepared by As- 
sistant Surgeon A, A. Woodhull; that of the Medical section by myself; 
and that of the Microscopical section by Assistant Surgeon E. Curtis. 
Since these catalogues were published the collections have doubled in 
size. The publication of a catalogue of the additional specimens, or a 
revised catalogue of the whole, would be a useful work. 
It gives me pleasure to state that the interest taken in this collection 
by the medical profession of the country is being annually more and 
more frequently displayed by the presentation of valuable medical and 
surgical specimens from all parts of the country. Such specimens are 
always acceptable, and especially, I may remark, that those which have 
served as the basis of original communications published in the medical 
journals have especial interest. You can all appreciate how useful it 
would be; how many misunderstandings would have been prevented if 
the actual specimens which have served for certain pathological descrip- 
tions could have been somewhere preserved and accessible to the criti- 
cism of subsequent investigation. But no medical museum that is not 
national in its character will ever serve as the central point for such a 
collection. 
The actual appropriations of money for our Museum have never ex- 
ceeded five thousand dollars a year. The sum is not a liberal one, and 
much more could be advantageously expended if it could be obtained. 
The Centennial Medical Commission, in giving the invitation to which 
I have responded to-night, expressed the wish that I would endeavor to 
represent to your eyes in some way the character of some portion of our 
collection. In compliance with their request, I have naturally selected 
my illustrations from the Medical and Microscopical sections, which are 
under my own immediate direction. I have made use of photography 
for the purpose, and Mr. Edgerton, of J. W. Queen & Co., 924 Chestnut 
street, has kindly undertaken to exhibit the pictures ©n the screen. First, 
I exhibit a series of photographs, novel, I think, in character, represent- 
ing certain pathological conditions of the intestinal canal. 
[Twenty-five lantern slides, representing pathological alterations of the intestinal rau- 
cous membrane, were here exhibited, and briefly commented on.] 
My other illustrations are taken from the Microscopical section. This 
section was originally established for the purpose of preserving the speci- 
mens acquired in the study of the pathological anatomy of some of the 
diseases of soldiers. Sections of morbid growths, and other specimens 
sent to the Surgeon General’s Office by the medical officers of the Army 
for an opinion as to their nature, have been added, with a certain number 
of other specimens, especially in the direction of normal and pathological 
histology. The collection now contains about 7000 permanently mounted 
microscopical slides. A single assistant, paid as a clerk of the first class, MEDICAL STAFF OF U. S. ARMY. 
301 
constitutes, under my direction, tlie whole personnel available foi the 
"°The process by which the photographs I am about to exhibit were pre- 
pared, was as most of you are aware, brought to its present state ot pei- 
fectio’n by my own original investigations. A complete misconception 
exists in certain quarters as to the time lam able to devote.to wo.k of 
this class. It has been simply my amusement—my relaxation from t 
daily routine and toil of the other labors winch I have outlined to you 
to-night. For years all the work of this kind I have been able to accom- 
plislAias been done on Sundays and holidays. ~ , ~ 
A part of this work was undertaken tor the sake of the 1 
lory of the War. 
[Twelve photo-micrographs were here shown exhibiting 
eased intestines, the magnifying power with which the slides were taken ia 0 0 
to 200 diameters. This was multiplied by 50 by the lantern pi ejection. J 
Another portion represents incidental histological work. 
[Here fifteen micro-photographs were shown, including nine of blood-corpuscles to demon- 
strate the impossibility of discriminating between the blood of man and certain other 
mammals. These slides were taken with 100 to 1000 diameters.] 
Still another portion represents work undertaken in connection with 
the investigation of attempts to defraud the Government. 
[Here fourteen slides, each magnified 150 diameters were exhibited’V* tHe' H 
ligation into the so-called “ calf-hair goods,” undertaken at the request of the Houoiable 
Secretary of the Treasury.] _ ... 
In connection with these investigations, the questioni ofthe 
certainty of microscopical appearances has constantly been th ust up 
Die ami T have been forced to the conclusion that not unti \ G 
especially when high powers are used the false appearances 
from dim-action and interference have been mistake, for teal sU uqtm-c. 
This would be a melancholy conclusion were I unable to point out how 
such misinterpretations may be avoided. It is impossible to to this 
detail on such an occasion as this, but I will show you a few pictmes 
illustration of my meaning.1 
[ The address was concluded by the exhibition of a senes 
and spurious appearances of certain diatoms often employe y k P iw the lantern 
the slides beiS magnified from 500 to 2500 diameters, and this increased by the lantern 
tkty times.] 
APPENDIX. 
Publications of the Surgeon General’s Office. 
„ Circular No. 9. War Department, Surgeon General’s Office, July 1, 1863. 
Consolidated Statement of Gunshot Wounds, by Surgeon • • 5 
V c'i™.iakv<>PlP5.BVWa.- Department, Surgeon General’s Office, Washington. 
September 8, 1863. Sickness and Mortality of the Army 
of the War. By J. J. Woodward, Assistant Surgeon, U. b. Aimy, pp. 8, bio., 
with G diagrams. 
[1863-1876.] 
1 [The descriptions of the several slides would require for their clear understanding the 
reproduction of the pictures referred to, and are therefore, at the request of the author, 
omitted.—Editor.] 302 
WOODWARD, 
Circular No. 6. War Department, Surgeon General’s Office, Washington, 
March 10, 1864. Reflex Paralysis. By Acting Assistant Surgeons S. Weir 
Mitchell, George R. Morehouse, and W. W. Keen, Jr., pp. 17, 16mo. 
Circular No. 1. War Department, Surgeon General’s Office, Washington, 
June 10, 1868. Report on Epidemic Cholera and Yellow Fever in the Army 
of the United States during the Year 1867. By Brevet Lieutenant Colonel J. 
J. Woodward, Assistant Surgeon, U. S. Army, pp. 156, 4to. 
Circular No. 2. War Department, Surgeon General’s Office, Washington, 
January 2, 1869. A Report on Excisions of the Head of the Femur for Gun- 
shot Injury. By Brevet Lieutenant Colonel G. A. Otis, Assistant Surgeon, 
U. S. Army, pp. 141, 4to. 
Circular No. 3. War Department, Surgeon General’s Office, Washington, 
August 17, 1871. A Report on Surgical Cases treated in the Army of the 
United States from 1865 to 1871. By Brevet Lieutenant Colonel G. A. Otis, 
Assistant Surgeon, U. S. Army, pp. 296, 4to. 
Circular No. 4. War Department, Surgeon General’s Office, Washington, 
December 5, 1870. Report on Barracks and Hospitals, with Descriptions of 
Military Posts. By Brevet Lieutenant Colonel J. S. Billings, Assistant Sur- 
geon, U. S. Army, pp. 494, 4to. 
Circular No. 5. War Department, Surgeon General’s Office, Washington, 
May 4, 1867. Report on Epidemic Cholera in the Array of the United States 
during the Year 1866. By Brevet Lieutenant Colonel J. J. Woodward, Assist- 
ant Surgeon, U. S. Army, pp. xviii., 65, 4to. 
Circular No. 6. War Department, Surgeon General’s Office, Washington, 
November 1, 1865. Reports on the Extent and Nature of the Materials avail- 
able for the preparation of a Medical and Surgical History of the Rebellion. 
Medical Report by Brevet Major J. J. Woodward, Assistant Surgeon, U. S. 
Army ; Surgical Report by Brevet Lieutenant Colonel G. A. Otis, Surgeon, 
U. S. Volunteers, pp. 166, 4to. 
Circular No. 7. War Department, Surgeon General’s Office, Washington, 
July 1, 1867. A Report on Amputations at the Hip-joint in Military Surgery. 
By Brevet Lieutenant Colonel G. A. Otis, Assistant Surgeon, U. S. Army, pp. 
87, 4to. 
Circular No. 8. War Department, Surgeon General’s Office, Washington, 
May 1, 1875. A Report on the Hygiene of the United States Army, with de- 
scriptions of Military Posts. By Brevet Lieutenant Colonel J. S. Billings, 
Assistant Surgeon, U. S. Arm}T, pp. lix., 567, 4to. 
Catalogue of the Surgical Section of the United States Army Medical 
Museum. Prepared, under the direction of the Surgeon General, by Brevet 
Major A. A. Woodhull, Assistant Surgeon, U. S. Array. Washington: Gov- 
ernment Printing Office, 1866, pp. 664, 4to. 
Catalogue of the Medical Section of the United States Army Medical 
Museum. Prepared, under the direction of the Surgeon General, by Brevet 
Lieutenant Colonel J. J. Woodward, Assistant Surgeon, U. S. Army. Wash- 
ington : Government Printing Office, 1867, pp. 136, 4to. 
Catalogue of the Microscopical Section of the United States Army Medical 
Museum. Prepared, under the direction of the Surgeon General, by Brevet 
Major E. Curtis, Assistant Surgeon, U. S. Army. Washington: Government 
Printing Office, 1867, pp- 161, 4to. 
[For Catalogues of the section of Human and Comparative Anatomy, see 
Centennial pamphlets infra.'] 
Catalogue of the Library of the Surgeon General’s Office. By Brevet Lieu- 
tenant Colonel J. S. Billings, Assistant Surgeon, U. S. Army. Washington ; 
Government Printing Office, 1872, pp. 454, 4to. 
Catalogue of the Library of the Surgeon General’s Office. By Brevet 
Lieutenant Colonel J. S. Billings, Assistant Surgeon, U. S. Army. Yol. 1, 
A—L, pp. 1193, 4to. Yol. 2, M—Z, pp. 956, 4to. Supplement, pp. 319, 4to. 
Washington: Government Printing Office, 1873-4. MEDICAL STAFF OF U. S. ARMY. 
303 
Specimen Fasciculus of a Catalogue of the National Medical Library under 
tlie direction of the Surgeon General of the U. S. Army, at Washington, D. 0. 
L.V Brevet Lieutenant Colonel J. S. Billings, Assistant Surgeon, U. S. Army. 
Washington: Government Printing Office, 1876, pp. 72, 4to. 
A Medical Report upon the Uniform and Clothing of the Soldiers of the 
United States Array. By Brevet Major A. A. Woodhull, Assistant Surgeon, 
U. S. Army. Washington: Surgeon General’s Office, 1868, pp. 26, Bvo. 
Report on the Pathological Anatomy and Histology of the Respiratory 
Organs in the Pleuro-pneumonia of Cattle, with 6 lithographs from photo- 
micrographs. Washington, June 15, 1870. By Brevet Lieutenant Colonel J. J. 
Woodward, Assistant Surgeon, U. S. Array, pp. 9, 4to. In the Report of the 
Commissioner of Agriculture on the Diseases of Cattle in the United States. 
Government Printing Office, 1871. 
Report of Results of Examinations of Fluids of Diseased Cattle, with reference 
to the presence of Cryptogamic Growths. By Brevet Lieutenant Colonel J. S. 
killings, Assistant Surgeon, U. S. Army, and Brevet Major E. Curtis, Assistant 
Surgeon, U. S. Army, pp. 12, 4to. In the Report of the Commissioner of Agri- 
oulture on the Diseases of Cattle in the United States. Government Printing 
Office, 1871. 
Photographs of Surgical Cases and Specimens, taken at the Army Medical 
Museum, with histories of 296 cases. By Brevet Lieutenant Colonel G. A. 
Otis, Assistant Surgeon, U. S. Army. "Washington, 1866-71. 6 vols., 4to. 
Reports accompanied by Photographs of Microscopic Objects. By Brevet 
Lieutenant Colonel J. J. Woodward, Assistant Surgeon, U. S. Army, viz.; 
Report on the Magnesium and Calcium Lights as applied to Photo-Micro- 
graphy. 6 pp., 4t0., 11 photographs. Surgeon General’s Office, 1870. 
Report on the Oxy-calcium Light as applied to Photo-Micrography. 3 pp., 
Ro-, 2 photographs. Surgeon General’s Office, 1870. 
Report on an Improved Method of Photographing Histological Preparations 
by Sunlight. 10 pp., 4t0., 11 photographs. Surgeon General’s Office, 1871. 
Report on the Histology of Minute Bloodvessels. 8 pp., 4t0., 11 photo- 
graphs. Surgeon General’s Office, 1870. 
Report on the Minute Anatomy of Two Cases of Cancer. 10 pp., 4t0., 2 
photo-lithographs. Surgeon General’s Office, 1872. 
Memorandum on Pleurosigma Angulatum and Pleurosigma Formosum. 4 
PP-, 4t0., 8 photographs. Surgeon General’s Office, 1871. 
Memorandum on Surirella Gemma. 1 p., 4t0., 2 photographs. Surgeon 
General’s Office, 1871. 
Memorandum on the Test Podura. 3 pp., 4t0., 5 photographs. Surgeon 
General’s Office, 1871. 
Memorandum on Amphipleura Pellucida. 1 p., 4t0., 2 photographs. Sur- 
geon General’s Office, 1871. 
Memorandum on the Nineteen-band Test Plate of Nobert. 4 pp., 4t0., 9 pho- 
tographs. Surgeon General’s Office, 1872. 
\r °Ur Letters to the Surgeon General, accompanying Photographs of the 
Mosquito, certain Parasites, the Proboscides of certain Flies, and miscellaneous 
photographs of Insects and parts of Insects. 8 pp., 4t0., 35 photographs. Sur- 
geon General’s Office, 1872, 
Lhe Medical Department of the United States Army from 1775 to 1873. By 
I’evet Major H. E. Brown, Assistant Surgeon, U. S. Arm}'. Washington; 
General’s Office, 1873. 
Ihe Medical and Surgical History of the War of the Rebellion, 1861-65. 
icpared under the direction of the Surgeon General. Part 1., Yol. 1., Medi- 
cal History, by Brevet Lieutenant Colonel J. J. Woodward, Assistant Surgeon, 
WS. Army, pp. xliii., 726; Yol. 11., Surgical History, by Brevet Lieutenant 
Colonel G. A. Otis, Assistant Surgeon, U. S. Army, pp. civ., 650. Appendix, 
c°utaining Reports of Medical Directors, etc., pp. 365. Washington: Govern- 
ment Printing Office, 1870. [Actually issued in December, 1872.] Part 11., 304 
WOODWARD, MEDICAL STAFF OF U. S. ARMY. 
Yol. 11., Surgical History, by Brevet Lieutenant Colonel G. A. Otis, Assistant 
Surgeon, IT. S. Array, pp. 1024. Washington: Government Printing Office, 
1876. 
A Report on a Plan for Transporting Wounded Soldiers by Railway, etc. 
By Brevet Lieutenant Colonel G. A. Otis, Assistant Surgeon, XI. S. Army. 
Surgeon General Office, 1875, 56 pp. Bvo. 
Pamphlets issued in connection with the exhibit in the Hospital of the Medi- 
cal Department, U. S. Army, International Exhibition of 1876, viz.: 
No. 1. List of Skeletons and Crania in the Section of Comparative Anatomy 
of the U. S. Army Medical Museum, for use during the International Exhi- 
bition of 1876. By Dr. H. C. Yarrow. Washington, 1876, pp. 52, Bvo. 
No. 2. Description of the Models of Hospital Cars, By Brevet Lieutenant 
Colonel J. J. Woodward, Assistant Surgeon, U. S. Army, 10 pp., Bvo. 
No. 3. Description of the Models of Hospitals. By Brevet Lieutenant Colo- 
nel J. J. Woodward, Assistant Surgeon, XT. S. Army, 22 pp., Bvo. 
No. 4. Description of the Models of Hospital Steam-Vessels. By Brevet 
Lieutenant Colonel J. J. Woodward, Assistant Surgeon, XT. S. Army, 12 pp., Bvo. 
No. 5. Description of Perot & Co.’s Improved Medicine Wagon. By the 
manufacturer, 16 pp., Bvo. 
No. 6. Description of the XT. S. Army Medicine Transport Cart, Model of 
1876. By Brevet Lieutenant Colonels D. L. Huntington and G. A. Otis, As- 
sistant Surgeons, XT. S. Army, 16 pp., Bvo. 
No. 7. Description of Selected Specimens from the Surgical Section of the 
Array Medical Museum. By Brevet Lieutenant Colonel G. A, Otis, Assistant 
Surgeon, XT. S, Army, 22 pp., Bvo. 
No. 8. Check List of Preparations and Objects in the Section of Human 
Anatomy of the XI. S Array Medical Museum, for use during the International 
Exhibition of 1876. By Brevet Lieutenant Colonel G. A. Otis, Assistant Sur- 
geon, XT. S. Army, Washington, 1876, pp. 135, Bvo. 
No. 9. Inst of Selected Microscopical Preparations from the Army Medical 
Museum. By Brevet Lieutenant Colonel J. J. Woodward, Assistant Surgeon, 
E. S. Array, 7 pp , Bvo. 
No. 10. Description of Selected Specimens from the Medical Section of the 
Army Medical Museum. By Brevet Lieutenant Colonel J. J. Woodward, As- 
sistant Surgeon, XT. S. Army, 21 pp., Bvo. 
No. 11. Typho-Malarial Fever: Is it a Special Type of Fever? Being re- 
marks introductory to the discussion of the question in the Section of Medi- 
cine, International Medical Congress. By Brevet Lieutenant Colonel J. J- 
XYoodward, Assistant Surgeon, XI. S. Army, 44 pp., Bvo. 
Other Official Publications of the Medical Staff. 
Report on Quarantine on the Southern and Gulf Coasts. By Brevet Major H. 
E. Brown, Assistant Surgeon, XT. S. Army. Washington; Government Print- 
ing Office, 1873, 42d Congress, 3d Session, Senate, Executive Document No. 9. 
Cholera Epidemic of 1873 in the United States. Reports prepared under 
the direction of the Surgeon General of the Army. A. History of the Cholera 
Epidemic of 1873 in the United States. By Brevet Major E. McClellan, 
Assistant Surgeon, U. S. Army, 513 pp., Bvo. B. History of the Travels of 
Asiatic Cholera. By John C. Peters, M.D., of New York, and Brevet Major E- 
McClellan, Assistant Surgeon, U. S. Army, 192 pp., Bvo. C. Bibliography of 
Cholera. By Brevet Lieutenant Colonel J. S. Billings, Assistant Surgeon, U. 
S. Army, 320 pp., Bvo. Washington : Government Printing Office, 1875, 43d 
Congress, 2d Session, House of Representatives, Executive Document, No. 95. 
Statistics, Medical and Anthropological, of the Provost Marshal General’s 
Bureau, etc. By Colonel J. H. Baxter, Chief Medical Purveyor, U. S. Army, 
Washington: Government Printing Office, 1875, Yol. 1., pp.1xii.,568 ; Yol. IL, 
pp. xxviii., 767. 305 
SECTION ON MEDICINE. 
PRESIDENT OP THE SECTION. 
ALFRED STILLE, M.D., LL.D., 
OP PHILADELPHIA. 
E. P. HOWARD, M.D., 
VICE-PRESIDENTS 
J. J. WOODWARD, M.D., 
OF MONTREAL. 
SECRETARY. 
XJ. S. ARMY. 
J. EWING HEARS, M.D. 
OF PHILADELPHIA. 
TYPHO-MALARIAL FEVER: IS IT A SPECIAL TYPE OF 
FEVER? 
BY 
J. J. WOODWARD, M.D., 
SURGEON, UNITED STATES ARMY. 
Since the earliest times Pestilence has followed in the footsteps of 
-Var. It has been the consequence of Ignorance as much as of Necessity, 
V 8 causes are to be sought, not merely in fatigues, exposures, and priva- 
D°ns necessarily incurred during the performance of heroic deeds; not 
Merely in the morbific influences of strange climates ; not merely in the 
niiseries of besieged places ; they are equally to be sought in the thou- 
sand preventable abnormal conditions to which armies are exposed when 
puddled together in ill-selected, over-crowded, and filthy camps, fed by 
or cupidity on scanty, improper, ill-cooked food, drinking 
contaminated by human excretions, and breathing air poisoned by 
Hunan effluvia. Hence arises a brood of camp diseases more destructive 
than the improved small-arras or rifled cannon of any foe; which, on 
Memorable occasions in times past, have annihilated whole armies, and 
>et more frequently decided the fate of campaigns in spite of the mili- 
aiT genius of generals or the heroism of their followers. 
Ibe humane spirit of modern civilization, revolted at horrors which 
science has shown to be to a great extent preventable, has made 
°f late years earnest efforts at prevention, and the intelligence of modern 
adniinistration has perceived that the success of such efforts is an indis- 
Peusable condition to success in war. It is this double motive that has 
Ca ed into existence the Medical Staff’, which has become of late years 
ail essential component part of the army of every civilized nation, 
e Aork to be done cannot be performed by a band of hired barber- 
N>igeons employed to bind up rudely the wounds received in battle; 
I ,Canuot.be performed by the voluntary assistance of the crowd of edu- 
cated civil physicians who may be led by motives of humanity to the 306 
WOODWARD, 
scene of suffering, after the mischief is done and pestilence has actually 
broken out; for its efficient performance it requires the existence of a 
trained Medical Staff. 
To possess the desired efficiency such a staff must be a component part 
of the array in time of peace. It must enjoy such rank and pay in its 
higher grades, and offer to its lower grades such prospects of reasonably 
rapid promotion as to secure the life-long services of the ablest medical 
men. These must devote themselves in times of peace to the study of 
the sanitary conditions which affect the health of armies, and war must 
find them ready to point out with authority the precautions which cannot 
be neglected without peril. The demands of philanthropy, the impulses 
of humanity, are best fulfilled by such a staff' when it best discharges 
its military duty, which is to see to it that of a given number of soldiers 
on the rolls, the largest possible number shall always be ready for duty. 
This proper duty of the Medical Staff is as much a military duty as 
that of the artillery or the infantry. It is the business of these to maim 
and destroy till the strength of the enemy is so diminished that he can 
no longer resist; it is the business of those to aid in keeping the fight- 
ing ranks full until their work is done. For the efficient discharge of 
this military duty the medical staff requires military rank as much as 
any other branch of the army service. It requires it, not merely because 
it is otherwise impossible to secure the continuous service of an efficient 
personnel, but because, without military rank, no personnel, whatever 
its qualifications, can be really efficient. It requires rank, because it 
requires authority. If its wise counsels can be thwarted at every step 
by the obstinacy of ignorance, it becomes a mere witness of evils which 
it is impotent to prevent. 
This is not the time or place to discuss the question as to whether the 
conditions just indicated as necessary to secure the most efficient medi- 
cal staff possible have yet been completely fulfilled in any army. I must 
leave that question to the thoughtful consideration of my hearers of all 
countries. It is enough for my present purposes to point out that coin- 
cidently with the elevation of the medical staff in modern times the 
camp diseases of modern wars have notably diminished in malignancy. 
Me no longer hear of armies destroyed by pestilence within the first few 
weeks or months after taking the field. The old bubo-plague and spotted 
typhus no longer figure in the history of wars between civilized nations. 
I admit that much remains to be done by Preventive Military Medi- 
cine. I admit that much remains to be learned with regard to the causes 
of disease. But this is no reason wffiy armies should not enjoy to the 
uttermost the knowledge we already possess. And it is after all but a 
partial application of this knowledge which has brought about the ame- 
lioration to which I have just referred. I think it is safe to affirm that 
no army ever yet took the field, even in the most modern times, that did 
not campaign in daily violation of well-established hygienic laws. And 
hence it will be found that if in any modern war the mortality from 
disease has been very small, it has been because the struggle has been very 
brief. We shall deceive ourselves if we overlook the element of time in 
the production of the diseases of modern armies. An army may very 
well escape with trilling mortality from an exposure of a few, weeks or 
months to influences which would have proved fearfully destructive if 
continued for a year or longer. 
This was well illustrated by the experience of the Armies of the United 
States during the civil war by which this country was recently convulsed. TYPHO -MALARIAL FEVER. 
307 
Notwithstanding the want of discipline among the newly-levied troops; 
notwithstanding the lack of experience in military medicine on the part 
of the newly-enrolled medical officers; notwithstanding all the faults of 
administration and the necessity of reform, of which so much has been said 
in certain quarters, the mortality from disease did not exceed 2.2 deaths 
per 1000 of strength monthly, during the first six months of the strug- 
gleI—a death-rate which, if it had continued, would have represented an 
annual loss from disease of 26.4 per 1000 of strength. But in point of 
fact a rapid increase in the mortality took place after the first of Novem- 
ber, 1861. The deaths from disease during the year ending June 80, 
1862, were at the rate of 49.3 per 1000 of "strength, and, in spite of in- 
creased discipline and increased experience, the reorganization of the 
Medical Staff, and other reforms, rose to 63.2 per 1000 of strength during 
the year ending June 30, 1863. During the year ending June 30, 1864, 
the improved discipline and sanitary management of the white troops 
were at length accompanied by a diminished mortality, and the death-rate 
from disease fell to 48.2 per 1000 of strength, or very nearly what it was 
during the first fiscal year of the war. "Subsequently, however, it rose 
again, in spite of every effort, and was 56.5 per 1000 of strength during 
the year ending June 30, 1865. These figures, it must be remembered, 
refer only to the white troops, who constituted the bulk of our forces. 
They include both the regular army and the volunteer troops. And I 
may remark that I have shown in the introduction to the first volume 
of the Medical History of the War,2 after an analysis of the records of 
the Surgeon General’s office, and a careful comparison with the records of 
the Adjutant General and the Quartermaster General, that the average 
annual mortality from disease among the white volunteers, during the 
four years of the struggle, must be fixed at 55 per 1000 of mean strength, 
while it was only 32 per 1000 of strength for the small regular army 
during the same period. 
But what shall I say of the mortality among the colored troops ? 
The statistical tables in the first volume of the Medical History show it 
to have been 211 per 1000 of mean strength during the year ending June 
30, 1864, and 139.8 during the year ending June 30, 1865. Even if we 
extend the view to cover the whole period from the day the first volun- 
teer colored regiment was mustered into service to the day the last was 
mustered out, a period of five years and four months, and distribute the 
mortality over the whole term, it will be found, as I have shown in the 
Introduction to the first volume of the Medical History,3 that it repre- 
sents an average annual mortality from disease of 133 per 1000 of mean 
sß’eugth—a proportion which it is impossible to consider without emo- 
tion. 
It is only just to express my conviction that a large part of this ex- 
cessive mortality was due to circumstances from which the colored men 
suffered before they were enlisted, rather than to mismanagement or 
maltreatment afterwards. It must be remembered that a large part of 
these colored soldiers were fugitive slaves. They fled into our lines 
literally naked and starving. The diseases which destroyed them were 
to a great extent engendered by the miseries they had suffered before 
they found a refuge under our flag. 
1 These figures and those in the following paragraphs are deduced from the Statistical 
tables of the first Medical volume of the Medical and Surgical History of the War of the 
(1861-5). Washington, Government Printing Office, 1870. 
Op. cit., Introduction, p. xli. 3 Op. cit., Introduction, p. xl. 308 
WOODWARD, 
In all—embracing in the count all arms and all colors, officers and 
men—the total mortality of the armies of the United States from dis- 
ease during the war (including the deaths during the year following, in 
which a large part of the mortality was from diseases contracted during 
the struggle), may be fixed at a little over 200,000 men, while battle and 
wounds destroyed rather more than 100,0002 This estimate of 200,000 
men dead of disease embraces, it must be remembered, not only about 
30,000 of the colored soldiers, upon whose mortality I have commented, 
but a nearly equal number of white soldiers, who died while prisoners 
of war in the hands of the enemy, under circumstances upon which I 
refrain from comment at this time, but for which the Medical Adminis- 
tration of the United States army can assuredly in no wise be held re- 
sponsible. 
These circumstances no doubt increased the mortality of our armies 
greatly beyond what it would otherwise have been. On the other hand, 
it must not be forgotten that discharges from the service for disability 
took place with a freedom—perhaps in strict justice I ought to say, with 
a recklessness—never before exhibited in any army. The total number 
of soldiers thus discharged may be estimated as not far short of three 
hundred thousand.2 Uo doubt very many of these men only went home 
to die. Uo doubt, also, many thousands of them, epecially those suffer- 
ing with lame backs and general debility, rheumatic pains, and cardiac 
palpitations, needed only a short sojourn in a northern climate, with a 
generous diet, to have fitted them again for the field. I cannot dwell 
here on this shameful story. It is one of the scandals of the war. I 
have never been able to collect data to justify even an approximate esti- 
mate of the proportion of these men who died. I believe it to have been 
comparatively small. Removed from the theatre of war, returned to the 
healthier circumstances of their homes, I doubt not that a large propor- 
tion of these men recovered their health, and that thousands of them, 
induced by the large bounties which were offered for recruits, found their 
way again into the ranks. 
Certainly the statistics I have cited afford food for earnest thought. 
Rut if their study is to be profitable, it must be undertaken with a 
careful consideration of all the circumstances. Above all, when these 
figures are compared with the results of other wars, the element of 
time must be taken into account, or the gravest misunderstandings will 
arise. A striking illustration of this possibility has been brought to 
my notice. 
In an oration delivered on the 2d of August, 1874, on the anniversary 
of the Military Medical School of Berlin,3 Professor Rudolph Virchow, 
1 In the Introduction to the first Medical volume of the Medical and Surgical History 
of the War, I have fully discussed the various official records, and arrived (see p. xxxviii.) 
at the following results, which are probably very near the truth ; 
Deaths from battle, wounds, and other violence 
. 93,909 
Deaths from disease 
. 186,216 
Deaths, the causes of which are not recorded . 
. 24.184 
304,369 
On the reasonable supposition that those deaths in which the causes are not recorded were 
distributed between wounds and disease in the same proportion as those whose causes are 
recorded, we shall arrive at the results expressed in the text. 
2 See Introduction to the first Medical volume just cited, p. xlii. 
3 Die Fortschritte der Kriegsheilkunde, besonders im Gebiete der Infectionskrankheiten. 
Rede gehalten zur Feier des stiftungstages der militar-arztlichen Bildungs-Austalten, am 
2, August, 1874, von 11. Virchow. Berlin, verlag von A. Hirschwald, 1874. TYPHO-MALARIAL FEVER. 
309 
one of the ablest medical thinkers in Europe, alluded to this enormous 
mortality from disease during our war, and contrasted it with the com- 
paratively small losses of the German army during the late war with 
France. After reciting the American figures, and, I may add, after 
speaking of the publications of the Surgeon General’s office in language 
so complimentary that, as one of the officers concerned in their prepara- 
tion, my modesty will not allow me to repeat it, the distinguished 
orator continued as follows: “The German army had, during the last 
French war, out of a strength of 913,967 men, a total loss of 44,980. 
Of these, 17,572 fell before the enemy, 10,710 died later of their wounds, 
12,253 fell a sacrifice to disease and pestilence; certainly a very favora- 
ble proportion. But we had before us the experiences of two recent 
Wars, which had been well discussed and taken advantage of, both scien- 
tifically and administratively. We possessed the inestimable experience 
°f the Americans, and, finally, we had German science.”1 
Truly, I will not yield even to Virchow himself in my appreciation 
of German science. I know well the debt of gratitude which modern 
medicine owes to German investigation. For myself, I have drawn 
much of the knowledge I value most from German sources. I admire 
Grerman science for its industry, which is without parallel ; for its origi- 
nality, which has already pushed discovery so far; but most of all, for 
the truly catholic spirit which knows no nationality, and for the manly 
which never hesitates to weigh authority by a comparison 
with the actual facts. 
Something of this spirit I have tried to catch, and I will not therefore 
allow myself to be misled as to the matter under discussion, even by the 
authority of Virchow. I cannot avoid interpreting the facts otherwise 
than he has done, and I feel that I am but performing a necessary duty 
when, standing here before you to-day, I declare it to be my opinion 
that not even German science would have sufficed to save the German 
army from a greatly increased percentage of mortality if the war had 
lasted a few years instead of a few months. 
The figures given by Virchow are from the official report of Dr. Engel.2 
-they represent a period of seven months. They must not be compared 
with the losses of our whole civil war, but with the losses of the first 
seven months. Let us make the comparison. Virchow’s figures repre- 
sent a mortality of 13.4 + per 1000 of strength for seven months, or 
F9 1- per lOuO monthly. Yow I have already shown you that the mor- 
tality from disease in our armies during the first six months of the war 
averaged 2.2 per 1000 monthly. During the following month, viz., 
-November, 1861, the mortality increased very greatly, so that, indeed, 
almost as many died during that month as during the whole six months 
preceding. Including these deaths, I find, on a discussion of the official 
data, that during the first seven months of the civil war, viz., from May 
1 to 30, 1861, the mortality from disease was at the rate of 
18.8 per 1000 of strength, or 2.7 per 1000 monthly.3 You see that the 
1 Op. cit., S. 7. 
Zeitschrift des Kciniglich Preussischen Statistischen Bureaus. Pedigirt von lessen 
Dr. Ernst Engel. Zwblfter Jahrgang, 1872. Berlin, 1872, S. 293. 
M r Se rat*os are deduced from the Statistical Tables in the first Medical volume of the 
1 rdical and Surgical History quoted above. I may add here, that the total number of 
eaths from disease from the commencement of the war to November, 1861, recorded on 
, e Alphabetical registers of the Surgeon General’s Office, is 3206. There are also 160 
1 eaths recorded during the same time, the causes of which are not specified. If we sup- WOODWARD, 
mortality of our army from disease, during equal times, was really but 
about one-third greater than that of the German army in the French 
war; whereas, as Yirchow presents the subject, it is made to appear 
more than fifteen times greater. 
Now, I am perfectly willing to admit that a part of the actual differ- 
ence in favor of the German army was really due to better discipline and 
a wiser application of preventive medicine. But Ido not believe that 
this is the only reason for the difference. The raw levies of the North- 
ern States were sent at the very first to the South, and campaigned or 
lay in camp during the time in question in the miasmatic valleys of the 
Mississippi, the Ohio, and the Potomac, while the German army did its 
work on the comparatively salubrious plains of France. What would 
have happened had the scene been exchanged ? How much of the dif- 
ference was really due to the wisdom of man, how much to a more 
favorable climate, and the absence of the intense malarial poison to 
which all were exposed who bore our arms? 
This malarial influence, and the pathological processes to which it 
gives rise, demand the most careful study of those who would endeavor 
to comprehend the problem of the health of armies in America. It is 
not merely manifested by the frequency of ordinary ague, of which very 
nearly a million cases1 were officially reported in our armies during the 
war; it colors and complicates other diseases to an extent which can 
hardly be credited by those who have not been eye-witnesses to its effects. 
Especially does it demand the consideration of those who may attempt 
the study of the fatal continued fevers which have been, and will be, the 
pose all of these to have been deaths from disease, the number will be 3866. Of this num- 
ber, 1457 died during the month of November, viz.: 1413 of disease, and 44 of causes not 
specified. The absolute number is but a little more than one-fourth of the German figures ; 
but the average strength of the troops in service during the time referred to was also about a 
fourth of the German army, so that the ratios are as stated in the text. The compara- 
tively small mortality at the commencement of our civil war is strikingly illustrated by the 
Medical History of the three-months’ volunteers. It will be remembered that at the com- 
mencement of the struggle President Lincoln called out 75,000 men to serve for three 
months. This call was issued April 15, 1861. According to the records of the Adjutant 
General’s Office, the actual number of men who were mustered into service on this call was 
91,816. Through the kindness of Assistant Adjutant General T. M. Vincent, I have 
ascertained from the death and disability records of the Adjutant General’s Office that the 
actual mortality of these troops during their three-months’ service was as follows; 
Deaths from battle, wounds, and other violence 
. 221 
“ from disease ....... 
. 151 
“ from causes not recorded ..... 
. 231 
Total ........ 
. 603 
If all the deaths of which the causes were not recorded were from disease, the total num- 
ber of deaths from disease would be 382, or 4.2 per 1000 of strength for the three months. 
This would correspond to a mortality of 1.4 per 1000 monthly, or less than three-fourths of 
the monthly rate which I have shown in the text for the first six months of the war. 
1 The number of cases and deaths reported as due to ague was as follows : 
White 
Troops. 
Colored 
Troops. 
Cases. 
Deaths. 
Cases. 
Deaths. 
Quotidian intermittent fever 
. 447,258 
452 
63.992 
58 
Tertian intermittent fever . 
. 375,170 
381 
51,045 
54 
Quartan intermittent fever . 
. 41,223 
84 
3,923 
15 
Congestive intermittent fever 
. 13,673 
3,370 
2,536 
794 
Total . 
. 877,324 
4,287 
121,496 
921 
The grand total for both white and colored troops is 998,820 cases, and 5208 deaths. 
See the first volume of the Medical History, cited above. TYPHO-MALARIAL FEVER. 
311 
scourge of the camps of every army that operates in the valleys of the 
Mississippi and its tributaries, or of the rivers that flow into the Gulf of 
Mexico, and into the Atlantic ocean south of the fortieth parallel. 
These camp fevers occupy a conspicuous place among the diseases 
which produced the mortality of our armies during the civil war. They 
caused more than one-fourth of all the deaths from disease. In fatality 
they proved second only to diarrhoea and dysentery. I suppose it is safe 
to estimate that diarrhoea and dysentery produced about 60,000 deaths 
111 the armies of the United States during the civil war, and camp fevers 
rather more than 50,000.1 A right comprehension of these two groups 
of diseases must therefore be regarded as the most important task of 
Military Medicine in America. 
It is my purpose in the present discourse to discuss certain points con- 
nected with the pathology of these camp fevers, and especially the com- 
plication of the typhous process by the malarial influences to which I 
have just referred. 
Already in the fall and early winter of 1861 reports began to come in 
from various quarters that a new form of fever was prevailing in our 
camps. The great majority of our army surgeons at that time were 
fresh from civil life. Many of them had been engaged in extensive pri- 
vate practice. Almost all of them were well acquainted with ordinary 
typhoid fever (enteric fever, typhus abdominalis) as it annually prevails 
111 the Northern States, and it was precisely these men who first called 
attention to the fact that the fevers they were now called upon to com- 
bat differed in many important particulars from those to which they 
"Were accustomed at home. 
This circumstance was noticed in both the Western and the Eastern 
armies ; but, so far as I have been able to ascertain, official attention was 
first directed to it in the Army of the Potomac, then encamped just 
beyond the banks of the river in front of Washington. By an order 
from the Adjutant General’s office, dated December 6, 1861, a Board of 
Medical Officers was convened for the purpose of visiting the camps of 
fie Army of the Potomac, and inquiring into the nature of the prevail- 
lng fever, especially endeavoring to ascertain —to use the language of 
the order appointing the Board—“ whether it is to be considered an 
tatermittent or bilious remittent fever in its inception, assuming in its 
course a typhoidal type, or a typhoid fever primarily.” This Board 
consisted of Surgeon A. N. McLaren, U. S. A.; Brigade Surgeon G. H. 
44,558 deaths from diarrhoea and dysentery were reported during the war, out of 
deaths from disease, the causes of which were specified in the reports. If we sup- 
P°se these diseases to have caused the same proportion of those deaths from diseases the 
causes of which are not specified in the reports, we shall obtain the estimate of the text, 
he cases and deaths of the several forms of camp fevers reported to the Surgeon General’s 
*hce were as follows : 
White 
Troops. 
Colored 
Troops. 
Cases. 
Deaths. 
Cases. 
Deaths. 
Typhus fever . 
. 2,501 
850 
123 
108 
Typhoid fever . 
. 75,368 
27,056 
4,094 
2,280 
Common continued fever 
. 11,898 
147 
Typho-malarial fever 
. 49,871 
4,059 
7,529 
1,301 
Remittent fever 
. 286,490 
3,853 
30,645 
1,002 
Total 
. 426,128 
35,965 
42,391 
4,691 
T his gives a total of 40,656 deaths from those fevers out of 156,885 deaths from disease, 
causes of which are specified in the reports. On the supposition just mentioned we 
otaiu the estimate in the text. 312 
WOODWARD, 
Lyman, U. S. Volunteers, and Assistant Surgeon M. J. Asch,lL S. Army. 
It convened December 16, at the quarters of Brigade Surgeon Lyman, 
who was chief medical officer of the division commanded by General 
Fitz John Porter; and during its subsequent labors examined the hospitals 
of this and other divisions, and collected a great deal of valuable infor- 
mation, in writing, by means of written questions addressed to the 
brigade and regimental medical officers of parts of the army which its 
members were unable conveniently to visit. As might have been expected, 
some diversity of opinion was expressed in the replies received. But in 
their general tenor the great majority of these replies confirmed the 
opinion formed by the members of the Board on the basis of their own 
personal observations. This opinion was that, while a certain number 
of cases of ordinary typhoid fever existed in the army, the large majority 
of the febrile cases were “bilious-remittent fevers, which, not having 
been controlled in their primary stage, have assumed that adynamic type 
which is present in enteric fever/’ 
In the following spring, after the Army of the Potomac commenced 
its Peninsular campaign, this mixed form of fever increased in frequency. 
It assumed formidable proportions during the siege of Yorktown, and 
reached its greatest intensity while the army lay encamped on the 
swampy borders of the Chickahominy. The hospitals of Washington 
and Alexandria, of Baltimore, Philadelphia, New York, and other 
Northern cities, were crowded to overflowing with the sick. Among 
the attending physicians were some of the best instructed medical men 
of the Northern States. They have shown that they recognized that 
they had to deal with an unusual pathological complex, by perpetuating 
the name of Chickahominy fever, which appears so often in their reports. 
It was under these circumstances that I was ordered, early in the 
summer of 1862, to serve on a Board of Medical Officers, who were 
directed to revise the form of sick report in use in the army. I was 
fresh from the Army of the Potomac, which I had accompanied from its 
camps before Washington, where I had spent the winter with it, I had 
lain in camp at Yorktown, and followed the army up the Peninsula. I 
had formed the opinion that the prevailing fevers of the Army of the 
Potomac were hybrid forms, resulting from the combined influence of 
malarial poisoning and of the causes of typhoid fever. I believed that 
individual cases received their characters in accordance as the one or 
the other of these influences preponderated in the individual, and that 
very often the picture was still further complicated by the coexistence 
of a scorbutic taint. Full of these opinions, I proposed to the Board, 
as I had previously suggested to the Surgeon General, to designate the 
complex condition in question by the name typho-malarial fever, and I 
induced the Board to add this term to the list of diseases printed on the 
blank form for the monthly sick report. I often regret that I did not 
also urge upon the Board the preparation of a circular letter to accom- 
pany the new sick report, explaining why this term had been adopted, 
and calling for special reports with regard to the cases which it was 
intended to designate. As it was, the term went upon the sick report 
without any explanation or a word of comment. But even under these 
circumstances, 23,346 cases were reported as typho-malarial fever during 
the following year, showing how widely the opinions I had formed were 
shared by the medical officers of the array. 
In September, 1863, I published in Circular, No. 15, of the Surgeon TYPHO -MALA RIAL FEYER. 
313 
Gretieral’s Office,1 a short statement with regard to the sickness and 
Mortality of the army during the first year of the war, in which I stated 
the meaning I designed to attach to the term typho-malarial fever, and 
111 November of the same year completed the publication of my Outlines 
°f the Chief Camp Diseases of the United States Armies,2 in which I 
presented my view’s at some length. I also gave a short account of the 
subject in Circular No. 6, Surgeon General’s Office, 1865.3 And now, after 
a careful study of all the pathological and documentary material accu- 
mulated during the war, I still hold substantially to the same views, 
aud hope in the second volume of the Medical History of the War to 
present the facts upon which my opinion is based in such a manner as 
t° command universal assent. In so doing, I shall, of course, present 
many additional matters of detail not contained in any of my former 
publications; and also, I may frankly say, I shall correct some errors of 
.Gail (particularly with regard to the pathological anatomy of the intes- 
Imes in these fevers), into which I fell during my earlier studies, and 
were incorporated in the account presented in my book on Camp 
-diseases. 
. In the same connection I hope to present historical proof of a proposi- 
J'I°n, which Ido not hesitate even now to announce to you, that such 
hybrids betw’een malarial fever and typhus, of one form or another, are 
Uo new thing in the history of armies. They were not first begotten on 
American soil. In fact, in every great army that ever yet campaigned 
:°r any length of time in a malarial region the prevalent form of fever 
nas been a hybrid between malarial fever and some form of typhus. By 
a malarial region I mean simply a region in which ague and remittent 
cvers are the common endemic diseases. The causes of these fevers act 
ays with peculiar intensity upon strangers; and an invading army is, 
neretore, peculiarly prone to suffer from them. At the same time the 
Uncleanliiiess and overcrowding of camps favor the spread of some form 
ot typhus, whether originating dc novo or introduced from without by 
pontagion. In some cases it has been spotted typhus which has made 
ts appearance; in others it has been abdominal typhus (typhoid fever), 
j as the typhus poison has been of one or the other variety, and as 
16 malarial influence has been more or less intense, the complex result 
ms varied—at times the malarial phenomena, at times the typhous 
pienornena being the more prominent. The morbid conditions resulting 
|l°m these twofold causes have usually also been still further modified 
}T the existence of actual scurvy, or at least of a scorbutic taint, the 
®ult of an improper and often scanty supply of food. 
H would be impossible, in the time allotted to me, to re-examine to 
g* ,I^lrcular No. 15, Surgeon General’s Office, Washington, D. C., September 8, 1863. 
USe A?ss and Mortality of the Army during the First Year of the War. The language 
111 this preliminary report was as follows: “ Moreover, while a certain amount of 
c!niG'ca,ted enteric and remittent fever certainly did occur, especially at the commence- 
ract ° "ar’ ie vast majority °f I*l6 camp fevers of the army were of a mixed cha- 
and er!.ex^it}iting undoubted enteric phenomena, variously combined with the periodicity 
inci , ier Peculiarities of malarial disease, and still further modified by the tendency to 
scurvy> which is the ordinary concomitant of camp diet. To indicate this mixed 
in j re’ t'le term typho-malarial fever, which I had the honor to suggest to the Department 
use ”lne’ appears appropriate, and. at the present time, is coming into very general 
as ol!' oodward. Outlines of the Chief Camp Diseases of the United States Armies, 
PP 864 Ve<i durill£ the present war. Philadelphia: J. B. Lippincott & Co., 1863. Bvo. 
Circular No. 6, Surgeon General’s Office, Washington, November, 1,1865, p. 109 et seq. 314 
WOODWARD, 
any great extent the history of armies from this point of view. I can 
only bring to your notice a few striking illustrations. First, let me recall 
the pestilential fever which destroyed the French General Lautrec and 
the army of thirty thousand men with which he besieged Naples, in 
1528. Flecker1 has analyzed the chronicles of the time with his usual 
eloquence, and has arrived at the conclusion that it was simply petechial 
typhus which raged in the French camp. After an examination of the 
authorities he cites, I cannot agree with this conclusion. .The siege 
began May 1. Almost the first act of the French General was to cut 
the aqueducts which supplied the city with water. By this rash act 
the plains on which he was encamped, intensely malarial at the best, 
were converted into a vast series of bogs and stagnant pools, from which 
the heat of the sun raised clouds of vapor, which hung around his camp 
like a pall. I must believe that Jovius2 was right in attributing the 
destruction of the French army chiefly to this act of madness. No con- 
temporaneous physician has described the pestilence that followed, but 
the chroniclers of the siege have recorded symptoms which are incom- 
patible with the theory of Hecker. Jovius tells us that many of the 
patients were affected with swellings of the belly and legs. They became 
so pale and death-like in their complexions that their friends were hardly 
able to recognize them. Scarcely able to crawl, and without attendants 
to nurse them, they often died in their tents of hunger and thirst. 
Sandoval3 describes the same death-like faces, and applies to them the 
epithet amarillos (yellow). These are not the symptoms of spotted 
typhus, but of intense malarial poisoning. "We saw just such cadaver- 
ous yellow faces, with swelled legs and bloated bellies, crawling about 
in the camps at Young’s Point on the Mississippi, and at other swamp- 
beset localities, during our own war. 
I agree, however, with Hecker, to whose work I must refer you for 
particulars, that spotted typhus was no doubt also present in the camp; 
and I suppose it complicated the acute fevers very much, as it did later 
in the same century in the Austrian armies in Hungary. Moreover, 
Guicciardini4 relates that after Lautrec first fell sick, during the month 
of July, things fell into confusion, the enemy cut off the convoys of 
provisions, and some of the soldiers actually died of starvation in con- 
sequence. These circumstances, I doubt not, also played their part in 
destroying the French Army. By the second of August there were but 
four thousand men fit for duty. Lautrec died August 15, and, the 
mortality still continuing, his successor thought only of flight. This he 
attempted August 29, but was pursued, and capitulated at Averse a 
few days later. Crowded into the stables of la Madeleine, the pestilence 
continued its ravages among the prisoners, and when, a little later, they 
were released by the conqueror, but a handful remained to find their 
way back to France. 
Next let me ask your attention to the story of the celebrated Hunga- 
1 J. F. 0. Hecker. The Epidemics of the Middle Ages. Transl. of Sydenham Soc., 
London, 1844, p. 212 et seq. 
2 Jovii (Pauli, Novocomensis, Episcopi Nucerini) Historiarum sui Temporis, Tomi IL* 
plorcntise, 1550-2, Lib. XXYI. I have not obtained access to the original, but find in the 
Congressional Library a German translation, printed at Frankfort, 1570. 
3 Sandoval. Historia de la vida y hechos del Emperador Carlos V. Pamplona, 1614-18. 
Part. IL, Lib. XVII., § XL, p. 12 et seq. 
4 Guicciardini. Della Istoria dTtalia. Lib. XX., Venice, 1738. I have used the 
English translation of A. P. Goddard, 3d ed., London, 1763. TYPHO-MALARIAL FEVER. 
rian fever, which for at least three centuries played so formidable a part 
H the campaigns undertaken by the House of Austria against the Turks, 
■f he valleys of the Danube and its tributaries are still the home of agues, 
Remittent and continued malarial fevers, big spleens, and malarial 
cachexias. Lying further to the north than our own Mississippi valley, 
fhe climate is nevertheless such that the marshy borders of the streams 
aiHl pools give rise to a malaria scarcely less intense than that with 
which we are familiar in the lower Mississippi. I may refer you to the 
Papers of Muller, Wenmaring, and Lantz1 for graphic descriptions of 
the characteristics of the country and of its prevailing; diseases in our 
own day. 
Now, in every considerable campaign against the Turks, in which the 
armies of the German Emperors invaded the Hungarian plains, from the 
beginning of the sixteenth century to the end of the eighteenth, a form 
ot fever prevailed among the troops so unlike the ordinary European 
fevers that it has always been known as the Hungarian fever, and so 
*atal as to occasion the proverb that “ Hungary is the grave of the Ger- 
mans.” This Hungarian fever has exercised some of the best medical 
minds of the last three centuries. It is now generally admitted to have 
oecn a hybrid between the endemic remittent fevers of the Hungarian 
sml and spotted typhus. The attention of civilized Europe was first 
directed to it when, after the luckless Hungarian campaign of Maximil- 
ian 11., in 1566, his pest-stricken soldiers returned to their homes. 
I hey scattered the contagion of spotted typhus throughout Germany 
°b their way. The disease bred by that contagion was also called the 
Hungarian fever, but it was simply spotted typhus, and the student of the 
older literature of the Hungarian fever finds no little coll- 
ision growing out of this circumstance,and no little difference between 
He descriptions of such eye-witnesses as Thomas Jordan and Tobias 
holier, who described the Hungarian fever as they saw it on Hungarian 
s°b, and the descriptions of those who merely observed the spread of 
sPetted typh us in the German towns, and gave it the name of the Hun- 
&anan fever because the contagion had been spread by soldiers returning 
r°m Hungary. 
-lie army of Maximilian, however, was not the first German army 
Mich had suffered from the Hungarian fever. In 1542 a pestilential 
ver broke out at the camp before Ofen, in the Imperial German army 
Rich Margraf Joachim von Brandenburg had led against the Turks. 
became still more fatal during the disastrous retreat, and according 
,? Haeser2 destroyed 30,000 men. Johannes Langius,3 who accompanied 
le Count Palatine, Frederick 11., in this campaign, as well as in the 
ej Nos- Muller. Die k. k. Militaergraenze, mit besonderer Berucksichtigung der ver- 
Br)1 Carlstadter, Banal mid Warasdiner Graenze. Med. Jahrb. desk. k. oest. Staates. 
Bp t5 v.1843).5. 89,231, 361. Bd. 36 (1843), S. 110, 235, 338. F. Lantz. Fhys. Med. 
S rroeibune Barangaer Gespannschaft in Ungarn. (Same Journal.) Bd. 55 (1846), 
w'ppl 361- Bd- 56 (1846), S. 99, 221, 349. B. Wenmaring. Ueber die Sumpf- 
has h , >er'. (Same Journal.) Bd. 57 (1846), S. 11, 129. Consult, also, J. M. Minderer. 
Bei Fieber (Hemitriteeus), in den Sudlichen Provinzen des Russischen 
1 , C ls> Hufeland’s Journal, Bd. 28, st. 2 (1809), S. 1. Muller, cited above, speaks of this 
2 has Bie Hemitritseus Daciae. Op. cit. Bd. 36, S. 343. 
340. S6Ser‘ Geschichte der epidemischen Krankheiten. 2te Aufl. Jena, 1865. Bd. 11, S. 
Langius. Med. Epist. Basel, 1554. Epist. 4 (p. 17). In Cura Causonis 
'-mirurgicorum temeritas. WOODWARD, 
campaign of 1526,1 has left an epistle, in which he describes this fever in 
such a manner as to leave no reasonable doubt of its identity. He tells 
us, also, that the camp surgeons, whose ignorance he pictures with 
bitter sarcasm, gave the disease the name of Bhreiine (Braune) on account 
of the condition of the tongue, which they supposed to be the most 
essential symptom. According to IReser,2 the Chronicler Wintzenberger 
gave the same epidemic the name, “ pestartige Braune.” These names 
long continued in use among the designations by which the Hungarian 
fever was known to the vulgar. 
The epidemic of 1566 is famous both on account of the manner in 
which typhus was spread through Europe by the disbanded soldiers, and 
on account of the classical description of the Hungarian fever by Thomas 
Jordan,3 who accompanied the army of Maximilian as his chief medical 
officer. The spring had been exceedingly wet, and the great Hungarian 
streams had overflowed their banks; the summer was unusually hot and 
dry; the German army was scantily supplied with food. When the 
fever first appeared the army was encamped at Komorn, at the point of 
junction of the Waag and the Danube—a marshy, intensely malarial 
plain. It became still more destructive in the camp at Raab, where the 
Saab and Rabnitz empty into the Danube. Such was the devastation 
caused by it that Maximilian, though his force when he went into camp 
at Raab was about 80,000 men, did not venture to take the offensive, 
and saw the gallant little garrison at Zigeth captured by the Turks after 
more than twenty vain assaults, without daring to strike a blow in their 
behalf. In the early autumn he ignominiously retreated with the re- 
mains of his array. After the retreat the pestilence was especially 
destructive at Vienna. The hospitals could not accommodate all the sick, 
and the dead and dying were scattered through the streets. Throughout 
all this devastation it was the German troops that suffered; the native 
Hungarians almost entirely escaped. 
The Hungarian fever broke out anew during the siege of Papa, in the 
year 1597. The Italian allies suffered most. According to Hteser, of 
more than 8000 of these troops, less than 1500 found their way back to 
Italy. This is the epidemic described in the admirable work of Tobias 
Cober.4 
Again it made its appearance, as we learn from Esslinger and Hseser, 
among the 12,000 German troops who occupied Hungary under the 
celebrated General Montecucculi,5 in the year 1661. The disease broke 
out in the swampy camp between Komorn and Keuhausel, and soon 
brought the fruitless campaign to an end. 
Once more it appeared in the army with which Prince Eugene besieged 
Belgrade in 1717. The Grand Vizier advanced to the relief of the be- 
sieged with a great army. The Turks took the offensive, and shut up 
Eugene, with his army of 60,000 men, in the marshy plain between the 
Danube and the Save. It was here that the Hungarian fever broke out, 
1 See Hecker. Art. Hungarica febris. In the Encycl. Woerterbuch der Med. Wiss. 
Berlin, 1838, Bd. XVII, S. 164; with which compare the Dissertation by (I. Agats. De 
Morb. Hungarico. Berlin, 1840. 
2 Op. cit., S. 341. 
3 Thomas Jordani, Pestis Phenomena. Franckfort, 1576. Cap. XIX. p. 219. De Lue 
Pannonia. 
4 Tobias Coberi, Obs. Med. Castrensium Hungaricarum. Decades tres. (Edition of H- 
Meibomius.) Helmstad, 1683. 
5 See Memoires de Montecucculi. Nouv. ed. Amsterdam et Leipsic, 1756. Livr. lIP 
ch. i., p. 321. TYPHO -MALARIAL FEVER. 
317 
accompanied by a fatal dysentery. A large number of men bad perished, 
when the gallant Prince, venturing all on the fortunes of a day, attacked 
the Turkish army and routed it after a desperate battle. The surrender 
°f Belgrade followed, and the peace of Passarovitz was the result. 
Still 
more terrible were the ravages of the Hungarian fever during the 
rl*.. _ o o _ 
disastrous campaign which the Emperor Joseph 11. undertook against 
the Turks in 1788. Disappointed with regard to the help he had antici- 
pated from Russia, and his troops decimated by pestilence, the feeble 
campaign terminated in a humiliating retreat. The imperial army at 
the commencement of the season numbered about 200,000 men ; its losses 
Bom disease have been estimated at between 30,000 and 40,000. 
Plie symptoms of the Hungarian fever have been described at great 
;fcngth by numerous writers. I can only refer to a few leading points, 
the patients were seized, usually during the afternoon or evening, with 
a slight, short chill, followed by a burning fever. This was accompanied 
7 a headache so intense that the vulgar called the disease sometimes 
the head disease (Haupt-krankheit); the raging brain disease (Hirnto- 
eejide-krankheit); or the head misery (Kopfwehe). So prominent was 
t‘ns symptom that in the earlier autopsies medical men sought for the 
cause of the affection chiefly in the encephalon, and, deceived either by 
the congested appearance of the choroid plexus, or by the presence of 
Vermiform clots of blood or fibrin in the ventricles or in the great sinuses, 
Actually supposed they had discovered worms in the brain, and gave to 
he disease the designation “Cerebri vermis” or “Hirnwurm.” With 
the headache came on a pain in the epigastrium so intense that the 
appellations “Herzbraune” and “Herzbreun,” were widely employed. 
°°n the fever was accompanied by a raging delirium; the tongue be- 
carne dry and covered with a brown coat, from whence the vulgar names 
Braune” and “ pestartige Braune,” already mentioned. Hemorrhages 
l°m the cracked tongue or from the gums were common. Then, there 
Was also the characteristic typhus eruption of the skin, accompanied by 
petechins, whence the disease was called “Febris Lenticularis,” especially 
Jy the Italian physicians. In cases which recovered, the favorable crisis 
Usually 
occurred on the fourteenth or twenty-first day, but fatal cases 
Atetl terminated much earlier. In some cases gangrene of the extrerni- 
tles occurred. 
All these symptoms, together with the unmistakable contagion, cer- 
ainly point to spotted typhus; but from a very early period, cultivated 
pejsicians, like Sennertus, for example, have pointed out that this fever 
rij red in several marked particulars from ordinary spotted typhus. 
Je. most striking differences were its tendency to present a decidedly 
mittent type in its earlier stages, and the accompanying gastric symp- 
°ms bilious vomiting and the like. Even Rulandus,1 who was disposed 
7 identify the disease with the febris lenticularis of the Italians, was 
7 A admit that during its early days it frequently presented, in a 
Geided manner, the type of a simple or double tertian fever. A cora- 
after -ar^n De Morbo Ungarico. Leipsic, 1610. Consult Cap. I. p. 9, where, 
atlUi that these remissions are deceptive in their character (lalsa specie), the 
SUr) 0r admits that in the case of Baron Reinhard, who died of the Hugarian fever, he 
terti ° l)urino the earlier history of the case, that he was dealing merely with a double 
lentAi Ar h‘s argument in favor of the identity of the Hungarian fever with febris 
for laris> see Cap. VIIL, \ XX. p. 376. Consult further, Cap. VIII., qusestio 39, p. 510, 
tan typg acaiust the supposition that the Hungarian fever has truly a tertian or quar- 318 
WOODWARD, 
mon form was the semi-tertian, to which the old Greek physicians gave 
the designation Hemitritasus; and hence the Hungarian fever has some- 
times been described as the Hemitriteeus Dacite. 
So marked were these symptoms that Sauvages, the great hfosologist,1 
classes the “Amphimerina Hungarica,” as he calls it, among the remit- 
tent fevers. The learned Haumann2 goes so far as to declare that the 
Hungarian fever is at the bottom merely the common summer fever 
which occurs every }Tear in Hungary, the valley of the Danube, and 
Southern Russia, and attains malignity only in epidemic years. Among 
modern epidemiologists, while Ozanam3still clings to the notion that 
Hungarian fever was merely typhus, both Hecker and Hosser4 express 
the opinion that it was typhus, modified by the intense malaria of the 
Hungarian plains. 
Side by side with the Hungarian fever a chronic affection occurred 
among the German soldiers in Hungary, which, like the Hungarian fever, 
was often spoken of as the Hungarian disease. (Morbus Hungaricus, or 
Lues Pannonica.) This was the celebrated Languor Pannonicus, or 
Asthenia Pannonica.5 It was a profound debility, accompanied with a 
disgust for food, unwillingness for exertion, diarrhoea, and pains in the 
back. It attacked large numbers of men, and not unfrequently proved 
fatal. I suppose it to have been the joint effect of chronic malarial 
poisoning and a scorbutic taint. Much in the old descriptions reminds 
me of a certain group of cases of general debility which were common 
enough in our own war. These, too, were rebellious to treatment so 
long as the patient remained in the malarial region, but recovered’ 
promptly, like some of the cases of Languor Pannonicus described by 
Tobias Cober, so soon as the patients escaped to a healthier atmosphere 
and better diet. 
Dysentery was another camp disorder which proved fatal in the Hun- 
garian campaigns. It is mentioned by various writers, as for example, 
by Cober, but does not appear to have attracted as much attention as it 
probably deserved. 
I cannot dwell further in this discourse on the story of the Hungarian 
camp diseases. I have said enough to indicate that the chief difference 
between these diseases and those of our own camps during the war of 
1861-5 consisted in the prevalence of spotted typhus in Hungary in- 
stead of abdominal typhus, which was the form from which our armies 
suffered. The degree of malarial complication must have been very 
similar. The extent to which any scorbutic complication existed i 3 
difficult now to ascertain. Almost all the writers complain of the food 
and cooking of the Hungarian camps; but the soldiers would appear to 
have had fresh meat in some abundance, for one of the constant com- 
plaints is that they persisted in cooking it too soon after killing. Scurvy, 
of a marked kind, however, does not appear to have occurred, and the 
most significant evidence of the frequent existence of a scorbutic taint 
is, after all, the constant development in every army, after a few months 
campaigning, of numerous cases of the Languor Pannonicus. 
1 F. Boissier De Sauvages. Nosologia Methodica. Amsterdam, 1768, tom. i. p. 327. 
2 Moritz Ernst Adolph Naumann. Handbuch der Med. Klinik. Bd. 111., Abth. I. (Ber- 
lin, 1831), S. 233. 
3 Ozanam. Hist. M6d. des Maladies Epidemiques. 2me. Edit., Paris, 1835, tome iii- P- 
-127. 4 Cited above. _ 
5 For a description of the Languor Pannonicus, see particularly the work of Cober, cited 
above. Consult, also, Sauvages, op cit., tom. i. p. 802. TYPHO -MALARIAL FEVER. 
319 
Of late years we have heard but little of this once dreaded scourge, 
Which only now and then attracts the attention of some medical writer 
whose tastes incline to historical studies. I cannot but believe, how- 
®v©r, that whenever a German array goes again into the valley of the 
Danube, as perhaps may happen before long unless the present disturb- 
ances in the Danubian provinces are fortunatel}r brought to a peaceful 
termination, the old Hungarian plague will once more appear in its 
tanks—a more formidable foe to be encountered than the sword of the 
Turk. 
I have thus presented to you a couple of striking illustrations of the 
hybrid disease resulting from the complication of malarial influences 
With the causes of spotted typhus. Let me next refer to some examples 
°f the similar complication with typhoid fever. 
The first instance to which I shall refer is the epidemic of the so- 
called morbus mucosus, which occurred at Gottingen during the years 
-t 160-61, and which has become famous, less on account of the extent 
°t the mischief done than because of the admirable description which 
We owe to two teachers in the Medical Department of the Gottingen 
University, Roderer and Wagler.1 The summer of 1760 was warm and 
i’amy; the winter which followed was wet, with notable vicissitudes of 
°°ld and mild weather. Besides the inhabitants, a garrison of French 
troops, numbering, with the camp followers, about 8000, was shut up in 
the town. Roderer and Wagler have drawn a striking picture of the 
Want of food, the uncleanliness, the general misery that prevailed. Al- 
■l’ea(ly by the' middle of July, 1760, intermittent fevers, sometimes of 
type, sometimes, however, of marked malignity, occurred to a 
u.ogree unusual in that region. During August the intermittents con- 
ynued to be prevalent, but malignant forms became more numerous, 
aild many of the cases assumed a continued type. At the same time a 
a'alignant dysentery made its appearance, and raged with fatal results 
. the month of November. The intermittents meanwhile had con- 
puied, but during the month of November both these and the dysente- 
,les were gradually replaced by the morbus mucosus, which became the 
Prevailing disease, and continued as an epidemic all winter. During 
and May, 1761, it was again, to a great extent, replaced by inter- 
but still scattered cases continued to occur during the summer. 
„n the autumn, intermittents again became the common disease, occur- 
lng often in a malignant form ; and smallpox, which had first appeared 
pring the summer of 1761, assumed epidemic proportions during the 
Winter of 1761-2. ill 
off 6 niucous fever was a continued fever, which in severe cases was 
fi •etl. prolonged beyond the twenty-first day, sometimes till after the 
i lu’tieth, though fatal cases often perished as early as the ninth. In 
s earlier stages it usually presented a decidedly remittent type, tertian, 
°uble tertian, or semi-tertian being the most common varieties, Sorne- 
as the patients convalesced, the continued fever passed into an 
mary intermittent before recovery took place. After the tever was 
Ul y Ul>der way it presented many of the symptoms of ordinary typhoid 
Delirium, frequent, feeble pulse, diarrhoea, meteorism, in the 
Cases petechise, made their appearance. At the beginning the 
±. ewas furred, and its swollen, red papillte projected through the 
1 5 it became brown and dry as the disease progressed. Hemorrhages 
1 J. D. Roderer et O. G. “Wagler. De Morbo Mucoso. Gottingen, 1762. 320 
WOODWARD, 
from the nostrils sometimes took place, especially about the sixth day; 
still more frequent were hemorrhages from the bowels. It is a signifi- 
cant fact that the extract of Peruvian bark often proved highly effica- 
cious in those cases in which the remissions were most marked. 
The disease derived its designation from the belief that an excessive 
secretion of mucus from the alimentary canal was its most characteristic 
phenomenon. This was manifested by the frequency with which mucous 
vomiting, with or without bile, occurred at the inception of the cases, 
just as we know it does in ordinary remittent fever. The diarrhoea was 
interpreted as but another expression of the excessive mucous secretion, 
and the dead lumbricoid worms which were often noticed in the stools, 
or during the progress of autopsies, were supposed to have been bred in 
consequence of the morbid excess of mucus in the alimentary canal. In 
the autopsies, the closed glands of the stomach and small intestines 
were usually found tumefied to a marked degree. This was erroneously 
supposed to be the consequence of an accumulation of the mucous secre- 
tion in their interior. Rbderer and Wagler have published three remark- 
able copper etchings of the appearances they observed. The lesions they 
have figured are not those characteristic of typhoid fever, but of ordinary 
intestinal catarrh. In one of the autopsies (No. Y.) they describe the 
agrninated glands, near the ileo-csecal valve, as marked with black pig- 
ment, quite like the condition often observed in our own war, and de- 
scribed as “ the shaven-beard appearance.” The mesenteric glands were 
enlarged. The anatomical evidences of peritonitis were often present. 
Dysenteric sloughs frequently existed in the colon. Nowhere, however, 
do I find any description of the bulky tumefaction, ulceration, and 
sloughing of the glands of Peyer, which is characteristic of typhoid 
fever. Nevertheless, I am by no means sure that this essential lesion 
did not exist in some of the cases at least. It must be remembered that 
the typhoid lesion was not then known as we know it now. Perhaps 
some of the gangrenous spots, of smaller or greater size, which our 
authors describe as having been observed in the small intestines of some 
of their cases, were really of this nature.1 This appears to me the more 
probable, because in the case of the very similar epidemic which Sarcone2 
observed in Naples in 1764, and which, in the circumstances under which 
it occurred, its course, symptoms, and the anatomical lesions observed 
after death, appears to have been identical with the morbus mucosus of 
Rbderer and Wagler, I read that these gangrenous spots were again 
observed in the alimentary canal of some cases, and that they occurred 
chiefly in the small intestines. Put even if this interpretation is correct 
—and I believe it is—l cannot think that the characteristic typhoid lesion 
was present in all the cases in which Rbderer and Wagler made autopsies, 
or it surely would have received greater attention from those acute obser- 
vers, and I must think that in part, at least, of their cases, there was no 
other lesion of the small intestine than a smart intestinal catarrh. 
The doctrine of the mucous fever, as taught by Rbderer and Wagler, 
took firm root in the medical mind of Europe.3 It figures largely in 
1 Op. cit., p. 162. 
2 Michael Sarcone. Istoria ragionata del mail osservati in Napoli, nel corso del! anno 
1764. Naples, 1764. There is a German translation by Fuesslin, Zurich, 1772, and » 
French translation by Bellay, Lyons, 1804. Our library contains the German translation 
only. , 
3 Ozanara, op. cit., tome i., p. 257 et seq., gives an excellent abstract of the works o 
Koderer and Wagler, and of Sarcone. TYPHO-MALARIAL FEVER. 
321 
many of the text-books of the first half of the present century, and you 
will even find the descriptions reproduced without criticism, under the 
head of “Mucous or pituitous fever,” in the admirable Dictionary of 
Copeland.l Some writers have expressed the opinion that this mucous 
disease was after all neither more nor less than ordinary typhoid fever.2 
I cannot agree with them. I see in the story, as told by the original 
observers, unquestionable marks of malarial complications ; indeed, also 
°f scorbutic complications. I do not marvel that the Gottingen ob- 
servers should have devoted sections of their work to the discussion of 
relationship of the mucous disease with intermittent fever, and of 
ds relationship with scurvy, and should have arrived at the conclusion, 
to use their own striking language, that the epidemic which they observed 
das the corrupted and degenerate progeny of intermittent fever. They 
thought they saw also a causal relationship between intermittent fever 
and dysentery, an opinion which I cannot discuss here, but which I 
must confess I share to a certain extent. No doubt, since their time, 
the term mucous fever has often enough been applied to simple typhoid 
tever, and although of late it has been banished from the books, it still 
survives among certain practitioners who were educated thirty or forty 
years ago, and I myself have heard it applied by old practitioners to 
unmistakable cases of typhoid fever within the last five years. The 
misuse of terms in medicine is, however, a common consequence of im- 
perfect knowledge, and we must not allow ourselves to be led astray by it. 
I cannot dwell longer now upon this interesting epidemic. Let me 
Dirn next to another illustration, in which the malarial element was still 
more potent, and with regard to which I need only present a few salient 
Points, because it is so often cited in connection with the diseases of 
armies that most of the leading facts must be well known to you all. I 
reter to the Walcheren fever, which decimated an English array in the 
year 1809. 
-The previous experience of English armies in the Netherlands had 
.own the malignant character of the malarial influences which prevail 
|ll that region. It had been described in striking language in the excel- 
led work of Sir John Pringle.3 He had recorded that all the flat region 
ctween the rivers Lys and Scheldt and the sea, was marshy and un- 
.‘calthful, the home of periodical fevers ; that a great part of Holland, 
Ueluding Dutch Brabant, was subject to the same disorders, and that 
116I16 air was worst of all in Zealand. He has left graphic descriptions of 
c fevers which prevailed among the English troops operating in these 
mv countries between 1742 and 1748. He had observed especially that 
mu the troops were encamped near stagnant waters the “ marsh fevers 
aie not only apt to begin with little remission, but, after intermitting 
m some days, to change into continued fevers of a dangerous nature.”4 
specially was this the case during the summer and autumn ot 1748, 
un the troops were encamped near the inundations of Dutch Brabant. 
uf1 epideniic of such fevers occurred among them. Pringle writes: 
r f the height of the epidemic it appeared that both intermittents and 
eniittents, by extending or doubling their paroxysms, frequently changed 
a arn^s Copeland. Diet, of Pract. Med., London, 1858, vol. i., p. 988. 
Vor example, W. Griesinger. Infections-Krankheiten. Virchow’s Haudbuch dev 
V V ath- u. Therapie. Bd. 11,, Abth. 2. Erlangen, 1857, S. 118. 
11 John Pringle. Observations on the Diseases of the Army. 7th Edit., London 
4 ’ P* 1 et seq. 
UP- cit., p. 173. 
21 322 
WOODWARD, 
into a continued and dangerous form, and that most of those we lost 
died in this way. These men, as we remarked, had a corrupted smell 
for a day or two before their death, and soon after, their bodies putrefied. 
Some had petechial spots, though the place where they lay was neither 
crowded with sick nor too close ; and to these spots were added some 
other symptoms, the same with those of the hospital fevers.”1 
The expedition of 1809 renewed the experiences of Pringle on a more 
formidable scale. The English army, of between 42,000 and 48,000 men, 
was quite healthy when it set sail from the Downs, July 28, but as 
early as the middle of August the number of the sick was so great as 
to excite alarm. By the 26th the number was 5000. By the 7th ot 
September it amounted to 10,948. According to Sir Gilbert Blane,2 
26,846 men were sent to hospital in Zealand between the 21st of August 
and the 18th of November. The expedition was paralyzed by these 
misfortunes, and after the surrender of Flushing, August 15, was 
unable to continue offensive operations. In spite of the fact that a large 
part of the sick who were sent home to England began to improve so 
soon as they escaped from the pestilential regions in which their diseases 
had originated, and ultimately recovered, the total mortality was large. 
It has been estimated at about 8000 men. I must refer you to Han- 
sard’s Parliamentary Debates, the Annual Register, the Edinburgh Re- 
view, and the Essays of Marshall, Sir Gilbert Blane, Dawson, Davis, and 
Wright,3 for the particulars of this disastrous expedition. I can only 
pause to emphasize a few facts. 
The diseases of the Walcheren expedition were diarrhoea, dysentery, 
intermittents, and a form of fever which began as a remittent, and sub- 
sequently assumed a continued form, and which at that time was desig- 
nated the Walcheren fever, or the Walcheren remittent. Sir Gilbert 
Blane, who visited the island of Walcheren during September and 
October, reported to the Government “ that he found so great a propor- 
tion of the sick to consist of those affected with the intermitting and re- 
mitting fevers peculiar to marshy countries, that there could be no doubt 
that the sickness of the army was owing to that cause.” He admits, 
however, that he found a certain number of cases of a fever which he 
called “typhus,” and of dysentery, particularly at Flushing, where “ the 
prevalence of these two diseases was very remarkable, particularly in one 
regiment, of which all the medical officers were either absent or dead, 
and of which the sick, originally affected with the endemic disease, 
were suffering also from typhus and dysentery in consequence of the 
want of cleanliness, as well as of proper medicines, diet, and attendance. 
Borland and Lernpriere,5 two other medical officers serving with the 
1 Op. cit., p. 181. 
2 Sir Gilbert Blane. Facts and Obs. respecting Intermittent Fevers, and the exhalations 
which occasion them. Med. Chir. Trans., vol. hi. (1812), p. 11. 
3 Hansard’s Parliamentary Debates. Series 1., vol. 15, Appendix 22 and 23, and vol- 
-16, Appendix “ Papers relating to the Expedition to the Scheldt.” The Edinburgh Annua 
Register for 1809. Edinburgh, 1811, vol. ii., parti, p. 660. The New Annual Register tor 
180&9. London, 1810, p. 316. Observations on the documents, including the evidence hear1 
at the bar, laid before Parliament on the subject of the late Expedition to the Scheldt. 
The Edinburgh Review, vol. 11 (1810-11), p. 331. ’Henry Marshall, Contribution to S a 
tistics of the Sickness and Mortality which occurred among the troops employed in tn 
Expedition to the Scheldt in the year 1809. Edinburgh Med. and Surg. Journ., vol. 4 
(1837), p. 305. Sir Gilbert Blane, op. cit. Davis. Wright, and Dawson—works cited below- 
-4 Op. cit., pp. 2 and 3. . >g 
6 J. Borland and W. Lernpriere. Report on the prevailing Malady among his Majesty 
Forces serving in the Island of Walcheren. The Med. and Physical Journal, vol. 
(1810), p. 183. TYPHO-MALARIAL FEVER. 
323 
troops on the island, reported, in the same spirit, that the malady was 
uthe endemic fever of marshy countries*, the effect of miasmata fiom a 
soil the most productive in deleterious exhalations of any perhaps in 
Europe stated that it prevailed also among the natives of the island 
as an intermittent or remittent fever, and that among the British tioops 
D assumed “ a character of greater malignancy.” 
But the most elaborate studies of the Walcheren fever were made by 
the medical men whose duty it became to treat the sick who were sent 
home to England. Dawson1 tells us that the Walcheren soldiers were 
affected with intermittents in a number surpassing those who weie 
attacked by the continued fevers; that many of the soldiers who were 
subjects of the continued fever had already labored under the intei nut- 
tent, and that on the other hand intermittents were common among 
those who had recently recovered from the continued fever. Davis, 
ivhose account of the fever is more elaborate, tells us that at the begin- 
ning it assumed the quotidian, tertian, double tertian, or quartan type, 
hurt that the most common of all was the double tertian. It assumed, 
however, the characters of a continued fever of typhoid type as it 
progressed, with muttering delirium, small rapid pulse, dry, black 
tougue, sordes-covered teeth, fetid odor, and black discharges from the 
bowels. _ . 
On account of the frequency with which this fever was associated 
dysentery, the characteristic lesions of dysentery were frequently 
found in the colon during the autopsies which were But Davis 
has also recorded the significant fact that “ the ileum and jejunum weie 
Bequently interspersed with tubercles, inflamed and ulcerated in diffei- 
ent parts.” This description would seem to indicate beyond doubt 
fhat the lesions, which we have now learned to recognize as character- 
■‘Stic of typhoid fever, were frequently present in the cadavers of 
fhose who had perished from the Walcheren disease. After a tnoug it- 
faf study of the evidence, no doubt is left in my own mind that tins 
fhver was not, as has often been asserted, simply a remittent, 
hat that it was a genuine hybrid between malarial and enteric level. 
Bid time permit, I might bring forward other interesting illustrations 
lr°m the history of the British Army in the East and West Indies and. 
elsewhere, from the Algerine experience of the French, and from otnei 
sources; but I fear that I have already occupied too much of your time 
w‘th facts of this class. I cannot, however, leave the subject of the 
experiences of other armies without bringing to your notice an unex- 
pected corroboration of the views I am urging upon your attention, 
I flu cl in an essay published by Virchow in 1871 on the fever and 
dysentery of the German army5 during the recent war with fiance, 
which he contrasts with the similar diseases of our own civil wai, as 
described by me in ray book on Camp Diseases, and in Circular Iso. b. 
Virchow hesitates to acknowledge “ typho-malarial fever as a special 
' C. P. Dawson. Observations on the Walcheren Diseases. London, 1810, p. <O. 
*J- -B. Davis. A Scientific and Popular View of the Fever of Walcheren. London, 
,0* See also Thomas Wright. History of the Walcheren Remittent. London, 1811. 
Op. cit., p. 192. „ 1 
, Essentially the same opinion with regard to the Walcheren fevei has been expressed 
/“■ J- Levick. Miasmatic Typhoid Fever. American Journ. of the Med. Sciences, 
AfiUB64, p. 409. 
R. V irchow. Kriegstyphus und Ruhr. Virchow’s Archiv., Bd. LII. (1871), S. 1. 
°te pp. 5 and so. 324 
WOODWARD, 
group of diseases, and exclaims, with cautious conservatism : “It seems 
to me we ought to be very careful in this direction.'’ Yet, in the same 
essay, while contending that the prevalent fever of the German army 
was simply abdominal typhus, as proved by numerous post-mortem 
examinations made at Berlin on soldiers brought back sick from the 
front, this cautious but acute observer finds himself compelled by the 
facts under his eyes to use the following emphatic language : 
“ Nevertheless, abdominal typhus affords such numerous diversities in 
its course that it is in the highest degree imperative to preserve every 
precaution in the interpretation of individual cases. Especially does 
the admixture (Zumischung) of the malarial element, which also in this 
war has shown'itself active, by numerous cases of intermittent fever, 
confuse the picture of the so-called normal course of typhus in a some- 
times very deceptive manner.” 
Now, I must protest that these words represent the very essence of 
the doctrine I am here to defend, and if the comparatively mild malaria 
of the plains around Metz was capable of complicating the course of the 
abdominal typhus which occurred in the German army to a sufficient 
extent to justify this eloquent language, what think you would the 
great pathologist have written could he have observed for himself the 
fevers of our own army in the valley of the Mississippi or by the banks 
of the Chickahominy ? 
I have occupied the greater part of my hour with these preliminary 
matters; but not, let me hope, in vain. I come now to a rapid sketch 
of the principal facts with regard to the typho-malarial fever of the civil 
war of 1861-5. 
The characters and distribution of the malarial fevers of the region in 
which that colossal struggle took place have been described in a most 
original and interesting work by our countryman, Dr. Daniel Drake,1 
who has embraced them under the general designation of autumnal 
fevers. This term serves very well to express the greater prevalence of 
intermittents and remittents during the autumn months ; but it must 
be distinctly understood that their occurrence is not limited to these 
months. In the regions in which they are endemic, they may occur at 
any season of the year, and their course can by represented by a curve 
in which the abscissas begin to lengthen early in the spring, and grow 
longer and longer, till they attain their maximum most generally at 
some time during September or October, after which the curve rapidly 
drops to a minimum during the winter. Sometimes the curve presents, 
also, a slightly irregular elevation during the early spring, justifying 
the term vernal intermittents, which has often been used ; but most 
generally the increasing frequency of these fevers in the spring simply 
represents the commencement of the annual rise in the curve which 
culminates in the autumn. This is well illustrated by curves which I 
have had constructed to represent the monthly number of new cases of 
agues and remittents reported in our armies in the Atlantic and Central 
regions during the civil war. These I hand you for examination, but 1 
cannot pause°to discuss them at this time. Doubtless the winter and 
vernal cases are to be regarded in part as relapses, in part as illustra- 
tions of the postponed development of the consequences of previous 
1 Daniel Drake. The Principal Diseases of the Interior Yalley of North America- 
Cincinnati, 1850. The same, second series, edited, after the death of the author, by S. 11- 
Smith and Francis G. Smith. Philadelphia, 1854. TYPHO -MALARIAL FEYER. 
325 
exposure; but, however you may choose to interpret them, I wish to 
insist upon the point that they occur with much greater frequency than 
some of the systematic writers would have us believe. 
Dr. Drake has shown that in a general way these fevers are most in- 
tense in the States that border on the Gulf of Mexico, and gradually 
diminish in frequency and severity as we go to the north, so that they 
no lono-er prevail in epidemic form beyond the 44th parallel, and cease 
to occur even sporadically at about the 47th. To the southwest, the 
Cordilleras of Mexico and the Southern Rocky Mountains constitute 
their boundaries, while in the higher latitudes they cease on the great 
plains, long before we reach the mountains. On the Atlantic slope they 
Prevail with constantly increasing severity as we go southward from 
Yew York, and though they do not occur on the table-lands and higher 
ground of’the Appalachian chain, yet they ascend high up the valleys 
of the streams which flow out of the flanks ot those mountains. 
In the volume of the Yiuth Census of the United States, which is 
devoted to Vital Statistics,1 there is an interesting map which exhibits 
the distribution of the mortality from intermittent and remittent fevers 
during the year 1870. Doubtless this mortality, which is but at best 
incompletely represented in the Census Report, can only be regarded as 
a very imperfect measure of the frequency and severity of these fevers; 
hot, imperfect as it is, its indications are valuable. It shows in a general 
woy the almost complete exemption of Yew York, the Yew England 
States, and the mountainous parts of Pennsylvania, Maryland, West 
Virginia, and Virginia, and a gradual increase in severity indicated by 
ao increasing mortality in the river valleys as we go southward from 
lhe fortieth parallel. It illustrates, also, in a striking manner, a fact 
oßieh arrested the attention of Drake,2 that in various scattered districts, 
from the influence evidently of strictly local causes, the malarial fevers 
display greater prevalence and malignancy than they exhibit fuit iei 
s°oth and on a lower level. 
It would be altogether foreign to my purpose to enter in the present 
discourse into any discussion as to the causes of these fevers. I simply 
Urge upon you to-day the great fact of their endemic existence, in some 
localities more frequently*'and with greater severity than in others, 
formidable even to the natives of the soil, but still more formidable to 
Grangers, throughout the whole region in which our great armies ope- 
lated during the civil war. The characters of the fevers thus distributee 
are too welf known to yon all for any description to be necessary here. 
I need only remind you of the frequent occurrence throughout the 
Southern States, side by side with ordinary ague, of malignant forms, 
tae so-called congestive chills or pernicious fever; of the_ severity ot the 
remittent fevers which prevail ; of the frequency of big spleens,, dis- 
°rdered livers, and malarial anaemias, and ot the great frequency with 
which, in these regions, an intermittent type is impressed on the ordi- 
nary acute phlegmasiae, and even on chronic disorders. 
Drake has also presented an interesting account of the distribution 
throughout the United States of typhoid or, as he calls it, typhous 
Ninth Census, vol. ii., Vital Statistics of the United States. Washington, 18■ <2. See, 
i'B°’8°’ Statistical Atlas of the United States—based on the results of the Ninth Census, 
A By p. A. Walker, 1874; in which the map in question is given on a larger scale, 
2 !fetter engraved, as Plate 42. 
tip. cit., First series, p. 704. 326 
WOODWARD, 
fever.1 This fever is the usual form in which typhus manifests itself in 
the United States. The spotted typhus of the Old World never appears 
on our soil except as isolated cases, imported, as “ ship fever,” into our 
seaports. Drake has correctly pointed out that while in a general way 
the typhoid fever of the United States is more prevalent in the Northern 
than in the Southern States, it nevertheless does occur both sporadically 
and in local epidemics even in the southernmost portion of our territory. 
This fact is strikingly illustrated by a map in the volume of the Ninth 
Census already referred to, which2 represents the distribution through- 
out the United States, during the year 1870, of some 24,000 deaths 
from typhoid fever. In constructing the map a few hundred cases of 
cerebro-spinal fever were included, but their number is too small to 
vitiate its value3 in illustrating the distribution of typhoid fever during 
the year in question. This map, while exhibiting in a general way a 
gradual decline in the mortality from typhoid fever as we go to the South, 
displays also a number of limited areas of high mortality, representing 
the endemic prevalence of the fever during that particular year in certain 
localities. Several of these areas of local prevalence are situated in the 
Southern States. In one of them, in Georgia, which embraces the region 
drained by the Altamaha and Satilla rivers, typhoid fever caused about 
one-fifth of all the deaths—a greater mortality than it produced in any 
part even of the New England States. In another almost equally re- 
markable area, embracing parts of the States of Mississippi and Alabama, 
having near its centre the town of Columbus, Mississippi, the propor- 
tionate mortality from typhoid fever was nearly as great. 
Drake has urged, as one of the distinguishing marks between typhoid 
fever and the autumnal fevers, that the former is not limited like the 
latter to a particular portion of the year, “ between the summer and 
winter solstice, but occurs, though unequally, at every season,” But he 
believes that “ on the whole, however, they are most prevalent in autumn 
and winter,”1 an opinion which has been shared by several careful 
writers.5 
Liebermeister6 has recently compared the statistics of the monthly 
prevalence of typhoid fever in some of the great European cities, and 
shown that in London, Berlin, and Basle, the curve which represents the 
course of the disease is distinctly autumnal in character. “The mini- 
mum is in February and April (in the Berlin curve a little later); the 
maximum is in September and October. (In Berlin, the maximum is in 
October,)” Munich alone presented an exception, the maximum falling 
in February. Now, I must say, my study of the sick reports of our civil 
war inclines me to. believe that the autumnal curve observed by Lieber- 
meister represents also the usual annual distribution in this country. I 
have constructed curves representing the monthly ratio of new cases to 
strength in each of the three regions. These curves present certain irre- 
gularities in the Atlantic and Central regions corresponding to the 
1 Op. cit.. Second Series, p. 358 et seq. 
2 See also Walker’s Statistical Atlas, cited above, Plate 46. 
3 Ninth Census, vol. ii., cited above. Special tables of Mortality, p. xxiii. Tbe 
number of cases is, enteric fever, 22.187; typhus fever, 1770; cerebro-spinal fever, 650. 
The cases reported as typhus were simply misnamed, and are to be regarded as enteric. 
4 Op. cit., 2d series, p. 358. , 
5 See, for example, G. B. Wood. Treatise on the Practice of Medicine. 6th ed- 
Philadelphia, 1866, vol. i. p. 383. . 
6 Liebermeister. Typhoid Fever, in Ziemssen’s Cyclopmdia of the Practice of Medicine, 
Amer. transl., vol. i. New York, 1874, p. 65. typho-malarial fever. 
327 
varying circumstances in the fortunes of the gieat airnics, but on the 
whole they represent the disease as most prevalent during the latte 
part of the summer and autumn, rather than during the autumn and 
winter. In the Pacific region the curve is strictly autumnal, ihe 
maxima are as follows: October in 1861, September m 1862, Novemhe 
in 1863, September in 1864, October in 1865. The minima were in Apul 
and May for 1862 and 1863, April, 1864, and March 1860 In the At- 
Untie region the maximum for 1861 in -November In 18b2 the e 
were two maxima, one during the Peninsular Campaign in u>, <- 
lowed by a great reduction on the withdrawal of that army, and a second 
maximum in October and November. In 1863 and 1864, the maxima 
were during July and August. In 1865, during October. Ihe minima 
fell in March, 1862; June, 1863; February 1864; and April,lß6s I 
the Central region the maximum for 1861 fell in Novernbei , in 186-, 
May. During 1862 the curve was quite irregular ; it rose to a maximum 
in May then diminished in frequency during the summer, and steadily 
increased after September through the winter, attaining its maximum in 
February, 1863, after which it diminished until June, and then again 
increased to a second maximum in August. The maximum lor_ 18b 
fell in September; in 1865, during September and October. Ihe minima, 
were in March and September, 1862 ; June, 1863; I ebruary in 1864 and 
186 ” 
I find from the Annual Reports of the Board of Health of the city of 
Boston for 1874 and 1875, that the mortality from typhoid fever dunng 
those years pursued a markedly autumnal course the maximum being 
during September in 1874, and during October in 187oJ In the District 
of Columbia the registration returns show that the greatest ccrabei 
deaths since 1872 have always occurred during the months of Au3u t 
“I ino^“btherefore, to the belief that typhoid fever Puente in fact 
in this country an annual autumnal curve very similar to that ot the 
so-called autumnal fevers. I base upon this circumstance no argument 
as to the relationship or nature of either disease, but piess it upon }ou 
attention as a fact which must not be overlooked. . , 1 
Next, let me remind you of the important fact that intermittent and 
remittent fevers often disappear more or less completely from neigh_ 
hoods in which they have long prevailed, and are replaced by typhoid 
fever. This circumstance could not escape such a faithful observer as 
Brake. He has described it in the following language 
“ Far in the North, remittent fever often presents, almost from the 
beginning, a tendency to the continued type, displaying the chau - 
ties of the synochus of Cullen’s Nosology. It is properly calledl au- 
tumnal fever, because it prevails most 111 that season, and is an eq 
for the true remittent fever of the warmer climates Nearly the same 
remark is applicable to this fever when, in the middle latitudes it ap- 
pears in the long-cultivated and drier portions of lennessee, Kentucky, 
Western Pennsylvania, and Ohio. Formerly it often abated into au 
intermittent; latterly, it is apt to degenerate into a continued type. 
Whatever criticism you may choose to bestow on the wording ot some 
r 1 See Second Annual Report of the Board of Health of the City of Boston 1874 and 
Third ditto, 1875. Both Volumes give charts representing the weekly mortality from 
typhoid fever. Also, Annual Reports of the Board ot Health ot the District ot Columbia 
for 1872, 1873, 1874, and 1875. 
2 Drake. Op. cit. First Series, p. 781. 328 
WOODWARD, 
parts of this remarkable passage, it is an honest attempt by a keen 
observer to describe a class ot facts which he had had the opportunity 
of observing on a great scale. The substantial truth, that in numerous 
districts throughout this land intermittents and remittents were the 
prevailing form of fever when the first settlements were made; that as 
time passed by and cultivation progressed, the intermittents diminished 
in frequency, the remittents exhibited more and more a disposition to 
pass into continued forms, and finally were replaced by ordinary typhoid 
fever, which became the prevailing epidemic fever—all this, I suppose, 
has occurred under the personal observation of many of the American 
physicians who listen to me to-day, and I need not weary you by multi- 
plying authorities in proof of a fact with which you must all be familiar. 
But next let me observe that the change thus effected is not always a 
permanent one. Often in individual years the intermittents and remit- 
tents reappear in epidemic-wise in regions such as I have just described, 
and then the typhoids vanish for a time, to return once more when the 
temporary prevalence of the periodical fevers comes to an end. 
Existing thus side by side, replacing each other in this intimate—if 
you will, in this intricate manner—it is evident that the unknown causes 
of the periodical fevers, and of typhoid fever, whatever they may be, 
must frequently coexist. Ought we not, then, to anticipate that "indi- 
viduals exposed to both would often suffer with fevers in which phe- 
nomena belonging to both affections would also coexist? 
I suppose the once popular belief that diseases are entities, and that 
a man can suffer from but one at time, is now so completely dead that 
it is quite unnecessary for me to bring forward facts and arguments to 
disprove it. I suppose it to be now well established that"individual 
cases of disease are always more or less complex, representing in every 
instance the total effect of all the morbific causes acting upon the in- 
dividual, and modified always by his individual resisting power, the 
result of his own individual organization and his own previous history. 
Even Sauvages, the greatest of all the systematic nosologists of the last 
century, already recognized this fundamental fact when he exclaimed, in 
the introduction to his work: “Genera and species of diseases are ab- 
stract notions. Throughout the universe neither genera nor species 
exist, but only individuals.”1 Is it wonderful, then, that hybrid forms 
of disease, exhibiting the ordinary symptoms of malarial and of typhoid 
fever, variously combined, should long have been observed in this coun- 
try ? In fact, such hybrid forms have long been observed in Europe 
also. In the first volume of his Institutes, published in 1781, Burserius2 
recognized them as a group; “ the Proportionata,” which he defines as 
species composed of the synochus and intermittent fever. 
This union, he says, occurs especially “when intermitting fevers prevail 
epidemically, or at least constitute the prevailing and stationary disease ; 
for then almost all diseases bear some resemblance to intermittents, or 
sporadic, or intercurrent fevers, ot whatever other kind, are combined 
with the intermitting fevers.” 
Hermann Schmidt,3 in his account of the so-called Summer fever, which 
was epidemic throughout Europe during the year 1827, has still more 
1 Sauvages. Nosolog. Method., Amsterdam, 1768, vol. i. p. 26. 
2 J. Bapt. Burserius. Institut. Med., vol. i., Milan, 1781. I quote ftom Seeker’s edi- 
tion, Leipsic, 1826, vol. i. p. 512. 
3 Hermann Schmidt. Über des Europseische Sommerfieber, Paderborn und Arnsberg, 
1830. TYPHO -MALARIAL FEVER. 
329 
elaborately described as the form of fever then most generally prevail- 
ing, a combination of intermittent fever with the endemic typhus of 
Europe (our typhoid fever). He has subdivided the resulting hybn 
forms into two chief classes: 1. Typhus intermittens submtrans, which 
he defined as a combination of typhus and intermittent fever with a 
predominance of the typhus element. 2. Febris intermittens typhosa, 
which he defined as a similar combination, with a predominance ot in- 
termittent fever. I would refer you to his elaborate treatise tor many 
suggestive details. , p 
Naumarm1 has quoted, with approval, the views of Bnrserma and 
Schmidt and mentions corroborative observations by several other 
Writers, to which I might add many more did the scope of this discourse 
Permit. 
Recurring to the American experiences, I would recall to your memory 
the fact that the existence of the hybrids under consideration did not 
escape the practical eye of Drake: “ When remittent fever terminates 
fatally in one or two weeks,” he observes, “a certain amount of subsul- 
tus, a dryness of the tongue, and intestinal hemorrhage, are sometimes 
Present, although no typhus fever may be prevailing in that locality, 
and tins brings us to inquire, not into the distinctive peculiarities ot 
these two forms of fever, but into their combination, into the hybrid or 
mongrel diathesis which results from the joint impress, in ever-varying 
proportions 0f the causes which produce true typhous and true remittent 
fevers.” 2 For these hybrid forms he proposes the designation, ‘ Kemitto- 
typilous or secondary typhous fever.'’ “I do not recollect, he says, to 
have seen a case of fever well-marked as typhous in the early stages 
terminate as an intermittent, nor a decided intermittent degenerate into 
a typhous. The union is between remittent and typhous. _ And this 
certainly is the most common combination; but the combination with 
intermittent does also occur, though less frequently, and both the possi- 
bilities which Drake tells us he never observed were seen often enough 
during the civil war. , , _ „ , . i 
fhe same combination of remittent and typhoid fevei w ic was 
served by Drake has also been described by the late Professor Dickson 
°f this city Dickson continually emphasized the doctrine of the fie- 
fihent blending of those febrile types which are ‘‘connate in cause and 
analogous in symptoms.” He tells us that “it is a mattei ot Aim ini 
remark, that in long-protracted cases of the ordinary remittent of mala- 
rious regions, there is a domination of the palpable contrast or alterna- 
tion of the period of febrile exacerbation and unison—a tendency m the 
f°rmer to continuousness, the latter being less an alleviation ot the 
symptoms—and the several symptoms themselves approaching moie 
and more in appearance those which belong to simple continued ever, 
nervous fever, or typhoid fever. In common professional language, such 
eases ‘take on the typhoid character.’” “On examination, TP101*!- 
Jesions will sometimes be found in the body dead of bilious remittents 
The mucous membrane of the stomach and intestines is hig i y injected 
m severe and short attacks. In more protracted cases, follicular ulcera- 
tjl°n may be found throughout the whole extent ot the bowel. 
‘ Op. cit. Bd. 111., Abth. ii., S. 235. 
Drake. Op. cit., Second Series, p. 556. IA, c , 
, Samuel Henry Dickson. Elements of Medicine. Philadelphia, 1855, p. 196. See also 
■J.18 Essay On the Blending and Conversion of Types in Fever, irans. ot the Amer. Med. 
Association, vol. v. (1852), p. 127. 330 
WOODWARD, 
Similar opinions were long entertained by my revered preceptor, Dr. 
George B. Wood. He has told you that remittent fever “is sometimes 
of a low, adynamic or typhous character from the commencement. This 
may be the result of a previous exposure to causes calculated to depress 
the vital powers and to deprave the blood; but it probably most fre- 
quently arises from the co-operation of a typhoid epidemic influence with 
miasmata.” He did not believe that the characteristic lesions of typhoid 
fever ever occur in pure remittents, as some have reported, and explained 
their observations by the remark that “ there is reason to believe that 
enteric fever has sometimes been mistaken for bilious or remittent fever, 
and lesions belonging to the former been placed to the account of the 
latter; and not unfrequently, in all probability, the two diseases are in 
greater or less degree mingled together.”1 
How, under the conditions which existed in the camps of our armies 
during the late civil war, these hybrid combinations, which had already 
attracted the attention of such men as Drake, Dickson, and Wood, in 
civil life, made their appearance, as might have been predicted, on a 
great scale, and produced, as I have already shown, a formidable mor- 
tality. It was for these hybrid forms that I proposed the term typho- 
malarial fever. I never meant this term to represent a specific type of 
fever, but intended it to designate all the many-faced brood of hybrid 
forms resulting from the combined influence of the causes of malarial 
fevers and of enteric fever. The term corresponds essentially to the “ Pro- 
portionata” of Burserius. It includes both the “ Typhus intermittens 
subintrans” and the “Debris intermittens typhosa,” of Herman Schmidt, 
and the “ Remitto-typhous” of Drake. These are merely varieties of the 
group of hybrids, all of which I intended to embrace. I pointed out, 
in my book on Camp Diseases, that this whole group might be conve- 
niently divided, for the purpose of study, into—l. Fevers in which the 
malarial element, without being the only pathological condition present, 
is the predominant one; and, 2. Fevers in which the typhoid element 
is evidently predominant, although the others are also present in a more 
or less distinct manner. To these I felt compelled to add a third group, 
namely, “Fevers of either of the first two varieties, in which from the 
first, or at some time during the progress of the affection, the scorbutic 
element becomes predominant.” To this general grouping of the cases, 
with all the light of subsequent experience, I must still substantially 
adhere. 
In the group of cases in which the malarial phenomena predominated, 
the disease began as a simple intermittent or remittent fever, of quoti- 
dian, tertian, or quartan type, the most frequent form being a simple or 
double tertian ; but after a week or ten days the fever assumed a more 
or less completely continued type, with many of the phenomena char- 
acteristic of typhoid fever, such as diarrhoea, abdominal tenderness, 
meteorism, muttering delirium, subsultus teudinura, dry, brown tongue, 
and the like. But even when the typhoid phenomena were most pro- 
nounced, some of the most characteristic of them were often wanting. 
Thus, sometimes there was no diarrhoea at all, but constipation instead. 
The characteristic tache rouge, or rose-colored eruption, was generally 
entirely absent; gastric disturbance, hepatic tenderness, and an icteroid 
hue of the countenance were much more generally present than in simple 
typhoid fever. 
1 Wood. Op. cit.,vol. i., pp. 307 and 309. typho -malarial fever. 
331 
Kow a large proportion of these cases terminated favorably, especially, 
as I think, becauseF quinine was so freely used in their treatment; he 
occurrence of ordinary paroxysms of ague was a frequent accident dm i 
the convalescence. And, just because of the frequency with which they 
recovered,! suppose, the number of autopsies in oases of this kind which 
I have been able to collect is much less than in cases of the second gioup, 
of which I shall presently speak. Still, I have colleoedia ™ * °* 
autopsies of cases of this kind, in which diarrhoea had boon p.esent d„n 
inK the fever and in which, after it had assumed a continuous type, it 
had Strikingly resembled typhoid fever but in which ctta7rh 
no other lesion in the alimentary canal than as mart ostmal^^'h 
Patches of inflammation, scattered irregularly throughout and 
large intestines, and enlargement ot the closed glands often associated 
with moment deposits, were the characteristic lesioi . . } 
glands of the small intestine appeared as little projecting Ber^hled 
of pinheads which often had constricted necks, so that they resembled 
tiny polypi.’ The agrainated glands of Peyer, slightly prominent. ,we 
seatof pigment deposit, which gave them the so-called shave 
beard appearance “Sometimes the villi of the !“all 
trophied; sometimes they had pigment deposits at theu t of 
large intestine the slightly swollen solitary glands were often the seat ot 
Pigment deposits, seated either in the glands alone orßetimes 
the surrounding mucosa, in which case the central dot of P’g“el" ™8 
surrounded by a little pigmentary ring. When the feve “jT” de’ 
as often happened, upon a chronic flux, or where dysentery had been de 
reloped during the course of the fever or ot the utcera- 
bee.,1 the immediate cause of death, the characterise c ol cula. u ce.a 
tions Of the colon or the phenomena of the diphpentic process compM 
cated the picture. Great enlargement of the spleen and conges on ot 
the liver, with or without fatty degeneration were ftequent concom 
tants. The condition of the intestinal canal in these oasM Uomlj resem- 
bled that which has been emphasized by Roderer and Waglcr, and.by 
Dickson. Between the simple inflammatory enlargement ot the clo 
glands which I have pictured, and the more luxuriant process whicl 
occurs’in ordinary typhoid fever, and which most patlo ° niyself 
he specific, every possible transition existed I, for one confess myselt 
unable to draw a line between the two conditions. Anatomical y they 
appear to pass into each other by insensible gradations. Th 
element of both is the accumulation of a swarm of 
puscles in the closed glands, in the surrounding lymph pas <tges, and tne 
adjacent connective tissue, associated, doubtless as we must de 
the study of other inflamed tissues, with multiplication of lymph 
tells of the parenchyma of the closed glands by .divisionphotigh it*ax 
ficult, if not quite impossible, to demonstrate thw latter pheiiome 
the present ease. The*sloughing and ulceration of the typhous 
process is, I think, sufficiently well explained by . J 
Process and the nutritive disturbances which thenoe ' “ ’ , 
conjuring up in our imaginations an undemonstrated specific someth g 
toThe°groufp of eases in which the typhoid phenomena predominated 
more closely resembled ordinary typhoid fever They began more ike 
it; they ran their course like it; like it, they refused to be cut short by 
quinine; after death they presented the characteristic lesions ot the 
patches of Peyer. But even these cases presented, also, many phenomena 332 
WOODWARD, 
which did not belong to ordinary typhoid fever. First of all, I must 
emphasize the manifestation of an unwonted tendency to periodicity. 
Tim was not merely an exaggeration of the daily exacerbation and re- 
mission, which we all know as a part of the history of the early stages of 
typhoid fever. The exacerbations assumed with great frequency "a ter- 
tian or double tertian type, which has no parallel in the ordinary typhoid 
history. With this tendency to periodicity, the gastric and hepatic dis- 
turbances common in remittent fever were often associated in the early 
stages, and ordinary ague paroxysms often occurred in the convalescence. 
The autopsies in these cases disclosed the ordinary lesions of typhoid 
fever. During my earlier studies I believed that I had observed certain 
peculiarities in the character of the ulcers in these cases, by which they 
might be distinguished from the lesions of simple typhoid.1 A larger 
experience, especially the examination of a large number of specimens 
received by the Medical Section of the Army Medical Museum, has con- 
vinced me that this opinion was premature. I renounce it as erroneous. 
There is really nothing in the lesions of Peyer’s glands, in these cases, to 
distinguish them from ordinary cases of typhoid fever; and it was just 
these lesions, so well known to you all that I need not pause to describe 
them, which were observed in the vast majority of those fatal cases of 
fever occurring during the late war in which autopsies have been re- 
corded or specimens preserved. As for the other lesions observed in these 
cases, tumefaction of the spleen, far beyond the degree ordinarily ob- 
served in typhoid fever, was common enough, and the pigment deposits 
in various tissues and organs, which are so frequent in malarial diseases, 
were very often encountered. Moreover, the colon lesions, characteristic 
of chronic fluxes or of acute diphtheritic dysentery, were frequently asso- 
ciated, as is well shown by numerous specimens in our Museum. 
I will not for a moment, however, countenance the sophism that, be- 
cause the lesions of ordinary typhoid fever were those most frequently 
encountered during the war in fatal cases of fever, uncomplicated 
typhoid fever was the prevailing febrile form. On the contrary, as I 
understand it, though this was the lesion in the majority of fatal cases, 
the slighter lesions described in connection with the first group were 
those which most probably existed in the majority of the cases which 
recovered. Aor will I admit the fallacy that, even in those fatal cases 
in which the typhoid lesion was most marked, the patients are thereby 
proved to have died of simple typhoid fever. I will not emphasize the 
big spleens, pigmentary deposits, or other anatomical evidences of ma- 
larial complication. I will even admit the uncertain diagnostic value 
of all these phenomena in the present state of our knowledge. Dut I 
cannot ignore the facts of clinical observation. I cannot but see in the 
periodicity and other clinical evidences of malarial complication to which 
I have briefly alluded, proof of the action of an additional morbid 
agency, to which I doubt not we must look for one reason of the great 
mortality of the fever cases in our armies. 
It often happened that, in fevers belonging to either of the classes I 
have just described, scorbutic phenomena complicated the picture, and 
sometimes even took a commanding place in determining the course 
and issue of the disease. I have affirmed, and shall elsewhere bring 
forward satisfactory evidence in proof of the assertion, that a mild but 
distinctly recognizable scorbutic taint was wide-spread among our 
1 Camp Diseases, p. 102. TYPHO -MALARIAL FEVER. 
soldiers. It manifested itself as a peculiar anemia, accompanied by 
muddy complexion, large, smooth, flabby tongue, and by neuralgic or 
pseudo-rheumatic pains in various parts of the body, especially in the 
buck. As a rule, it was only after this scorbutic anaemia had existed 
lor some time, either alone or variously complicated with symptoms due 
f° malarial poisoning, that the characteristic scorbutic conditions of the 
gums, the scorbutic indurations about the joints of the lower extremities, 
mid the well-known scorbutic purpura made their appearance. These 
easily-recognizable symptoms of fully-developed scurvy were but mod- 
erately frequent. The preliminary anaemia, however, was common 
enough, though often overlooked or misunderstood. 
Kow, when either of the forms of typho-malarial fever, which I have 
described, occurred in individuals suffering under the scorbutic taint, the 
Bymptoms were modified to a degree corresponding to the intensity of 
scorbutic condition. The effect of the complication was to increase 
the tendency to mental and bodily prostration during the disease, to 
tardy convalescence subsequently, and to increase the frequency of pe- 
techial and purpuric eruptions, and of hemorrhages from the nose and 
bowels. Sometimes the characteristic scorbutic condition of the mouth 
w.as developed during the progress of the fever, when it had not pre- 
viously made its appearance. When the characteristic typhoid process 
Vms developed in individuals laboring under a marked scorbutic taint, 
the symptoms closely resembled those of spotted typhus. Fatal hemor- 
i'hages from the bowels were common in such cases, and on the dissec- 
tion, the lower patches of Peyer were found converted into dark-red or 
black pultaceous sloughs of considerable size and thickness. I suppose 
the scorbutic condition to have modified the typhoid ulceration in such 
oases, just as we often see it modify the condition of superficial ulcers 
0r °f gunshot wounds. 
hhe outlines of the chief phenomena of typho-malarial fever which I 
inve thus endeavored to present to you to-day are necessarily incomplete, 
.0r it is, of course, impossible to go into the details of so large a sub- 
Ject in a paper like this. I hope to be able to fill up these outlines 
ln. a satisfactory manner in the second volume of the Medical History 
of the War. 
. And this brings me, at length, to answer the question—ls typho-raala- 
fever a special type of fever?—and I reply, unhesitatingly, that it 
not. I, at least, am free from the blame of that error, if any one has 
‘dlen into it. In my first published account of typho-malarial fever, I 
expressly denied that it could be regarded as a new disease. “ Much 
lather,” I said, “should it be considered simply as a new hybrid of old 
and well-known pathological conditions, in which the exact train of 
symptoms is as variable as the degree of preponderance attained by each 
0 fbe several concurring elements.”1 And this is the view which I ad- 
vocate to-day. The essential point which I desire most to impress upon 
>°u is the recognition of the group of hybrids between typhoid fever 
ai)d the malarial fevers. The scorbutic complication was a mere acci- 
dent of the war; its existence is by no means essential to the idea of 
ypbo-malarial fever, but in dealing with the typho-malarial fever of the 
ai* I could not omit it from the picture. 
It was, and still is, my belief that the mixed forms of fever which I 
lave thus sketched constituted the great majority of the continued 
1 Op. cit., p. ill. 334 
WOODWARD, 
fevers of our army during the civil war. I still, however, adhere to the 
opinion which I expressed in Circular No. 15 of 1868, and in Circular 
No. 6 of 1865, that simple typhoid fever and simple remraittent fever did 
also occur, though the statistics fail to show to what extent; and I still 
adhere, also, to the view then expressed, that a large portion of the cases 
actually reported during the war “ as typhoid and remittent fevers are, 
to a great extent, to be regarded simply as those in which the typhoid 
or the paroxysmal phenomena predominated.” 
It would follow, from.the views I have advanced, that typho-malarial 
fever ought to be encountered also in civil life, particularly in our Southern 
States; not, indeed, to the same extent that it existed during the war, 
when hundreds of thousands of soldiers, born and bred in the Northern 
States, campaigned in the malarial valleys of the South, but to an extent 
which deserves thoughtful recognition. And this, I must believe, from 
my own observations, and from facts communicated by professional friends 
in various parts of the South, is actually the case. 
Since the close of the civil war my doctrine of typho-malarial fever 
has been accepted with approval in many quarters, and the term has been 
extensively used. Dr. Meredith Clymer1 has adopted it as a synonym of 
“American Camp Fever” in his edition of Aitken’s Science and Practice 
of Medicine. Dr. George B. Wood,2 though unwilling to adopt the 
name, has fully recognized the great prevalence during the civil war of 
“this mixture of the two fevers.” In the sixth edition of his work on 
Practice of Medicine, published in 1866, he remarks: “Since the last 
edition was published this complex affection has been much more preva- 
lent than before, probably because great numbers of young men engaged 
in the armies at an age when the predisposition to enteric fever is strongest, 
have been in an unusual degree exposed to the joint action of the causes 
of the two fevers; to that of enteric fever, in the almost unavoidable 
tilth attendant upon great encampments, and to that of bilious remittent 
or intermittent in the low grounds from which miasmatic effluvia are so 
abundantly extracted in our Middle and Southern States in the latter 
part of summer and in autumn.” 
Dr. Austin Flint,3 whose former experience in the South makes me 
regard his opinion in this matter as particularly valuable, in his Treatise 
on the Practice of Medicine, has adopted the term typho-malarial fever 
as a convenient designation to represent the hybrids which had been 
indicated by Drake and Dickson, and which Flint himself tells us he has 
recognized in his own lectures to medical classes for twenty-five years. 
His article on simple remittent and typho-malarial fever is an admirable 
one, to which I refer you with pleasure. 
With this intelligent corroboration and support of my views on typho- 
malarial fever, there has been, I must admit, some indiscriminate use of 
the term, which is well calculated to bring it into discredit. I have 
myself known it to be erroneously applied to simple typhoid fevers, in 
the clinical history of which I at least could see nothing to indicate a 
malarial complication, and to simple remittents in which I could perceive 
no typhoid symptoms. I think I have observed, also, a tendency in 
certain quarters to bestow the term upon almost any obscure febrile affec- 
1 Wm. Aitken. The Science and Practice of Medicine. With additions by Meredith 
Clymer. Philadelphia, 1872, vol. i. p. 607. 
2 Op. cit., vol. 1. p. 377. t 
3 Austin Flint. A Treatise on the Principles and Practice of Medicine. Philadelphia, 
1866, p. 749; also Fourth Edition. Philadelphia, 1873, p. 934. TYPHO -MALARIAL FEVER. 
tion which offered diagnostic difficulty. May I not hope that the publi- 
cation of this paper may serve to diminish abuses of this kind hereafter? 
-But although widely accepted, my views with regard to typho-maharial 
*cver have not escaped criticism. Dr. Roberts Bartholow,1 formerly an 
Assistant Surgeon of the Army, and now a successful practitioner in 
Cincinnati, has attacked them with a good deal of acrimony in an article 
011 the Camp Fevers of the Civil War, which he contributed to the Medi- 
cal Volume of the Memoirs of the United States Sanitary Commission. 
Red away by the energy of his attack, he goes so far as to affirm boldly 
a typh element did not in my experience exhibit itself as a modifying 
condition in remittent fever.” He declares the camp fevers of the army 
V have been remittent, simple continued, typhoid, and typhus, and affirms 
that “ these several forms of fever preserved as distinct clinical features 
|rl the army as the same forms of disease in civil life.” To give force to 
tns criticism, he even goes to the extent of misrepresenting my views, 
and says: “There were, therefore, according to Woodward, really no 
cases wholly typhoid, or wholly remittent, in the army”—although I had 
distinctly affirmed the occurrence of such cases in all my publications on 
cne subject. I will not pause in this place to answer these criticisms of 
■Ur* Bartholow in detail. I would merely remark that, although he 
Shakes typhus one of the forms of camp fever, he himself admits that he 
llas no knowledge of it from personal observation. And though he is so 
ready to deny that the typh element, as he calls it, can complicate malarial 
teyers, he is compelled to concede that the malarial influence can com- 
plicate typhoid fever. This he has explicitly affirmed to be a common 
°ceurrence in civil life, in another article contributed to the same volume 
°| the Memoirs of the Sanitary Commission. His language is : “I have 
a* ready adverted to the fact that, as populations increase in malarious 
districts, typhoid supplants the intermittent and remittent fevers. Dur- 
lng the transition period a mixed fever prevails; it is a typhoid fever 
a malarial complication.”2 He admits, therefore, the combination 
0J- malarial and typhoid fevers, but holds that the typhoid element is 
aJways dominant. Against this, I maintain that sometimes the one and 
®dmetimes the other of the two elements predominates, and I must believe 
liat the facts are on my side. I may add that the distinguished editor 
01 the volume of Memoirs in question, Dr, Austin Flint, felt himself 
cfr.l upon to append to Dr. Bartholow’s essay the following remark: 
the general favor with which the term typho-malarial has been received, 
and the readiness with which it has come into vogue, show that it 
expresses a pathological doctrine consistent with clinical experience.”3 
f'l his hasty criticism, Bartholow falls into another error—so mis- 
chievous, that I cannot permit it to go unchallenged. He denies the 
mquency of a scorbutic taint among our soldiers during the civil war, 
cUl<l thinks that even the cases reported as actual scurvy include many 
°f 44 ordinary stomatitis.” He says; “In a pretty extended course of 
0 servation, I did not meet during the war a single well-marked case of 
scorbutus.”4 A general belief that Bartholow’s opinions as to this mat- 
m are correct would be a serious obstacle to any attempt to improve the 
a indentation of our soldiers in any future war. In fact, however, this 
pinion is so far wide of the truth, that I can only understand it as an 
, Roberts Bartholow. Camp Fevers, being chap. 2of the Medical Volume of the 
cinoirs of the U. S. Sanitary Commission. New York, 1867, p. 193 et seq. 
tip. cit., p. 126. 3 Op. cit., p. 214. 4 Op. cit., p. 196. 336 
WOODWARD, 
illustration of tlie extent to which one may be led astray by the eager- 
ness of controversy. It is not necessary to leave the volume in which 
Bartholow’s paper is printed to find evidence to contradict him. You 
will find such evidence in the paper by Dr. Sand ford B. Hunt,1 which 
constitutes the third chapter of the volume; and in the first chapter or 
the volume, by Dr. Bartholow himself,2 he makes a series of statements 
which fully justify my views. Thus, he affirms that the amount ot 
aliment furnished to the various armies was too often “ determined by 
the transportation available for bringing it forward, and by the so-called 
military necessity ;” and that “the armies operating in the interior region 
were more affected by deficiencies in commissariat supplies than those 
on the Atlantic coast,” of which fact he gives several striking examples. 
He explicitly states that “ the diet was not sufficiently varied.” “Anti- 
scorbutics came to be furnished after the first year of the war, but the 
chief antiscorbutic—the potato—was practically unavailable, from the 
difficulty of transporting and preserving it,” 
Is it wonderful that, in this connection, Dr. Bartholow, adopting the 
very term he criticizes when used by me, should have felt compelled to 
write : “A scorbutic taint was to be observed in troops who had served 
in the South for a considerable period;” and, further on, that “an im- 
poverished state of the blood, due to defective alimentation, undoubtedly 
existed to a large extent. It exhibited itself in various forms, but espe- 
cially in increasing the fatality of diseases and in impressing an adynamic 
character on those of mild and tractable forms.” Still further; “The 
camp fever of the army was essentially typhoid. It was modified by 
various accidental and specific causes. We have just alluded to one of 
the specific modifying causes—malaria. The most important of the 
others was scorbutus.” 
It would occupy too much time for me to attempt to bring forward 
even a small part of the evidence on which my belief of the wide-spread 
existence of a scorbutic taint among our troops during the late w'ar rests. 
My own observations and opinions have been corroborated by those of 
numerous capable medical officers. As for actual pronounced scurvy, so 
fully developed that it could be recognized by the average regimental 
surgeon, 30,714 such cases, not of the scorbutic taint, but of “ scurvy,” 
were officially reported among the white troops during the war, and 
16,217 among the colored troops.3 
The other critic to whom I desire to refer is Dr. Jerome Cochran, of 
1 Op. cit., p. 64. 2 Op. cit., pp. 16-19. 
3 The ratio of these cases to strength greatly increased during the latter part of the war, 
and attained formidable proportions among the troops sent to Texas during the year fol- 
lowing the war. The following ratios are computed from the tables published in the first 
volume of the Medical History of the War:— 
Ratio of Cases of Scurvy per 1000 of mean strength. 
WHITE TROOPS. 
Year ending June 30, 1862 
“ “ “ “ 1863 
4.7 
12.6 
“ “ “ “ 1864 .... 
9.6 
“ “ “ “ 1865 
22.4 
“ “ “ “ 1866 
28.4 
COLORED TROOPS. 
Year ending June 30, 1864 
66.5 
“ “ “ “ 1865 
65.0 
“ “ “ 1866 
141.6 TYPHO-MALARIAL FEVER. 
337 
Mobile, whose obiections I find in the Transactions of the Medical Asso- 
ciation of the State of Alabama for 1875.1 This gentleman s service as 
a surgeon in the Confederate Army inclines me to regard ms somewhat 
grotesquely presented criticism with a respect I could not have left had 
it proceeded from a less reputable source. Singularly enough his objec- 
tions precisely contradict the obiections ot Barth olow; so that i migi 
readily call upon either gentleman as a useful witness to contradict the 
asseverations of the other. Bartholow will see nothing in the continued 
fevers of the war but the typhoid element; Cochran will see nothing in 
the fevers around Mobile but the malarial element. , 
“ During the last six months,” he writes, “ several cases of protracted 
fever, primarily of malarial origin, but assuming in their course certain 
typhoid symptoms, have been related to the Society under the name o 
typho-malarial fever.” He objects to this term and the theory which it 
implies. He thinks the fevers in question are purely malarial. fne 
la rial mother is easily found, the fruitful mother of many children, but 
for the typhoid father I have looked in vain through all the streets and 
a%s, in all the wards and suburbs of the city” and again: ‘I can 
only continue to say that if we have typhoid fever here, I have never 
seen it.” 
Kow, the very same volume in which Dr. Cochran publishes this, con- 
tains a tabular statement of the deaths in Mobile during the year 1874 
Amono- these I find three from intermittent fever, twelve from remittent 
fever, seven from congestive fever, one from typho-malarial fever, six Dora, 
yellow fever, one from hemorrhagic-malarial fever, and five from typhon 
fever.2 Dr. Cochran himself tells us in the course of his remarks that his 
antagonists among the Mobile physicians declare the existence in that 
toWn of “ a continued fever with diarrhoea, dry tongue, frequent deh- 
hutn, a rose rash, running a persistent course of three weeks or more, 
and defying all treatment to arrest its progress;” but he will not admit 
that this fever is typhoid. He does not bring forward any dissections 
in proof of his views ; indeed, he does not appear to have made a single 
autopsy in any of the cases in dispute. He bases Ins opinion entirely 
°n a priori considerations deduced from his belief in the incompatibi ity 
°f the idiopathic fevers. He proclaims that “ there can be no doubt 
whatever of the truth of John Hunter’s general doctrine, that no two ot 
them can exist in the same part of the body at the same time. can 
°nly express my belief that if Dr. Cochran had spent a part of the time 
Mhich he has employed in criticizing my views, in making, wi 1 
fellow-practitioners, some autopsies on the cases of fever, which ie • s 
they persist in calling typho-malarial and typhoid, he won c 
arrived at results quite at variance with the opinions he has expressed. 
T And now, one word before I close, as to the question ot nomenclature 
ps it convenient to bestow a single term, as I have done, upon ew i _ 
hrood of hybrid forms resulting"from the simultaneous action of malaria 
and of the causes of typhoid fever; or, is it best to use several designa- 
tions according as the one or the other of the two elements predomi- 
nates? We might give the cases in which the typhoid element pie- 
thelname miasmatic-typhoid fever, suggested by Levick, 
1 Jerome Cochran. Note B. Typho-malarial Fever. Trans, of the Med Association of 
State of Alabama, 28th Session, 1875. Montgomery, Ala., iam, p.d4(. 
, * O?; cit/suprat also a lecture by the same author, Miasmatic Typhoid Fever. Med. 
ailc* Surg. Reporter, June 21, 1862, p. 283. 
22 338 
WOODWARD, 
and call those in which the malarial element predominates typhoid- 
miasmatic fever. Such a double nomenclature we have already seen 
was suggested by Hermann Schmidt. We might go still further, and 
apply special names, in accordance as the malarial element showed itself, 
by giving to the early stages of the case an intermittent or remittent 
type. I do not think this is at all necessary. I think a single term 
which shall include all the hybrids quite sufficient; but I shall not 
quarrel with any one who wishes to make further subdivisions. 
If we agree to represent all these hybrid forms by a single appel- 
lation, is the designation Typho-malarial the best for the purpose ? 
Would it be an improvement to adopt the term “ entero-miasmatic,' 
suggested as a substitute by Dr. George B. Wood?1 I confess to a 
preference for the term I have suggested. It is easy enough to pro- 
nounce, and seems to me to express its meaning very well; but I attach 
far less importance to the employment of the name which I have sug- 
gested than I do to the recognition of the compound forms of fever 
which I intended to represent by it. The name is, after all, a mere 
matter of choice. But if I have rightly presented the subject, a just 
appreciation of the hybrid forms which I have urged on your atten- 
tion to-day is a matter of grave practical importance. Hot merely as a 
question of Military Medicine, though most important in that connec- 
tion, for I take it that whenever again hereafter an army recruited in a 
comparatively non-malarial region shall campaign on a malarial soil, 
these hybrid forms will appear once more in epidemic proportions; but 
meanwhile, I suppose, in sporadic or endemic-wise, we shall continue 
to have these cases to deal wTith in civil practice in all the miasmatic 
regions of our Middle and Southern States, and their right compre- 
hension is, therefore, a question of serious moment to every Ameri- 
can physician engaged in practice in such localities. 
Discussion on Dr. Woodward’s Paper. 
After the reading of the preceding paper, Djf. Roberts Bartholow, of 
Cincinnati, said;—l have listened very attentively to the paper just read, and 
as it refers to some criticisms of mine, I feel called upon to reply. I have 
studied Dr. Woodward’s writings, and, with many other physicians of the 
United States, have labored under the impression that he had attempted to 
erect the Typho-malarial fever into a distinct type of disease. Now he recalls, 
denies, and repudiates what he has formerly published. In the paper which I 
had the honor to contribute to the volume issued by the Sanitary Commission, 
and to which allusion lias been made, I simply stated that there were distinct 
cases of simple typhoid and of remittent fever in the army of the United 
As a practitioner in the Ohio Yalley, I have seen cases of fever in some ot 
which the malarial, and in others of which the typhoid element predominated. 
The paper just read throws no new light on the subject. The form of disease 
referred to has been long since known. I must repudiate the idea that the 
statements in my paper were made in an acrimonious spirit. When eminent 
medical men publish their views, the most obscure member of the profession 
has a right to express a difference of opinion, and should not be stigmatized 
as acrimonious simply because he utters his opinions in a determined and fear- 
less manner. 
Dr. Woodward said:—l wish simply to say that Dr. Bartholow under- 
took to write a history of the fevers of the Civil War for the Sanitary Com- 
1 Op. cit., vol. i. p. 377. TYPHO-MALAEIAL FEVER. 
mission. He criticized my views, as I thought, in an acrimonious spirit, and 
I resolved at the time to reply, but have not till the present occasion had 
a convenient opportunity. If after reading my paper, Dr. Bartholow still 
thinks that I have misrepresented his criticism, 1 will offer him an apology 101 
having done so. , 
Dr. N. S. Davis, of Chicago, saidl had not supposed that the term 
“ typho-malarial” was intended to indicate any specific form of fever, and am 
surprised that the author of the paper seems to combat the idea that it should 
be so received. I supposed that it meant simply the intermingling of the 
causes of two distinct forms of fever, in such a way that they influenced the 
human system at one and the same time. This phenomenon of intermingling 
has been familiar to me ever since I took up my residence m Chicago, in 1849. 
Then it was almost universally believed that our levers were of a malarial 
character: very few recognized typhoid fever as such. The locality was mg i y 
malarious. The population was about 30,000, and there was not a loot of 
sewerage. The supply of water was drawn from superficial wells, and the 
Prevalence of intermittent and remittent fevers was very distinct. Ten or 
twelve years later, when sewerage had extended, and a supply ol lake water 
had been supplied, the intermingling was observed. Cases of fever at their 
°nset were regarded as malarial, but, not yielding to the influence of quinia, 
Were ultimately recognized as of a typhoid character. As time passed on, the 
typhoid element predominated, and we now find no difficulty in recognizing 
the intermingling of types. 
Dr. W. Scott, of Cleveland, Ohio, saidl rise to bear testimony to some 
°f the facts set forth in Dr. Woodward’s paper. Physicians of thirty years 
standing in the Ohio Valley, and especially in the southern portion of the 
State remember the time when this complex condition was unknown. Our 
experience is that the typhoid element is not affected by the use of quiiiia. 
When 1 have recognized this mixed form of disease, I have given quinia in 
sufficient doses to destroy the intermittent character of the affection, when the 
fever persists in the continued form. In 1864 I was in Nashville, and observed 
many cases of scurvy among the soldiers in the Nashville hospita s. 
Dr. Wm Pepper, of Philadelphia, said:—At the time I first read Dr.V ood- 
Ward’s publications on the subject of typhoid and malarial fevers, they made a 
dear impression on my mind ; and I think his views as now expressed are the 
same with slight modifications as to the anatomical relations of these two 
affections. I confess, however, to some hesitation as to the propriety of em- 
ploying a special term to distinguish a disease which is not itself specific. A 
§reat deal of confusion has resulted from the use of such terms; and i have 
found many who regard typho-malarial fever as wanting the specific characters 
of typhoid fever, and as, therefore, not requiring the same care as the ordi- 
nary uncomplicated form of the disease. We meet with cases of typfio-maia- 
rial fever in this city, and I have myself become very familiar with it. it is 
found itself, however, to present so many forms and varieties, partly depending 
°n the relative proportion in which the typhoid and the malaria e emends aic 
combined, as to render it very difficult to give a clinical definition of it. More- 
over, I have not found that the symptoms which are usually given as indicating 
fbe coexistence of the two poisons, are as constant and reliable as appears to 
be thought by many, and as they certainly must have been m the array cases 
upon which Dr. Woodward founded his classical memoir. Thus, for instance, it 
!s true that in the malarial form of typhoid fever an initial chill and an early rise 
m temperature are more common than in the uncomplicated torm. But there 
ai'e so many irregularities in the mode of onset and course of typhoid fever, 
aPart from any complication, as to render this of uncertain value. And in 
this connection I would add that careful study of the irregular and abortive 
forms of typhoid fever has convinced me that the fixed inles for the tempera- 
ture curve in this disease adopted by many authors, must be vety consideiably 
Modified. What I have said of the initial chill and the fever-curve, I might say 340 
WOODWARD, TYPHO -MALARIAL FEVER. 
of the kind of tongue thought to be characteristic ; of the relative frequency 
of eruption, diarrhoea, epistaxis, etc., in the two forms of the disease. We 
are not in the habit of erecting into special types of disease the cases of other 
affections which are complicated with malaria—as, for instance, pneumonia, 
dysentery, etc., and, although in the case of typhoid fever this complication is 
certainly more frequent than in any other affection, it appears doubtful to me 
whether it would not be better to include typho-malarial fever under the general 
head of typhoid fever, and to merely designate it as the “miasmatic form” of 
that disease. Still, there is a feeling among physicians that the use of the term 
“typho-malarial” is convenient, and it is perhaps desirable that for the present 
at least it should be recognized. 
The Secretary read the following remarks contributed by Dr. J. A. Estlan- 
DER, of Finland :—At certain periods, malarial fever is very common along the 
southern coast of Finland ; at other periods it disappears altogether. During 
the last years of the decade 1850-60, it reigned over the whole coast, but from 
1860-68 it disappeared so completely that not one single case was to be met with 
at the hospital. From the last-named 3rear until the present time, it has again 
plagued this part of the country very severely, but seems now to be fast decreas- 
ing. This periodicity seems to depend on the atmospheric pressure, for when 
during our short summer the average range of the barometer is high, the water- 
level is low, and the bottom of the sea, in the numberless small creeks and bays 
penetrating the shores of the Gulf of Finland (where, by the way, no tide is 
perceptible), lies uncovered and exposed to the sun. When, on the contrary, 
the mean barometer is low, all is covered with water, and the summer is rainy 
and cold, but free from malaria. The abdominal form of typhoid fever may be 
called endemic in my country7, for cases of that fever occur every year and at 
every season, although sometimes with more, sometimes with less, intensity 
and frequency. At such periods, when the malarial fever is very intense, we 
often see cases exactly like those so well described by Dr. Woodward. These 
cases most frequently appear in spring and autumn, and particularly in the 
early part of the last-named season, to wit, the month of August, for such, in 
this land of short summers, this month is designated. For this reason, this 
fever is in my country commonly called “ Augusti-feber.” Dr. Woodward has 
named this form of fever “Typho-malarial,” to define it as a hybrid of the 
typhoid and the malarial fevers, and I gladly accept this name and its signifi- 
cation. It is a well-known fact that during a period when the malarial consti- 
tution is predominant, many diseases combine in a curious manner wdth this 
fever, as for instance diarrhoea and bronchial catarrh, particularly in children, 
and therefore such a concurrent action of separate intoxications, as the name 
“Typho-malarial” implies, has many analogies in pathology. 
On motion of Dr. Woodward, seconded by Dr. Pepper, the following was 
adopted as expressing the opinion of the Section:—“Typho-malarial fever is 
not a specific or distinct type of disease, but the term may be conveniently 
applied to the compound forms of fever which result from the combined influ- 
ence of the causes of the malarious fevers and of typhoid fever.” 341 
are diphtheritic and pseudo-membranous croup 
IDENTICAL OR DISTINCT AFFECTIONS? 
BY 
J. LEWIS SMITH, M.D., 
PHYSICIAN TO THE INFANT HOSPITAL, NEWYORK, ETC. 
. The term Pseudo-membranous Croup, Membranous Croup, or, for brev- 
Croup, is applied to a sporadic inflammation of the larynx, which is 
accompanied by the formation of a pseudo-membrane upon, the laryngeal 
surface. It is attended by no symptoms, except such as are referable to 
the local disease, and it destroys life by the mechanical effect of the exu- 
dation. Croup is universal; Steiner says, “ Croup extends over the whole 
World, but strikingly diminishes in frequency, according to A. Hirsch, 
as we pass from the higher latitudes to the tropics.” Therefore nearly 
every physician in general practice meets cases from time to time. My 
present purpose is to consider the relation of this malady to an inflamma- 
tl9n of the same parts, which is accompanied by a similar exudation and 
;vith similar local symptoms, but which we know to be a form of, or a 
Manifestation of, a contagious and epidemic disease, namely, diphtheria. 
There are two theories regarding the relation to each other of croup 
and diphtheritic laryngitis. The first is that they are entirely distinct, 
the one is a simple, non-specific inflammation, not capable of repro- 
ducing itself, while the other is specific and contagious; that, therefore, 
they sustain to each other, as one of our writers has well said, a similar 
Mlation to that which exists between ordinary metritis and the metritis of 
puerperal fever, having sufficient clinical differences to j our regard- 
dig them as disti net maladies. The second theory is thus enunciated by one 
ffs foremost advocates (Steiner): “ The attempt to distinguish croup and 
diphtheria as two entirely distinct diseases has been unsuccessful, both 
r°m an anatomical and a clinical standpoint; indeed there are many 
good reasons for supposing that these two affections are only varieties 
and modifications of one and the same process, which, in consequence of 
special influences and collateral causes, as yet imperfectly understood, 
Makes its appearance at one time as croup, at another as diphtheria, now 
111 a sporadic form, now as a wide-spread epidemic, now as a primary, 
How again as a secondary affection.” 
The attempt to elucidate the nature of croup, and determine its relation 
0 diphtheritic laryngitis, is attended by unusual difficulty for one who 
his observations in a locality where diphtheria prevails, as is the 
case with most of us who reside upon the Atlantic coast. The difficulty 
a luded to arises from the impossibility of making a clear and certain 
Mgnosis of croup, where diphtheria is endemic. Has not every phy- 
Slcian in such a locality, now and then, believed, that he was treating a 
?as® croup, such as he had, perhaps, observed in former years, even ad- 
enng to the diagnosis till the death of the patient, when the subsequent 
nstory of contagiousness has taught him that, after all, the case was one 
0 diphtheria? There is no symptom or anatomical fact observed at the 342 
J. L. SMITH, 
bedside which will enable the physician to say that the case is croup, and 
not laryngeal diphtheria. Absence of a pseudo-membrane upon the fauces 
does not, as some seem to think, establish the diagnosis of croup, for I 
have treated undoubted cases of diphtheritic laryngitis, ending fatally, in 
which there was not only no diphtheritic pellicle upon the surface of the 
pharynx, but only a mild degree of catarrhal pharyngitis, Nor is the 
absence of glandular swelling under the ears certain proof that the laryn- 
gitis is croupous, instead of diphtheritic, for, although it is true that 
considerable tumefaction is a sign of diphtheria, yet this swelling is 
sometimes absent in cases which are clearly diphtheritic. 
For correct and reliable tacts in regard to croup I have found it neces- 
sary to consult medical literature, and to depend upon my own recollec- 
tion, and that of the older physicians of New York, as to cases which 
occurred prior to 1857, at which time diphtheria became established as 
an epidemic and endemic of the city, and upon the observations of intel- 
ligent physicians in localities where diphtheria does not prevail. lam 
under obligation to physicians who have thus aided me. The relation of 
croup to diphtheritic laryngitis may be conveniently considered under the 
following headings— 
I. Croup a local malady ; diphtheritic laryngitis the expression or manifes- 
tation of a general disease.—The late Dr. Hillier, of London, a close ob- 
server of diseases, inclined to the belief that croup was a constitutional 
malady, but the following facts strongly indicate its local nature. Its 
causes, as we shall see, are the same or similar to those of the ordinary 
inflammations, which are admitted to be strictly local. There is no evi- 
dence, from the symptoms, of any systemic infection or blood disease, 
and recovery immediately follows relief of the local malady. The de- 
pression which attends cases ot diphtheria is lacking. If croup were a 
general disease, there should be, it seems to me, in some cases at least, 
anaemia, poor appetite, weakness, etc., indicative of the blood change, for 
a longer or shorter time after the removal of the laryngeal obstruction 
and abatement of the inflammation. 
As evidence, also, that croup is not a constitutional disease, is the fact 
that the inflammation is almost invariably—l have heard of no excep- 
tional case—limited to a single tract of the mucous membrane. It is 
the uniform recollection ot the older physicians of New York with 
whom I have conversed in reference to this matter, that they never ob- 
served a case ot croup, before the advent of diphtheria, which was attended 
by membranous exudation upon other surfaces than that of the pharynx 
and air passages. Were there systemic infection, or blood poisoning, in 
croup, we should expect that, in some instances at least, the character- 
istic inflammation and exudation would occur in other localities also, as 
in diphtheria, especially since nearly every mucous membrane in the 
system is susceptible of croupous inflammation. Another fact indicative 
ot the local nature of croup, is its tolerance of depressing remedies, as 
we shall see hereafter. Constitutional diseases having inflammatory 
lesions, badly tolerate such agents. From clinical and anatomical facts 
like the above, the profession has long regarded croup as a local malady, 
and I can see nothing in the most recent investigations regarding its 
nature to shake the belief in this opinion. 
How is it with diphtheritic laryngitis, as this inflammation ordinarily 
occurs? Is it local, occurring independently of blood changes and pro- 
duced by the lodgment of the diphtheritic virus upon the laryngeal sur- CROUP AND DIPHTHERIA. 
343 
|ace; or is it the result of the presence of the diphtheritic virus in the 
‘Rood, so that it sustains the same relation to the general disease, that the 
pharyngitis of scarlet fever and the bronchitis of measles do to those 
diseases? The latter theory, namely that the laryngitis and other in- 
flammations of diphtheria are the result and outward manifestation of 
au infected or poisoned system, was generally accepted by the profession 
°f this country and Europe during the last twenty-five years, until the 
Publication of the bacterian theory. This theory (according to which 
is claimed that a microscopic organism, which is the cause or specific 
principle of diphtheria, has been found making its way from the surface, 
pn which it has lodged or been received from the air, through the tissues 
lnto the circulation) has shaken the belief of many in the constitutional 
Mature of diphtheria, and they incline to the other view, which certain 
experiments seem to support, that diphtheria in ordinary cases begins 
locally, and that blood poisoning may or may not result, but that if it 
hoes, it is secondary. 
It is a matter of great importance—an importance transcending that 
°I almost any other subject relating to the pathology of this dreadful 
scourge—that we should ascertain clearly and certainly which of the two 
prevailing theories is true, since the theory influences practice. Is the 
opinion correct, that the primary event is the entrance of the poison into 
He blood; or the other opinion, that the poison is received upon an 
exposed surface, where it excites inflammation, and that the blood either 
oscapes contamination, or receives the poison by absorption or penetra- 
fioii from the inflamed surface? 
Experiments on the lower animals have thus far failed to demonstrate 
He primary nature of diphtheria, as it occurs in the human race. Among 
the most recent experiments which have a bearing upon this subject, are 
Hose of Dr. Rajewsky, performed with the approval and at the instance 
(d Prof. Von Recklinghausen. Rajewsky poisoned the blood of rabbits 
injecting diphtheritic matter into it, and then produced catarrhal in- 
flammation of the intestinal mucous membrane by injecting a weak solu- 
tion of ammonia into the intestine, when the interesting result followed, 
that the catarrhal became a diphtheritic inflammation. Obviously in 
these experiments diphtheria was primarily constitutional. The diph- 
theritic inflammation was developed from within—from the poisoned 
state of the blood. But in another class of experiments, he first pro- 
duced catarrhal inflammation of the intestines in the same manner as 
before, and then injected diphtheritic matter into the intestine. The re- 
sult was the same as regards the production of diphtheritic inflammation 
i. “ A 1 
uPpn the intestinal surface, for upon the inflamed portion, to which the 
Poison was applied, the characteristic diphtheritic pellicle appeared. It 
!nay be inferred, that in this class of experiments the primary action was 
ocaE but may not absorption of the poison have preceded the local dis- 
ease, as is now believed to be the case in syphilitic inoculations?1 (Bum- 
stead.) 
Ihe fact that diphtheritic inflammations ordinarily occur upon those 
surfaces which are most exposed to currents of air, and upon which any 
eleterious substance floating in the air would be most likely to lodge, 
Jas been supposed to lend support to the theory that diphtheria is at first 
Realized in these exposed parts. But if these inflammations were ordina- 
ry produced by the direct contact of the poison received from the air, 
1 Lond. Med. Times and Gaz., Dec. 11, 1875. 344 
J. L. SMITH, 
coryza ought, it seems to me, to be the primary diphtheritic inflamma- 
tion in a large proportion of cases ; whereas it is not ordinarily pri- 
mary,and in many cases does not occur at all. The fact is that the diph- 
theritic virus, in whatever way its reception occurs—whether in the 
ordinary manner, or through a wound of the skin—appears to he espe- 
cially attracted to the fauces and contiguous p>arts, or to find in them 
the seat of its greatest activity, so that even if the disease is received 
through a distant part of the system, pharyngitis is apt to occur. Thus 
Hillier relates the case of an eminent surgeon who, performing trache- 
otomy on a child supposed to have croup,"punctured his thumb. The 
puncture was painful, and on the following day a pustule occupied its 
site. This was opened and poulticed. “A day or two later, on removing 
the epidermis, the subjacent cutis was found in the condition of a pecu- 
liar dark slough ; there was an entire absence of suppuration, and exces- 
sive pain. Ibis was followed in six days by a diphtheritic deposit on 
the tonsils. The wound on the thumb was long in healing.” A month 
later, diphtheritic paralysis occurred.1 In cases like the "above, if they 
are correctly interpreted, and the poison is received through the skin, it 
is evident that the inflammations on the exposed mucous surfaces are not 
produced by the direct deposit of the virus, but that they result from the 
blood poisoning. And the important and interesting fact appears, that, 
in cases thus contracted by inoculation, diphtheria is constitutional, be- 
fore the pharyngeal or laryngeal inflammation occurs. 
Eut if we could obtain no farther light in reference to the primary nature 
of diphtheria than what is afforded by experiments on animals and acci- 
dental inoculations in man, we would probably never know, when called at 
the commencement of a case contracted in the usual manner, whether we 
had to treat a merely local affection, or a constitutional disease with local 
manifestations. We must fall back to the wider field of clinical experi- 
ence for help to an understanding of this matter. The following facts, 
taken collectively, afford, in my opinion, strong corroboration of the 
theory that there is primary systemic infection in diphtheria, as it is 
commonly contracted:— 
(1) The long incubative stage in certain cases.—Although the incubation 
of diphtheria is ordinarily from two to five days, it is sometimes an 
entire week, as in the following examples ; In April, 1876, a little girl 
died of malignant diphtheria in West 41st Street, New York. Her 
sister, aged one year, remained with her from April 14 to 17, when she 
was removed to a distant part of the city, and placed in a family where 
theie was no sickness, and had been no diphtheria. On the night of 
April 24, seven days after her removal, this infant was observed to be 
feverish, and on the following day, when I was called to examine her, 
the characteristic diphtheritic patch had begun to form over the left 
tonsil. In April, 1875, two sisters, aged seven and five years, resided 
with their parents, in a boarding-house, in West 22d Street, Yew York. 
A playmate in the same house had symptoms which were supposed 
to be due to a cold, but which were diphtheritic, when one night 
severe laryngitis occurred, and ended fatally the next day. The phy- 
sician who had been summoned diagnosticated diphtheria, and the two 
sisters were immediately removed to a hotel. But seven days subse- 
quently, diphtheria commenced in the older child. The younger was 
at once removed to a distant part of the same hotel, but on the sixth or 
1 Hillier on Diseases of Children. CROUP AND DIPHTHERIA. 
seventh day subsequent she also became affected with a fatal form of 
the disease. , , . . , , A 
Now according to the doctrine that diphtheria is at first local, and 
that the inflammations result from the irritating effect of the virus 
which lodges upon the mucous membrane, this virus must remain inac- 
tive a week upon the surface where it is received. Such inactivity in a 
Poison of unusual energy and malignity would be very improbable. 
Nut we have sufficient explanation of the long incubation, i , in \\ la 
ever way the poison is received, it first enters the blood, and the inflam- 
mations occur consecutively to the blood-changes. _ It is a law in path- 
ology that those specific diseases which have an incubation of several 
days, are constitutional. . . . ... , , 
(2) Another fact, which indicates primary blood poisoning in diphthe- 
ria, is observed in certain cases, namely, the occurrence of severe constitu- 
tional symptoms for a longer or shorter time, perhaps for half a day, before the 
appearance of the usual inflammation. Thus a girl of five years having 
malignant diphtheria, whom I saw in consultation, was carefully exam- 
ined on the first day of her sickness by the attending physician, and 
although he closely inspected the fauces, there was no appearance 
which Indicated the nature of the malady till the subsequent day. in 
Bhch cases, a sufficient number of which I have observed, there is apt to 
do complaint of soreness of the throat, or difficulty in swallowing, almost 
from the beginning of the general symptoms; but the pain and tender- 
ness seem to be in the deeper tissues of the neck, and the fact that 
t'edness of the mucous surface does not appear till some hours subse- 
quently, is evidence that the inflammation is developed from within, and 
not from the irritating effect of the poison upon the surface. . 
Again, treatment of the inflammations by the most reliable and efficient 
antiseptics and disinfectants which we possess, commenced at the earliest 
possible moment and repeated at short intervals, does not pi even ic oc 
nnrrence of indubitable symptoms of blood poisoning in cases of a severe 
type. Thus I have treated every portion of the inflamed surface, as tar 
as it was accessible, every second or third hour, with carbolic acid and 
°tber disinfectants, almost from the very commencement of diphtheria, 
and so thoroughly that any vegetable or animal poison, with which the 
reniedies had come in contact, would probably bave been destinyec, 01 
rendered inert, and yet, except in mild cases, symptoms of diphtheritic 
io' bavo occurred, and as early and unifoindy as i 
getic local measures had been employed. While, therefore, Ido not tail to 
recommend local treatment as calculated to prevent septic poisoning, ana 
relieve the inflammations, I have lost confidence in it as a means of pre- 
senting the entrance of the diphtheritic poison into the blood, its power- 
iessness to prevent contamination of the blood by the diphtheritic vnus 
18 an additional evidence that this contamination occurs independently ot 
Ibe local disease, and probably precedes it. . . 
(3) The quick succumbing of the system in certain malignant cases is evi- 
dently due to diphtheritic toxaemia. We sometimes observe a fatal result 
°n the second, third, or fourth day, without any dyspnoea, or sufficient 
laryngitis to compromise life. Cases of this kind, terminating fatally even 
}n the first day, have been reported. The system is suddenly overpowered 
fry the poison, struck down, as it were, by the piofound blood change, 
wffiile the inflammations are still in their incipiency. 
(4) Important evidence of the constitutional nature of diphthena is 
afforded also by the state of the kidneys. Ko internal organs are so often 346 
J. L. SMITH, 
affected in diphtheria as the kidneys, and on account of their location 
and anatomical relation, it is evident that the poison first passes through 
the system before it reaches them. Any clinical or anatomical fact, there- 
fore, which indicates that the diphtheritic virus has reached and affected 
the kidneys, affords proof that it has penetrated the system, and poisoned 
the blood. Now the occurrence of albumen, with granular or hyaline 
casts, in the urine, in cases unattended by dyspnoea, affords proof of nephri- 
tis, caused by the action of the poison on the kidneys. Dr. West, from 
observations made in-London, believes that albuminuria is commonly 
present in diphtheria, but the frequency of its occurrence varies in dif- 
ferent epidemics, according to the severity of the type. 
During the latter part of 1875, and in 1876, prior to Aug. 1, I en- 
deavored to obtain and examine the urine in every case of idiopathic 
diphtheria, having a clear diagnosis, which came under my notice, both 
in family practice and in the institutions with which I have an official con- 
nection, Ordinarily, during the first week of a case, I found that the urine 
deposited urates on cooling, and that the nitric acid test showed a large 
relative quantity of urea, but I suspect that this was due to a somewhat 
diminished quantity of urine. But the occurrence of albumen was of 
chief interest, and the results of the examinations as regards the presence 
or absence of this, are recorded in the accompanying table. In most of 
the cases the urine was examined several times in the course of the dis- 
ease, and, if albumen were present, a microscopic examination was also 
made. In nearly all the specimens which contained albumen—all but 
three or four—casts, usually granular, but now and then hyaline, and 
sometimes both kinds in the same specimens, were observed. In those 
cases of albuminuria which recovered, there were comparatively few 
casts, or none. If the albumen were abundant, and casts plentiful, the 
case was usually fatal, though not perhaps till after the lapse of three or 
four weeks, when death occurred with symptoms of exhaustion, paraly- 
sis, or feeble heart-action, sometimes with oedema of lungs supervening 
suddenly, and, probably, formation of heart clots. The albuminuria, 
unlike that of scarlet fever, seldom occurred except in the grave cases; 
and in the majority of instances it did not appear till near the close of 
the first week, or in the second, and, in a few instances, not till a later 
period. Although the albuminuria of diphtheria is much more grave 
than that of scarlet fever, it has in my practice been attended by much 
less serous effusion or dropsy, often by none which was appreciable. The 
urine, although containing a large quantity of albumen, often had nearly 
the normal appearance, instead of the smoky or hazy color so common in 
the albuminous urine of scarlet fever. 
1. Cases attended with the usual membranous exudation upon the fauces, with 
or without coryza, and without laryngitis or with only catarrhal laryw 
gitis ; fifty-eight cases. 
Result not 
■ Died. Recovered. stated. Total- 
With albuminuria . .13 5 1 ]9 
Without albuminuria ... 4 27 1 32 
State of urine not recorded .3 4 . . 7 
11. Gases attended with membranous laryngitis as the 'predominant 
inflammation; nineteen cases. 
Died. Recovered. Total. 
With albuminuria ... 4 1 5 
Without albuminuria ... 2 4 .. 6 
State of urine not recorded .7 1 .. 8 CROUP AND DIPHTHERIA. 
347 
The mortality of the cases embraced in the above table was probably 
arger than the average in New York practice, for several of them were 
seen in consultation, and their was severe. Those in which the 
state of the urine could not be ascertained, were usually in children so 
}°ung or so near death that it was impossible to obtain sufficient urine 
.°r examination. It is not improbable, also, that, occasionally, in cases 
which it is stated that there was no albumen in the urine, it may have 
Deen present at a more advanced stage of the disease, or on days when 
he examination was not made; but, as stated above, there were usually 
several examinations of the urine made during the progress of each case. 
B'r John Rose Cormack, of Paris, in a series of interesting and useful 
Papers relating to diphtheria, published in the Edinburgh Medical Jour- 
hal during the present year, states that albuminuria, and of course the 
Nephritis on which it depends, sometimes begin as early as the first day. 
observations confirm this statement, as in the following cases;— 
i >I?ASE I—L. McD., aged th ree years, was first visited by me on Peb. 29, 
• °‘6. I learnt from the parents that she had been feverish during the preced- 
no forty-eight hours, and her urine very scanty. A moment’s examination 
as sufficient to show that the case was one of malignant diphtheria, for the 
auces were already nearly covered by the diphtheritic pellicle, the temperature 
as and the pulse 140. The skin was hot and dry, and there was 
°derate swelling under the ears, and a muco-purulent discharge from the 
o.strils. On account of the scantiness of the urine, the amount not exceeding 
oiv-y daily, it was impossible to obtain sufficient for examination till the fol- 
°wing qay_ jq was tjien foun(j have a specific of 1032, to contain a 
lePosit of urates and hyaline and granular casts, a diminished amount of urea, 
aild a large quantity of albumen. It can hardly be doubted from the scanti- 
fiess of the urine, and the large amount of albumen found when the urine was 
1 examined, that albuminuria had been present on the first day. 
I-'Ase ll.—The following was a similar case : K., aged four years, living in 
, ®st 36th Street, was visited by me in consultation on Jan. 29, 1815. Her 
°kness had also continued forty-eight hours ; her fauces were swollen, and 
vered with the diphtheritic pellicle, which was dark and offensive; respira- 
n guttural; pulse 120; temp. 101° ; she had a free discharge from each 
urine scanty, its specific gravity 1030 ; it contained a small amount 
albumen, with casts, and a large amount of urates, with no apparent dimi- 
tl°u of the urea. Death occurred on the fourth day. 
In such severe cases, in which albumen and casts are found in the 
I]ne at the first visit of the physician, there can be little doubt that the 
foP*ritia begins nearly or quite as early as the pharyngitis, and there- 
tple’. poisoning of the blood must antedate the renal disease, diph- 
fileria is in these cases very early, probably from the occurrence of the 
ISa s37nptoms, a constitutional malady. 
fj .gain there are cases, though rare—only one I can recall to mind 
niing the last two years in my practice—in which the external mani- 
sballons of diphtheria are very mild, even insignificant, and quickly 
but in which the kidneys are severely affected. The occurrence 
SUch cases is best explained on the supposition that the first departure 
r-orn fhc state of health is in the blood, and that the blood change gives 
t() the inflammation of the mucous membrane externally, and of the 
u neyg internally, rather than upon the supposition that the transient 
*'f significant inflammation of the mucous membrane is the first 
in the series of morbid changes, and that this inflammation leads 
Poisoning of the blood, and the establishment of a much more severe J. L. SMITH, 
and protracted inflammation in the kidneys. The following is the case 
alluded to;— 
Case lll.—The house, 229 West 19th Street, New York, is an old wooden 
structure, and the family, which has occupied it during the last five years, has 
been three times visited by diphtheria, the first case, that of the oldest child, 
proving fatal. In February, 1816, one of the children had diphtheria in a 
moderately severe form. He recovered, and, after my visits had been discon- 
tinued, his sister, aged six years, who had had scarlet fever when eighteen 
months old, became feverish and complained of her throat. No rash appeared 
on her skin, and there was apparently no coryza. Inspection of the fauces by 
the parents revealed a small diphtheritic patch over each tonsil. Although 
diphtheria was so frightful a malady to this family from their past experience, 
the case seemed so mild that the parents treated it without medical attendance, 
by the remedies which had been employed for the boy. A mixture of carbolic 
acid, subsulphate of iron, and glycerine, was applied to the fauces every third 
hour, sufficiently often, apparently, to destroy all bacteria or other vegetable 
or animal organisms with which it might have come in contact, and within two 
or three days the inflammation of the throat seemed to the parents to be cured. 
Nevertheless, with this insignificant inflammation of the fauces, so quickly 
subdued, and with no other apparent inflammation of the mucous surfaces, 
there was severe internal disease going on as the result of the general infection* 
The child did not regain her former appetite ; she had increasing pallor, al- 
though able to play about the house ; and, finally, in the third week, when I 
was called to see her, slight oedema of the face and limbs was observed. Her 
urine, which was scanty, was found to contain pus and blood corpuscles, albu- 
men, and granular casts, and nearly two months elapsed before, under treat- 
ment, it became normal, and her health was restored. 
One more clinical fact which I have often observed, may be cited in 
support of the opinion that diphtheria is primarily constitutional, and 
that the inflammations are secondary, and dependent on the blood poison- 
ing. It is this: When the inflammations of the mucous surfaces have 
apparently ceased, or only slight catarrhal inflammation remains, and 
the apartment in which the patient has been treated has been thoroughly 
disinfected, and local treatment discontinued, we are perhaps surprised 
to observe the reappearance of the diphtheritic pellicle, though less in 
extent and with less severe symptoms than at first. It is highly improb- 
able that diphtheria has been contracted a second time. The rational 
explanation is that the reappearance of the inflammation is due to the 
fact that the blood is still infected ; that, as when syphilitic eruptions 
reappear, it is not yet fully purified of its noxious elements. I have seen 
this return of the diphtheritic pellicle even in mild cases in which there 
was no other evidence of general disease. If the second occurrence of 
the inflammation is due to the poisoned state of the blood, is it not 
probable that the first inflammation is also thus produced? 
I have perhaps occupied too much space in attempting to show, what 
indeed many already believe, that croup is simply a local malady, 
while diphtheritic laryngitis is one of the inflammations which result 
from a general But within the last three or four years, the old 
doctrine that diphtheria is local in its commencement, and is therefore, 
in at least many instances, amenable to early local treatment, has been 
revived, and so promoted by the advocates of the bacterian system, That 
it already influences the treatment in many quarters. There are physi- 
cians, as I have had opportunity to observe, who attach little importance 
to constitutional measures, if they are called early to a case, and who 
rely almost entirely on local treatment for the relief of the patient. CROUP AND DIPHTHERIA. 
349 
But with a correct understanding of the nature of diphtheria, lam con- 
vinced that we must continue to regard constitutional remedies as ot 
Prime importance. , 
The evidence is therefore strong that, while croup is primarily and 
constantly local, diphtheria, as it ordinarily occurs, is a general disease 
from its commencement, and that the laryngitis and other inflammations 
result from and manifest the blood poisoning. 
11. Anatomical characters identical in kind, as regards the state of the 
larynx, hut differing in degree or intensity.—Most ot the microscopic exami- 
nations of the pseudo-membrane, made during the last twenty years in 
country and Great Britain, in cases of supposed croup, must be re- 
ceived with hesitation and distrust, on account of the great difficulty to 
which allusion has already been made, of making a clear diagnosis m 
localities where diphtheria prevails. Bor although diphtheritic laryn- 
gitis can often be diagnosticated from croup, the reverse namely, the 
diagnosis of croup from diphtheritic laryngitis, is attended by such dif- 
ficulty and is so uncertain, that we can obtain, as already stated, reliable 
Satieties of croup only from those observers who reside in localities in 
Which diphtheria does not occur. , . , .... ■, 
fortunately, for our purpose, there are or have been localities where 
Pathologists have been able to observe the clinical and histological char- 
acters of croup, free from the embarrassment to which I have alluded. 
Thirty years ago the great treatise of Carl Rokitansky, on Pathological 
Anatomy, appeared, a vast repository of pathological facts, derived from 
thirty thousand dissections. Ho one has ever had better opportunities 
than he, for studying the anatomy of diseases, and no opinion has cal- 
led, and still carries, greater weight than his, m all subjects relating to 
forbid anatomy which do not involve the use of the nncroscope. am 
informed that even up to the present time, i n Vlenna, where Rokita y 
observations were made, diphtheria is almost unknown, anc in is 
tise he scarcely makes any allusion to it, so little did he know o • 
may therefore confidently believe that what this renowned observer 
states in relation to croup, relates to the genuine disease. 
, Says Rokitansky, “ The croupy process occurs on all 
branes, and sometimes extends over a very wide tract, ibe mucous 
Membrane of the respiratory organs shows an especial tendency to it 
and we meet accordingly with laryngeal croup, tracheal croup, ronc 
cr°up, and croupy pneumonia.” He says, also, which I wish to empl a- 
size, “ Neither during nor after the croupy process does the mucous mem- 
brane suffer any material injury to its texture ; the speedy productioi 
of mucus and epithelium prevents any further organization ot the p a t 
ex_udation, .... and it never enters into an organic cemnee 
with the mucous membrane.”1 Dr. Heitzmann, now ot h>cw 01. ’ 
Was assistant to Rokitansky till 1874, informs me that diphtheria bad 
!}°t appeared in Vienna up to the time when he left that city, and that 
Rokitansky still held the same views in regard to the anatomical char- 
ters of croup. , , p 
. Brof. Rindfleisch, of Bonn, says of the pseudo-membrane of croup: 
• . . it spontaneously separates, since it is loosened by a moderate 
Production of pus, first at the edges, and then raised from its base. . . 
Barely is a secondary enlargement of the pseudo-membrane perceived, 
1 Pathological Anatomy, vol. iii., page 56, Sydenham Society s Translation. 350 
J. L. SMITH, 
never a reproduction at the same spot.” “The boundary between the 
mucous and the false membrane is naturally very much obliterated 
by this gradual transition of the cells of both sides, although it never 
becomes quite indiscernible. It, however, is undoubtedly evident, that 
the pseudo-membrane is produced by a secretion of young elements at 
the surface of the irritated mucous membrane, and by their gradual in- 
duration, sclerosis, vitreous tumefaction, or by whatever other name we 
wish to call the degeneration.” “ The pseudo-membrane is of a pecu- 
liarly stratified structure, since upon a layer of cells, at tolerably equal 
distances, there always follows a layer of fibrin, and this sequence is 
repeated from one to ten times, according to the thickness of the mem- 
brane. Whether I am correct, in directly calling those second layers 
fibrin, must of course remain a question. Ido it upon the first impres- 
sion which its configuration makes, and with the reservation that there- 
with I always have in mind only a fluid albuminate, but indurated by 
the transudation into the air.”1 
Mr. Jabez Hogg, President of the Medical Microscopical Society of 
London, in 1873, said, as reported in the Monthly Microscopical Journal 
for that year ; “A portion of a croupous cast, examined under a power 
ot 350 diameters, is seen to consist of pavement and cylindrical, or colum- 
nar epithelium, and a transparent albuminous substance, entangling the 
scattered contents of epithelial cells, molecular matter, fat and mucous 
corpuscles, and a few foreign bodies, involved in a homogeneous matrix. 
When stained by a weak solution of ammoniacal carmine, or aniline dye, 
and carefully spread out with needles, the columnar epithelium retains its 
cilia, each cell being filled with clear protoplasmic and nucleated con- 
tents. It is therefore highly probable that these cells are not long re- 
tained, but are rather thrown off soon after their formation.” 
It will be observed that these authorities, from whom I have quoted 
(and most microscopists and pathologists agree with them), state that 
the pseudo-membrane of croup consists, mainly, of altered epithelial cells, 
held together by an albuminate which exists either in the form of layers, 
or a network. In the interstices, or meshes of this network, we find, in 
addition to the epithelial cells, granular matter, with embryonic and pus 
cells. The mucous membrane underneath is more or less denuded of its 
epithelium, is thickened and softened, and of a bright red color from 
active congestion of its vessels; or the redness is diminished and it 3 
color paler, if the inflammation has to a considerable extent abated. 
Hoes croup produce any other anatomical changes, in addition to those 
which have been described above, and which are located in or along the 
air passages ? Apart from those blood changes which occur in all in- 
flammations, I believe that there are no other uniform lesions, except 
such as result from the passive congestion of organs which is ordinarily 
present in advanced cases, and which is proportionate in degree to the 
amount of laryngeal, or laryngo-tradical obstruction. When the dys- 
pnoea becomes so great that hvidity of the lips and tips of fingers occurs, 
a correspondingly severe and dangerous congestion of the internal organs 
results. Hence oedema of the lungs and albuminuria may supervene in 
the last hours of croup. lam convinced from my own observations, and 
from the nature of this malady, that those who" believe that they have 
observed other lesions of croup, as enlarged and altered spleen, enlarged 
1 Pathological Histology, translated by Kloman and Miles, %% 364, 365, 367. CROUP AND DIPHTHERIA. 
Deyerian and solitary glands, etc.,have observed merely accidental lesions, 
°r have mistaken diphtheritic laryngitis for croup. . . T i 
Let us now consider the lesions of diphtheritic laryngitis, in order 
to determine their precise nature, I have obtained the help ot skilrul 
nncroscopists in New York. Dr. Satterthwaite kindly consented to 
make microscopic examinations of the organs in the first and second 
eases. The specimens were placed in a solution of bichromate ot potas- 
sium immediately after their removal from the bodies. The following 
ease occurred in ray private practice;— 
Case IT. H a°-ed four years, and two brothers S., who lived directly 
°Pposite in the same street in New York, were daily playmates. On January 
21, H became feverish and complained of sore throat, and lour days 
subsequently died of malignant diphtheria. This case was carefully examined 
by me in consultation, and minute records of it preserved. Before it termi- 
nated, the two brothers S. became affected with diphtheritic laryngitis, ihe 
J’ounger brother, aged three years, was for a time in a very critical state from 
the dyspnoea, but recovered in about one week. The older brother, aged six 
years” died, having the following history: On January 29, two days after the 
Commencement of diphtheria in his playmate, H ,he vomited and became 
feverish, and his voice became hoarse. These symptoms continuing, 1 was 
asked to visit him on Feb. 2. His respiration at this time was harsh, and 
audible in the adjoining room, and the cough croupy ; pulse 96 ; temperature in 
axilla 100° ; he takes considerable nutriment, and sits quietly, or walks about 
tbe room; fauces red, and slightly swollen, but without any diphtheritic 
exudation upon their surface; has slight glandular swelling underneath the 
ears; the urine contains no albumen, and the nitric acid test shows no excess 
°f urea. The constant inhalation of the spray of lime-water is recommended, 
>vifh the use of tonics. Feb. 4. Pulse 96, temperature 99 ; breathes with 
fmch difficulty at times, but there is still no pseudo-membrane upon the fauces, 
has expectorated since the last record two thick pieces ot pseudo-membrane, 
each about one inch in length, apparently from the larynx ; specific gravity of 
somewhat in excess of the normal quantity. Feb. 5. 1 ulse 92; tempeiaUue 
lolf°; has a small diphtheritic patch, not more than three lines in diameter, 
°ver the left tonsil. Feb. 6. The pellicle upon the tonsils has disappeared , 
lhe urine for the first time albuminous, thirty-six hours before death ; vs 
specific gravity 1024; temperature 103°; dyspnoea great; pulse about iw . 
Death occurred on Feb, 7. • , 
. lectio Cadaveris, 19 hours after death; body spare, but not emacia , 
r'gor mortis present; has post-mortem extravasation of blood along the bac , 
aud a thin blood-stained fluid escapes from the mouth; two or three draclims 
°,f transparent liquid in the pericardial sac; a large yellowish-white clot hi s 
tlle right ventricle, and is prolonged into the pulmonary artery; the ” 
uuricle also contains a large clot, soft and dark in its centre, but finnei an ot 
* whiter color externally ; left ventricle contains a few soft dark cfots, 
tittle fluid blood; left auricle partly filled with blood of a tarry appeaiai'ce, 
tonsils not enlarged, but soft, and a yellowish diffluent secretion Res in te 
depressions on their surface; subcutaneous glands of the neck slightly , 
olle being somewhat larger than a filbert; under suiface o epi_, o is, ant 
entire surface of larynx, covered by a firmly adherent pseudo-membrane which 
entirely conceals from view the vocal cords and the sinuses of Moigagni; the 
Pseudo-membrane is continued over the surface of the trachea, emg less at ic- 
fent than in the larynx, and, near the bifurcation, it floats freely ;it does not 
extend into the bronchus or bronchial tubes of the left lung, and this lung is 
normal. In the right luno- the pseudo-membrane extends as far as the bron- 
chial tubes of the third order; the upper lobe of the right lung is in the 
second stage of pneumonia, its cut surface being rough and granular, am 352 
J. L. SMITH, 
liquid escaping from it on pressure; the right, middle, and lower lobes are 
congested, and in the lower lobe is a single hepatized nodule ; those portions 
of the bronchial tubes which are not covered by the false membrane exhibit 
the appearance of catarrhal bronchitis. The liver is large, and not fatty; 
spleen small, moderately firm, and contracted (this is noteworthy, as the spleen 
has been found large and soft in diphtheria); kidneys congested and swollen, 
and a stellate appearance of the vessels under their capsules; surface of both 
small and large intestines congested. 
Microscopic Examination.—Red corpuscles of the blood well-preserved, some 
of them round, others crenated, and all granular; large masses of transparent 
material, containing red corpuscles, floated in the blood. The rod and chain 
forms of bacteria were observed in the blood, but not in greater number than 
are often seen in other blood the same number of hours after death. (A few 
grains of chloral had been added to this specimen of blood immediately after its 
removal.) Substance of heart apparently normal, showing no fatty degenera- 
tion, nor infiltration; no bacteria can be recognized in the substance of the 
heart. Kidneys: Right kidney examined ; Malpighian bodies congested, and 
extravasations of blood throughout this organ; tubal epithelium granular; 
increase of connective tissue in points near periphery of kidney, showing inter- 
stitial nephritis, but no increase observed in this tissue in other parts of the 
organ; no bacteria that could be certainly recognized as such in the kidney• 
Spleen: Multitudes of granules in scrapings from the cut surface of this organ, 
many of them so small as to be with difficulty recognized with a magnifying 
power of over 600 diameters; some of them gave the appearance of the usual 
forms of bacteria. 
Larynx: Thickness of false membrane which covered the entire surface of 
this organ varied from to of an inch; thickness of mucous membrane 
about g of an inch; epithelial border of mucous membrane could be traced 
inwards to j-J-q of an inch, where it became indistinct, merging into the 
other tissues which were more or less infiltrated with embryonic cells and 
blood. The false membrane consisted of a network of a homogeneous mate- 
rial, most of the meshes being empty, but those nearest the epithelial layer 
containing more or fewer epithelial cells. The boundary line between the false 
membrane and the mucous surface could not be distinguished by the micro- 
scope in many of the sections, the network of the pseudo-membrane extending 
into the mucous membrane. But in other places the line of separation could 
be distinguished, and here and there the pseudo-membrane and mucous surface 
were separated by collections of embryonic cells. The lymph follicles and 
racemose glands were apparently normal; mucous surface infiltrated with 
granular matter and red blood corpuscles; cylindrical epithelial cells, some ot 
them with cilia, were distinctly visible both along the free border, and in the 
under surface of the pseudo-membrane. Trachea: The false membrane mea- 
sures from about T- (J to of an inch in thickness; the mucous membrane go 
of an inch, and its epithelial layer qof an inch; the epithelial cells are much 
more distinctly visible than in the larynx, and the line of separation of the 
adventitious layer and the mucous surface is everywhere distinctly seen under 
the microscope; the false membrane has the s.ame general appearance as in the 
larynx, but the mucous membrane is in a better preserved state than that of 
the larynx; it is nevertheless infiltrated with granular matter, plastic matter, 
and red blood corpuscles; lymph follicles and racemose glands apparently nor- 
mal ; in the trachea, as in the larynx, a large number of embryonic or lymphoid 
cells—most of them no doubt becoming pus cells—lay between the false mem- 
brane and the mucous surface. 
Case V.—A second case, having the following history, occurred in the 
Catholic Foundling Asylum in New York. George, aged two years and seven 
months, was under treatment for a second attack of measles, the eruption 
appearing on March 23, 1876. On March 24, the pulse was 136 and tempera- 
ture The fauces presented a deep-red appearance, indicating severe CROUP AND DIPHTHERIA. 
pharyngitis, but without any membranous exudation. March 25. Pulse 140; 
temperature 
The Sister who has charge of the ward, noticing unusual offensiveness of the 
hreath, has inspected the fauces and found on them the diphtheritic pellicle, 
tesi°. prom this date the dyspnoea progressively increased, and death 
°ccurred on March 30. 
Seotio Gadaveris.—A considerable part of the interior of the larynx is 
c°ated with the diphtheritic pseudo-membrane, which is firmly attached to the 
mucous surface; it extends without interruption over the larynx, and perhaps 
oyer one-third to one-half of the tracheal surface. It is not attached to this 
surface, but hangs over it like a curtain, suspended from its attachment in the 
larynx. Further down in the air passages there is the usual catarrhal inflam- 
mation of the mucous surface. 
Microscopic Examination.—Larynx: The false membrane is found to consist 
a network, apparently fibrinous ; in places, in the larynx, it is raised from 
tee mucous membrane by an accumulation of embryonic or lymphoid cells 
Underneath ; in other places it is adherent to the mucous membrane, but with 
a line of attachment which can be distinctly made out with the microscope; 
MlUe in othei. piaces still the network extends down into the mucous membrane, 
and no distinct line of separation can be seen. In the upper, or exposed por- 
ften of the false membrane, no embryonic or lymphoid corpuscles are observed, 
Ut they are abundant in the deeper portion, and they infiltrate the whole 
mucous membrane extensively ; upon the mucous surface, wherever the pseudo- 
membrane is detached, these corpuscles are abundant; in parts of the false 
membrane they fill so completely the interstices of the network that epithelial 
CeUs can scarcely be distinguished within them ; in places, in the sections 
pAamined, the epithelium seemed to be wholly replaced by granular matter; 
111 general, the border line between the diphtheritic membrane and the mucous 
mudace is marked by a somewhat denser exudation of the albuminate—a fibri- 
appearing material—than is seen in the false membrane geneially; the 
m°odvessels in the mucous membrane of the larynx are numerous, and dis- 
tended with blood. Trachea: The epithelium, consisting of from two to 
n’e6 layers, is seen to be intact wherever it is observed; the surface of the 
epithelium is covered with minute markings, probably the cilia in contraction; 
te pseudo-membrane is not seen to be reticulated as in the larynx, perhaps fi om 
le contractions which had occurred in it; it appeared granular and fibrous, 
aild contained but few corpuscles. Lungs: A portion of one lung was found 
:*ePatized, and the alveoli of this portion contained pus cells, epithelial cells, 
Jjf°°d, and a fibrinous appearing material (croupous pneumonia). Kidneys: 
le changes observed in these organs were those of tubal nephritis'; the tubes 
yere highly granular, both in the pyramids and cortex; no increase in the 
interstitial connective tissue was noticed ; in places the tubes were not granular. 
le muscular tissue of the heart seemed normal. 
In the following case, in which the larynx was not involved, Dr. Carl 
teitzniann, late of Vienna, made a microscopic examination of the kid- 
in order to determine more exactly the histological changes which 
tTte*e organs undergo in diphtheria, and how these changes contrast with 
lesions which may result from simple passive congestion, such as is 
present in the kidneys in fatal cases of croup. 
Case YI._J a<*ed four years, an inmate of the Catholic Foundling 
sylum, began to have sore-throat on March 4, 1816. The fauces were red 
t, somewhat swollen, but without any membranous exudation, and the diph- 
itic nature of the disease was not at first suspected. M}- attention was 
called to this case on March 11, on account of almost total suppression of 
I'Re. The fauces were still injected, and somewhat swollen from catarrhal 
11 animation; there was a copious muco-purulent discharge from the nostrils ; 
28 354 
J, L. SMITH, 
pulse 148. March 13. Pulse 144; temperature urine still nearly sup- 
pressed, though one drachm of infusion of digitalis is administered every fourth 
hour, and bromide of potassium, four grains, every second or third hour, for 
the restlessness. Dr. Reid, in using the catheter, observed a diphtheritic patch 
op the vulva ; there is moderate tumefaction under the ears ; the patient vomits 
often during the last days ; she has livid spots, from extravasation, under the 
skin ; and vision is much impaired, if not lost; it is impossible to obtain any 
urine for examination. Death occurred without convulsions on March 15. 
Microscopic Examination of the Kidneys. (By Dr. Heitzmann.)—Thetubuh 
contort! of the first and second order of the cortical substance of the kidney 
almost all enlarged ; their epithelium swollen in many places to such a degree 
that no calibre of the tubules can be seen ; the epithelium richly provided with 
coarse granules, the enlarged living matter ; the original cement substance 
missing; instead of this, new transparent lines formed within the protoplasm, 
indicating the earliest stage of catarrhal inflammation, with partition and neW 
formation of epithelial elements ; the same changes, though in a less marked 
degree, observable in the epithelium of the straight ducts of the pyramidal sub- 
stance, while the flat epithelial bodies of the narrow ducts appear almost un- 
changed. The connective tissue between the ducts and the enlarged glomeruli 
is somewhat increased in size, and it contains newly-formed nuclei in moderate 
number, with enlarged bloodvessels, some of which are much distended with 
blood-corpuscles ; no fatty degeneration in kidneys. In a few places, accumu- 
lations of dark granules occur within the ducts and their epithelium. These 
granules, not being united with each other by threads, nor staining with car- 
mine, are considered to be micrococci, such as occur in any decomposing ani- 
mal tissue. Whether they were present during the life of the patient, or were 
due to early cadaveric putrefaction (which is common after death from diph- 
theria), is uncertain. But since 1 have seen micrococci and bacteria in the fresh 
urine of children suffering from diphtheria, I would not deny the possibility m 
the occurrence of micrococci in the uriniferous tubules during life; nay, even, 
they majr produce the inflammatory process in a way still unknown to us. 111 
the case under consideration no trace of casts was found within the tubules, so 
that the inflammatory process doubtless was not a croupous one, but a relatively 
slight process, termed catarrhal or interstitial nephritis. 
The above microscopic examinations in cases of diphtheritic laryn- 
gitis and nephritis, correspond with those made by other observers. The 
following facts in reference to the histological characters of croup and 
diphtheritic laryngitis, we wish especially to call attention to;— „ 
(1) The croupous and diphtheritic pseudo-membranes consist alike of 
altered or degenerated epithelial cells, mingled with embryonic, or grow- 
ing pus cells and matured pus cells, all held together by an albuminate, 
probably fibrin, which exuding in a liquid state from the mucous mem- 
brane underneath, surrounds the cellular masses like mortar around the 
stones in a wall, and hardens on exposure to the air. The consistence 
and toughness, therefore, of the adventitious layer, are largely due tu 
the albuminate. The exact chemical character of the albuminate, am 
the chemical changes which the epithelial cells, of which the pseudo- 
membrane is composed, have undergone, have not been clearly ascer- 
tained, but so far neither the microscope nor chemical tests show an) 
-qualitative differences which hold good as a means of distinguishing! 
the false membrane of croup from that of diphtheria. Supposed dif- 
ferences, observed by some, have not been noticed by others with other 
■specimens. The tests of organic chemistry are not sufficiently delicat 
for the detection of any uniform difference in the nature of the two exu- 
dations, if any difference exist, which seems improbable. 
(2) The laryngitis of croup, as compared with that of diphtheria,lS CROUP AND DIPHTHERIA. 
ftiore superficial. Most inflammations of mucous surfaces, which are due 
to sudden changes of temperature or exposure to currents of air, as sim- 
ple coryza or bronchitis, are more superficial than specific inflammations, 
0r inflammations due to poisonous principles, acting locally, or through 
the blood. Croupous laryngitis is no exception. It produces less infil- 
tration in the mucous membrane and submucous tissues, and consequently 
less thickening, and less exudation of the albuminate from the deeper 
vessels, than occurs in diphtheritic laryngitis. 
(8) Croup is a transient inflammation. It commonly begins to abate 
Vrhen the exudation which relieves the congested vessels has occurred, 
■thence the statement of Rindfleisch, that the pseudo-membrane when 
detached by suppuration underneath, is never reproduced. The cause of 
Cl’°up acts only for a brief period, and therefore the effect soon begins to 
?hate, if there is no fresh exposure. This transitory nature of croupous 
inflammation contrasts with the greater persistence and depth of the 
laryngitis of diphtheria. It is probably not absolutely true that the 
pseudo-membrane of croup is never reproduced. Nevertheless, the dis- 
tinction holds good, that there is much less tendency to its reproduction, 
ai}d less tenacity of the inflammation in croup than in diphtheritic laryn- 
gitis. There seems to be a marked similarity, not only in the nature and 
Illations of the false membrane, but in the progress of the inflammation, 
in croupous phlegmasia, as it occurs in the different divisions of the res- 
piratory tract, that occurring in the minute bronchial tubes and in the 
alveoli of the lungs, in the common disease croupous pneumonia, being 
understood on account of its frequency. As in this disease the exu- 
dative stage soon ceases, and resolution commences with the decline of 
the inflammation, so in laryngeal or laryngo-tracheal croup the greatest 
danger is from the first exudation, and if the first pseudo-membrane can 
,e removed treatment there is a fair prospect of a favorable termina- 
tion. In this fact lies one of the chief points of contrast in the anatomy 
croup and diphtheritic laryngitis, for from the persistence of the diph- 
theritic inflammation, and longer continuance of the exudative stage, the 
diphtheritic pseudo-membrane, if expelled, will probably reform, as in one 
°t the cases related above, and reform more than once. 
(4) The pseudo-membrane of croup is more or less closely adherent to 
ne_ mucous surface underneath, but most microscopists who have ex- 
amined specimens removed from the bodies of those who have died of 
dii doubted croup, agree that it does not penetrate it. The superficial 
character of the inflammation, and the fact that the exudation occurs 
iom the superficial vessels, afford explanation of this fact. In diphthe- 
iitic tracheitis, we have found, in the specimens examined above, that 
m pseudo-membrane also lay upon the mucous surface without pene- 
•ating it; and in one of the cases, in which pneumonia had occurred, 
-p fibrinous exudation also lay free within the alveoli of the lungs. 
in the larynx, the albuminate, which formed the network of the 
pseudo-membrane, penetrated the mucous membrane in places so that the 
ine of demarcation was extinguished; while in other places a distinct 
me of separation of the exudation and raucous membrane was observed 
inder the microscope, though the two surfaces were in close contact; 
in other places still, the exudation was elevated above the mu- 
cous membrane by the secretion of embryonic or pus cells underneath 
fis intimate relation of the false membrane to the mucous surface w' 
dpg since pointed out by Yirchow, and has been confirmed by 
since. But it is to be remembered that exceptional "es 356 
J. L. SMITH, 
have been reported, in which the pseudo-membrane lay entirely upon the 
mucous surface without penetrating it. This admits of explanation 
without impairing the accuracy and truthfulness of the general state- 
ment in reference to the intimate relation of the diphtheritic pellicle 
with the surface of the larynx. For the adventitious layer is detached 
by cell formation or suppuration underneath, so that in most specimens, 
as in those described above, there are places in which the detachment 
has already occurred. If then the stage has arrived in which there is 
more abundant and general suppuration, the detachment of the false 
membrane will be in a corresponding degree more extensive. To this 
intimate relation of the exudation with the mucous membrane in diph- 
theria, is due the fact that points and patches of ulceration are so com- 
monly observed in this membrane when the diphtheritic layer is de- 
tached. Perhaps cases occur, which from their commencement are ex- 
ceptions to the above statement in regard to the relation of the pseudo- 
membranes to the laryngeal surface in croup and diphtheria. Perhaps 
there are cases of mild diphtheritic laryngitis in which the exudation lies 
entirely upon the surface, as it lay on the tracheal surface in the cases 
narrated above, but there can, I think, be little doubt that in a series 
of cases of the laryngitis of croup and diphtheria, the anatomical differ- 
ence, as stated above, would commonly be observed in the two diseases. 
(5) While the lesions of croup, apart from those of the respiratory 
apparatus and pharynx, result from the passive congestion which corre- 
sponds in degree with the amount of dyspnoea, there are or may be in 
diphtheritic laryngitis additional lesions which result from the blood 
poisoning, as hemorrhages upon the free surface or in the tissues of 
organs, sometimes fatty degeneration of the cardiac muscular fibres, and 
frequently desquamative or interstitial nephritis. The last case related 
above shows that the renal affection may be an interstitial nephritis, 
with almost total suppression of urine, occurring without desquamative 
nephritis, and therefore without the formation of casts, while in other 
cases the inflammation is largely desquamative, as shown by the presence 
of a large number of casts. This frequent occurrence of severe nephritis, 
interstitial and desquamative, contrasts strongly with the milder form of 
renal affection which occurs in croup. In croup there is passive conges- 
tion, with perhaps albuminuria, if the dyspnoea be severe, but I can find 
no evidence that there is any liability to those dangerous forms of nephri- 
tis with suppression or scantiness of urine, which are so common in diph- 
theritic laryngitis as well as in diphtheria when manifested by other forms 
of external inflammation. The following case may, I think, be app1’0' 
priately related in this connection, as showing the blood changes and 
renal disease to which I have alluded, as common in diphtheritic larym 
gitis, but as absent or very exceptional in croup. It is true that the case 
was one of diphtheritic catarrhal laryngitis, but there is obviously 11 
essential difference between dipththeritic membranous and catarrhal 
inflammations, and, wherever the former occurs, we commonly find at the 
same time a border or zone of the latter coexisting with it. This case 
is also interesting to the practitioner, as showing the inefficiency of the 
antiseptic treatment to prevent the blood changes of diphtheria:— 
Case YII.—M., aged four years, inmate of the Catholic Foundling Asylum, 
New York, began to be sick May 6,1816 ; was languid and feverish, temperature 
104°, had redness of fauces and an exudation over each tonsil, no coryza, 
vening, temperature 103°. May 7. Pulse 120; temperature 100°. May • 
Ise and temperature as yesterday; urine scanty; no albuminuria, and no dis CROUP AND DIPHTHERIA. 
357 
charge from nostrils ; the membrane extends from the sides of the throat to 
the roof the month; sp. gr, of urine 1021, urine contains no albumen, no 
excess of urea, and no deposit of urates. May 10. Pulse 140; has considera- 
ble rndema of fauces, and breathing guttural in sleep ; vomited once since yes- 
terday • the urine contains for the first time a moderate amount of albumen, 
with hyaline casts ; sp. gr. 1018, acid ; no urea deposited on adding nitric acid; 
that alarming symptom in diphtheria, epistaxis, has occurred to-day. Hie 
records which were written daily till death, which occurred on the 14th, show 
a gradual increase of albumen with hyaline casts in the urine, increasing scan- 
tiness of urine, so that on the 13th not more than half an ounce was passed in 
twelve hours; temperature not rising above 100|°, nor pulse above 108; poor ap- 
petite, occasional vomiting, and epistaxis. Death occurred from feebleness and 
blood-poisoning, notwithstanding that, from the first day, three grains of sali- 
cylic acid were given the first hour, two grains of quinine the second hour, and 
tincture of iron'and chlorate of potassa the third hour, these doses having been 
continued night and day in alternation; with the application of carbolic acid 
and subsulphate of iron to the fauces, three times daily ; with nutritious diet, 
and the moderate use of stimulants. There were no symptoms referable to 
i'be larynx, unless a slight cough. 
Sectio Gadaveris.—Mucous membrane of larynx, trachea, and bronchial tubes 
intensely and uniformly injected, but without any membranous exudation; 
bang's fully inflated, as if from commencing vesicular emphysema, and pale in 
bont; numerous extravasations of blood in the substance of the lungs and 
°ther organs ; the hemorrhages in and under the mucous membrane of stomach 
80 abundant that the gastric surface presented a mottled appearance like the 
skin in measles. 
Microscopic Examination. (By Dr. Satterthwaite.)—The mucous mem- 
brane of the larynx and trachea was hypersemic, but was otherwise apparently 
formal; muscular tissue of heart normal; spleen soft, but not appreciably en- 
ai’ged. The scrapings of the cut surface ol this organ contained led blood- 
c°rpuscles; bodies from two to five times the size of the blood-corpuscles, 
bolding in their interior oil drops and fine granules, and having a yellowish- 
le°l color; granular lymphoid corpuscles, and granular debris. The walls ot 
i-be stomach were congested, but without any noticeable exudation upon the 
surface ; the extravasations of blood, described above, were found to be chiefly 
H the submucous tissue. In some places the gastric tubes were bare, but in 
other places covered with amorphous matter; but whether the covering sub- 
stance was altered epithelium or diphtheritic exudation was not determined. 
be epithelium covering the more exposed portions of the tubes was in man) 
Places not distinct, while that covering the deeper portions of the tubes was 
clearly defined; at the pylorus, upon the valve, the mucous membrane was de- 
ficient ; those portions of the true peptic glands lying below the tubes were 
normal. The mucous membrane in the lower part of the ileum was congested, 
b eyer’s patches, and the solitary glands, both in the ileum and large intestines, 
vere prominent, and surrounded by halos or rings of inflammation. Both the 
cortical and pyramidal tubes of the kidneys contained granular epithelium. 
. In croup the blood certainly undergoes anatomical changes as in other 
inflammations, and becomes overcharged with carbonic acid when the 
inspiration is embarrassed ; hut I am not able to find records of any 
case of undoubted croup, or of croup occurring in a locality where diph- 
theria does not prevail, in which such profound destructive changes 
occurred in the blood, as were present in the above case of diphtheritic 
catarrhal laryngitis, and as are common in diphtheria whether accom- 
panied by laryngeal or other form of inflammation. X must, therefore, 
conclude that croup and diphtheritic membranous laryngitis possess such 
focal and general anatomical differences as justify our regarding them as 
essentially distinct. 358 
J. L. SMITH, 
111. Clinical Facts which indicate the Duality of these two Diseases— The 
season of the year and the weather influence the occurrence of croup. 
Exposure to currents of air and sudden changes of temperature are its 
common causes. In tropical climates, croup is .less frequent than in the 
moist and cold climates of higher latitudes. In localities swept by cold 
winds, or liable to sudden variations in the atmospheric heat, croup, 
as well as pseudo-croup and bronchitis, are common, for these diseases 
have a common cause. The following example, which I recall to mind, 
may be cited as showing how croup is commonly produced. A little 
girl, at a time, and in a locality in which no diphtheria was occurring, 
had an ordinary attack of measles. As she was beginning to convalesce, 
though still having some cough, she sat for some time in an open window 
through which the wind was blowing. On the following night mem- 
branous croup commenced, ending fatally in about two days. 
The cause of diphtheritic laryngitis is different. It is" a contagious 
principle which poisons the blood, and produces certain inflammations 
quite independently of atmospheric conditions. Exposure to winds and 
sudden thermal changes play a very subordinate part in causing diph- 
theritic laryngitis. They may sometimes act as predisposing causes, by 
irritating or inflaming the mucous membrane, for clinical experience and 
experiments on animals show that in a system affected by diphtheria, 
the specific inflammation is most apt to appear on such surfaces as are 
irritated or inflamed. Only in this respect can diphtheritic laryngitis 
be said to have the same cause as croup. In cases which I have observed, 
I have rarely had occasion to suspect that the patient had taken cold. 
I have frequently seen the laryngitis occur when there had been every 
precaution to prevent taking cold, and the proportion of cases of diph- 
theritic laryngitis has been, I think, nearly as large in warm and equable 
portions of the year, as in seasons of cold and changeable weather. 
Again, croup very seldom occurs under the age of eighteen months, 
nor over the age of fifteen or sixteen years. Physicians in Hew York, 
whose practice extended over a number of years before diphtheria com- 
menced, tell me that they never saw croup after the fifteenth or sixteenth 
year. How diphtheria and diphtheritic laryngitis are not rare between 
the ages of six months and two years. I have seen minute white points 
over the tonsils, in an infant of six weeks, whose brother was dying of 
diphtheritic laryngitis, and there are a few cases on record of new-born 
infants affected with diphtheria,1 though it is the universal experience 
that very young infants are less liable to diphtheria than those who are 
older. 
Every physician, again, who has witnessed a severe epidemic of diph- 
theria, or who has practised where diphtheria is endemic, knows how 
frequently it occurs in youth, and in the first years of manhood. The 
statistics of Hew York epidemics furnish a considerable number of cases 
which were fatal from diphtheritic laryingitis between the ages of twenty 
and forty years. There is, therefore, a marked difference as regards the 
limits of the age in which diphtheritic laryngitis and croup occur. 
_ But the strongest argument in favor of the duality of croup and 
diphtheritic laryngitis, and one which, to my mind, is conclusive, is 
derived from the fact that the one is non-contagious and the other highly 
contagious. Physicians of Hew York, who saw cases of croup prior to 
1 See Best. Med. and Surg. Joarn., March 11, 1875 ; also Contributions to the Patho- 
logy and Therapeutics of Diphtheria, by A. Jacobi, M.D., New York, page 26. CROUP AND DIPHTHERIA. 
359 
the time when diphtheria occurred, and country physicians, in localities 
where diphtheria has not yet prevailed, have informed me, without an 
exception, that they never saw any evidences ot the contagiousness ot 
croup. Would not intelligent physicians, whose united practice in locali- 
ses not yet visited by diphtheria gives more than a century of observa- 
tion, he able to record a single instance of the contagiousness of croup, 
it H possessed in any degree a contagious principle ? Contrast this fact 
with the fearful contagiousness of diphtheritic laryngitis. Now I hold 
that if two maladies are identical in every other respect, but one is con- 
tagious and the other non-contagious, it will be necessary to give them 
different places in nosology. Contagiousness, although it be a new pro- 
perty assumed by an old and well-known malady, so transforms its nature 
that it becomes to all intents and purposes new and distinct. 
The following is also an interesting fact, as showing an important dif- 
ference between croup and diphtheritic laryngitis. In New York City, 
Satisfies of the mortality have been preserved since 1804, and in the long 
period from 1804 to 1850, inclusive, no case of diphtheria, or none recog- 
nized as such, occurred within the city limits. Now, during this time, 
Cl,oup was not infrequent, the yearly number ot deaths from it never 
falling below 60, which was the number in 1817; nor exceeding 356, 
Which was the number in 1850 ; the average yearly number being 148.2, 
and the total number for the forty-seven years being 6904. Physicians 
°f New York, whose practice extended over the latter part of this period, 
Btate that they occasionally, at rare intervals, saw cases during this time 
which resembled diphtheritic pharyngitis, but which went by the name 
N malignant angina, or malignant sore throat. One ot the prominent 
BUrgeons of New York lost a child from this sore throat about the year 
1833. 
Nokitansky tells us that all the mucous surfaces are liable to croup- 
es inflammation ; and were these pseudo-membranous pharyngeal, or 
Pseudo-membranous laryngeal, inflammations ot the first halt of the pie- 
sent century, croupous; or were they the inflammations ot diphtheiia, 
Which still lingered in the city in a modified form since the great epide- 
mic of the eighteenth century, which Golden and Bard described? Cer- 
lain tacts may be stated which indicate the croupous, and not diphtheritic, 
nature of these inflammations; first, the absence ot all history ol conta- 
giousness; and, secondly, the fact that the laryngitis was so much more 
Sequent and fatal than the pharyngitis. The statistics of diphtheria, 
the world over, show, as every one knows, an excess of cases ot diphthe- 
nitie pharyngitis over the eases of diphtheritic laryngitis; while the 
number of fatal cases of diphtheritic pharyngitis and diphtheritic hiryn- 
gdis is either about equal, or as two to one. From the year 1804 to 1800, 
there were in New York 6964 deaths from membranous croup while the 
deaths from all other forms of inflammation ot the throat, including the 
membranous, for they were all grouped together, numbered only 1387, 
°r about one-fifth of the number of deaths from croup. Now does not 
the wide difference between the frequency and mortality of these inflam- 
mations during the half century, when there was no diphtheria to modify 
diseases, and of diphtheritic pharyngitis and laryngitis of the present 
mie, indicate a difference in the nature of the inflammations in the two 
Periods ? 
Let us state the argument in different terms. If the croup of New 
Toyk, in the first half of the present century, were a modified diphthe- 
laryngitis,-can any one tell us why membranous pharyngitis, during 360 
J. L. SMITH, 
the same period, was comparatively rare, and fatal membranous pharyn- 
gitis so very rare that the majority of physicians did not meet with a 
case in years of practice ; when in true diphtheria, the world over, mem- 
branous pharyngitis is the most frequent diphtheritic inflammation in 
fatal cases, as well as in those which have a favorable issue ? 
Writers have also very properly called attention to the fact, as showing 
an essential difference between croup and diphtheritic laryngitis, that 
the former is seldom followed by paralysis, whereas paralysis is common 
in those who_ recover from diphtheria, whatever the form of inflamma- 
tion from which they have suffered. 
The results of treatment also indicate a difference in the nature of 
croup and diphtheritic laryngitis. In croup, emetics, even those of a 
depressing nature, are tolerated. There is rarely any serious depression, 
except in advanced cases of croup, from the occasional use, in emetic 
doses, of ipecacuanha or tartrate of antimony and potassium, so as to 
expel muco-pus from the bronchial tubes, or any portion of the pseudo- 
membrane which may be detached. In diphtheritic laryngitis, the 
employment of these agents, under any circumstances, is hazardous, and 
the profession generally, observing their ill effects, have abandoned the 
use of all emetics in diphtheria, even those which are least depressing. 
I recollect that, in Hew Tork City, soon after diphtheria began to be 
prevalent, physicians were sometimes astonished at the rapid sinking of 
patients with diphtheritic laryngitis, whom they had treated as they had 
previously treated cases of croup. Thus a girl, aged about ten years, 
with moderate dyspnoea, but whose case did not seem to be immediately 
dangerous, took an emetic of “ hive syrup,” by the physician’s advice, 
and sank so rapidly that she died in an hour or two later. More recently 
I saw a child of three years, whose dyspnoea did not seem to be extreme, 
suddenly sink into fatal prostration, under doses of tartrate of antimony 
and potassium which the physician in attendance had ordered. 
While in croup death results from the obstructed respiration, and con- 
sequent imperfect oxygenation of the blood, there is the same source of 
danger in diphtheritic laryngitis, but also the additional danger which 
results from blood poisoning and structural changes in important organs, 
as the heart and kidneys. Hence, fatal as is croup, diphtheritic laryn- 
gitis involves greater danger, and is less amenable to treatment. More- 
over, as we have seen above, in ordinary cases, there are probably greater 
infiltration of the mucous membrane and longer continuance of the exu- 
dative process in diphtheritic laryngitis than in croup, and consequently 
greater liability to reproduction of the pseudo-membrane. It will be 
recollected that in one of the cases related above, the patient expectorated 
two pieces of pseudo-membrane, of considerable size, three days before 
death, but that the denuded places had been so completely refilled that 
the surface from which He detachment had occurred was not apparent at 
the autopsy. If the views now expressed in reference to the relative 
duration of the exudative period in croup and diphtheritic laryngitis be 
correct, and I see no reason to doubt them, it is evident that the expulsion 
of any considerable portion of pseudo-membrane affords much stronger 
hope of a favorable termination in a case of croup, than in one of diph- 
theritic laryngitis. 
Statistics of tracheotomy for membranous laryngitis which was sup- 
posed to be chiefly croup, derived from the surgical practice in Hew 
York City some years since, before diphtheria became fully established CROUP AND DIPHTHERIA. 
as an endemic, gave a mortality of about 77 per cent.,1 whereas the result 
°f this operation at the present time, in cases which are believed to be 
chiefly diphtheritic, is much less favorable. A prominent surgeon of 
New York informs me that in about twenty consecutive cases of trache- 
otomy for diphtheritic laryngitis, he has saved only one; and anothei sur- 
geon has saved only one in thirteen cases; while another still, who has 
Probably performed tracheotomy oftener than any other practitioner in 
New York, has saved only two in about forty operations during the last 
four years, and has reason to doubt the genuineness of the disease in one 
°f the two which recovered. My data arq insufficient for positive state- 
ment, but I incline to the belief, from cases which have_ been reported 
to rne and from conversations with the surgeons, that it is necessary, in 
cases which do well, to retain the canula longer on an average after the 
operation for diphtheritic than after that for croup. We 
expect this, if there is greater infiltration, and a more protiacted 
exudative stage, in the former than in the latter disease; and although 
I have known the canula to be safely removed, in one case of diphtheritic 
laryngitis, at the close of the third day, I think it is oftener necessary 
to retain it the greater part of a month, or even longer. Yffishing to be 
Understood as not committing myself to this last statement in regard to 
the leno-th of time during which it is necessary to maintain the artificial 
°penin| in tracheotomy3 for croup and diphtheritic laryngitis, for my 
records3 are too few for a positive assertion, nevertheless the results of 
medical and surgical treatment indicate, in my opinion, a wide differ- 
cuce in, the two forms of inflammation. . . 
Those who believe in the essential oneness of croup and diphtheritic 
laryngitis, believe, as far as I can learn, that the croup of foimei times 
has been greatly modified to become the diphtheritic laiyngitis of the 
present day. But how far can a malady undergo modifications and yet 
Preserve its identity ? Invest a local disease with a specific principle, 
?r call into activity a specific principle which has hitherto lain dormant 
m it, rendering it a constitutional and contagious disease, and its nature 
18 so transformed that it becomes to all intents and purposes a new mal- 
ady. Jt is not dressing up an old disease in a new garb, but it is chang- 
lug its very essence or nature into something new and distinct. 
.In this connection an interesting fact is suggested. Those who prac- 
tise in localities where diphtheria is endemic, often observe other forms of 
mflammation becoming diphtheritic. The pharyngitis of scarlet fevei, 
the primary disease has continued a few days, is often complicated 
Wor transformed into, a diphtheritic inflammation; and I have seen 
diphtheria thus commencing spread as an independent malady. A simi- 
ar change in the character of the inflammation is also common in 
Uieasles, especially during severe epidemics of diphtheria. And not in- 
frequently an inflammation of the air-passages, apparently at first catar- 
Vlal) and probably so diagnosticated by the physician, presents in a few 
days the grave characters of the specific inflammation of diphtfieiia. it 
therefore, in my opinion an open question, whether the exudative 
inflammation of croup mavnot afford a favorable nidus foi t ie leception 
and development of the diphtheritic virus, so that a case commencing as 
cr°up may become one of diphtheria. Perhaps this may explain the 
apparent fact that croup is less frequent in localities wheie diphtheria is 
established, than in former times. 
1 See the author’s Treatise on the Diseases of Children. 362 
J. L. SMITH, 
Discussion ON Dr. J. Lewis Smith’s Paper. 
After the reading of the preceding paper, Dr. William Pepper, of Philadel- 
phia, said It seems to me that the recognition of a radical difference between 
diseases which possess strong points of resemblance and analogy, is a very 
delicate matter, and that the arguments in favor of such separation should be 
very clear and unanswerable. In the present case we have to deal with forms 
of disease characterized by the production of a peculiar pseudo-membrane 
upon the surface affected. Although there are many grades of severity, and 
therefore many differences in degree, between the lesions in different cases of 
croup and diphtheria, I am confident that no essential difference exists either 
in the microscopical or chemical characters of the pseudo-membrane in the two 
forms of disease, nor in its relation to the subjacent surface. This form of 
exudation is so peculiar and distinctive that a strong presumption would seem 
to exist in favor of the relationship of two affections in both of which it is 
developed. In considering the arguments against this relationship, which have 
been so fully and ably presented by Dr. Smith, I am unable to feel that they 
are convincing. We must not think of diphtheria only in its grave epidemic 
form, but also in the mild, sporadic form which so frequently occurs. 1 meet 
very frequently with isolated cases of undoubted pharyngeal diphtheria (for I 
would carefully exclude all cases of herpetic follicular angina with pseudo- 
membranous formation of a different kind), in which the constitutional symp- 
toms are not vexy asthenic, albuminuria is usually absent, glandular swelling is 
not very gx’eat, there is no evidence of profound constitutional infection, and 
paralysis rarely follows. In such cases there is by no means the vexy marked 
difference from the general symptoms of membranous croup that has been 
assumed to exist. 
It has frequently beexx my experience also, as I have stated elsewhei’e in 
connection with Dr. J. Forsyth Meigs, to find that cases which had been regarded 
as idiopathic croup, had really beexr preceded by slight faucial diphtheritic 
deposits, and were consequently undoubtedly diphtheritic in nature. It is 
true that the pseudo-membrane may first occur in the larynx in some cases, but 
I should be glad to see more careful and numerous records of such cases, where 
no pellicular formation in nares or fauces was present at any period. In dif- 
ferent epidemics, and at different times, the proportion of cases of diphtheria 
in which the deposit occurs in the larynx is very variable. At times very few 
cases of croup occur; at others, the number is lai’ge; in a few epidemics, the 
larynx has been, as a rule, the fii’st and only part affected. In these instances 
the attendant constitutional symptoms, and the rate of mortality, have been 
such as are found in grave epidemics of naso-pharyngeal diphtheria. Last 
winter I attended a case of membranous croup with highly sthenic general 
symptoms, in the eldest of three children. No faucial deposit was detected, but 
there had been nasal catarrh for a few days before the laryngeal symptoms 
appeared. The child died from suffocatioxx, the operation of tracheotomy 
having been refused. In every respect this case x’esembled so-called idiopathic 
membranous croup; yet, before the child’s death, the youngest sister sickened 
with a dangerous naso-pharyngeal diphtheria, from which she recovered with- 
out laryngeal implication. I might quote other cases of similar character. 
Nor do I think the x’esxxlts of treatment afford a reliable basis of separation. 
We cannot regard diphtheria, any more than pneumonia, as though it had a 
constant and uniform type. There are cases of the one, just as of the other, 
which will bear and justify a treatment which would prove injurious in other 
instances, and I believe that the general treatment suitable for cases of sporadic 
pharyngeal diphtheria is also well adapted, with the addition of special means 
required by the mechanical obstruction of the larynx, to the treatment of 
sporadic membranous croup. 
I shall add but a word on the argument of contagion. There is still need CROUP AND DIPHTHERIA. 
°f careful clinical work here, and the subject is now full of difficulty and 
pbscurity. When epidemic diphtheria assumes the laryngeal form, the disease 
is clearly infectious or contagious, as is the pharyngeal form. When, on the 
°Hier hand, pharyngeal diphtheria occurs in its mild sporadic form, any evi- 
dence of infectiousness or contagiousness is often wanting. I have known a 
another, affected with an undoubted attack of this form of the disease, to nurse 
her child of thirteen months throughout the entire course of the disease with- 
°nt communicating it to the infant. I would refer, on the other hand, to the 
case of apparent sporadic membranous croup, above quoted, which was the 
pause, seemingly, of severe diphtheria in a younger sister. Is there anything 
m the anatomical conditions of the larynx and pharynx respectively—-the much 
richer lymphatic supplv of the latter, and the greater tendency to putiefactive 
changes in all exudations in that part—which may influence the liability to 
institutional poisoning, and also to infectiousness, differently in the two 
cases ? 
I have no desire to assume a partisan position on this subject. I would be 
Understood only as saying that the evident strong analogies between the two 
forms of disease, and the want of conclusiveness, as it seems to me, of the 
in favor of their essential dissimilarity, make me feel it hazardous 
*n the extreme to assert that they are radically distinct affections; and that I 
nnd myself more and more inclining to the view that they are only different 
ol'ms or types of one pathological condition. 
Hr. Henry Gibbons, of California, said:—When you, Mr, Chairman, and my- 
self attended lectures in this University, no such word as diphtheria was known 
ln the English language. Since then we have, by slow degrees, long study, and 
diligent practice, become convinced that there are two distinct forms of disease 
7~°ne which we know as croup, and the other as diphtheria. Years ago we 
bled for an attack of croup, and nearly always cured it. _ _ 
Hr. J. J, Woodward, U. S. A., said :—I would like to ask Dr. Smith if, in pre- 
paring his paper, he consulted the first or second edition of Rokitansky’s woik . 
thought from the reference to this eminent pathologist’s views that his later 
edition, in which he speaks of diphtheria, had not been consulted. _ 
Hr. C. J.Hare, of London, said This question of the identity or non-identity 
°f croup and diphtheria is receiving a great deal of attention on the other side 
2; Hie Atlantic as well as on this. At this time there is a sub-committee of the 
H°yal Medico-Chirurgical Society of London investigating the subject. I ad- 
niit that we should search after truth, but I think that medical men spend a 
gl’eat deal of time in re-determining questions that have already been deter- 
ttflned. j think that after hearing the paper just read, there can be no doubt 
2bout there being two diverse and distinct diseases. The microscope has faded 
!n other cases asT well as in this. There appear to be distinctions which it is 
UllPossible to overlook. The symptoms of the two diseases have been so fully 
®ntered upon by the author of the paper that it would be out of place for me even 
recapitulate those which are, as I conceive, distinctive between them ; but 
here are two circumstances or conditions which, taken alone, prove to my mind 
the diversity of the two affections. I allude to the contagiousness of diphtheria, 
fnfl to the paralytic affections which frequently result from it. ihose who 
knew croup some thirty or forty years ago, and before the prevalence of diph- 
tlleria, will remember that the d’isease they then knew was never contagious, and 
Was never followed by paralytic affections. Nor do the old authors, who de- 
scrii)ed so graphically the symptoms of croup, ever mention these points. 
, any one venture to say that if the contagiousness and the affections I 
alluded to had been part and parcel of croup they could possibly have 
Jeen overlooked, or could have failed to be described? No; they were not 
referred to, for the simple reason that they did not exist; and they did not 
ex'st then, because the disease at that time known was tine croup and had no 
sUeli symptoms; whereas, in recent years, we have also had to deal with an- 
°ther and different disease—diphtheria, of which contagiousness and the 364 
J. L. SMITH, 
sequelae I have named are characteristic conditions. Our treatment lias been 
modified, not because one disease has run into the other, but because we have 
two distinct diseases to deal with. The result as regards treatment, leaves no 
doubt whatever in my mind as to the non-identity of these two affections. 
Dr. R. P. Howard, of Canada, said:—l cannot believe with the last speaker 
that this matter is so definitely settled in the minds of the scientific world. 
The fact that the Medico-Chirurgical Society of London has just appointed a 
committee to inquire into the matter proves this to be so, and the circumstance 
that the French school still regards membranous croup as laryngeal diphtheria, 
proves that the scientific mind is not agreed upon the question. I think that 
there is a good deal of truth expressed in the paper read on the subject, and 
that we Will have to work honestly and fairly for a long time to come, before 
we can controvert some of its statements. If a large number of cases of so- 
called membranous croup were investigated after death, we might have the 
data by which to arrive at some truth on the subject. 
Dr. W. Oldright, of Canada, said :—ln 1865, while I was practising on the 
shores of Lake Huron, there was an epidemic of sore throat of a peculiar charac- 
ter. During that time I think I met with one case of true diphtheria. On a 
Thursday night, a young man became intoxicated, and lay out all night; he 
was attacked by the disease, and on Sunday morning gangrene set in, and by 
evening the line of demarcation appeared. Shortly afterwards he died of 
strangulation. The young man’s brother was also attacked, and became para- 
lyzed and remained so for about four months. Another remarkable case was 
that of a boy about eleven years of age, who on being attacked became per- 
fectly black in the face and throat. His face and ears were swollen terribly, 
but his intellect remained perfectl}>- clear. He died in two or three hours. 
Dr. R. Bartholow, of Cincinnati, said:—As a clinician I have held that the 
differential diagnosis of croup and diphtheria rested on three conditions—the 
local affection, the constitutional state, and the sequel*. In croup, the exuda- 
tion or false membrane lies in contact, merely, with the mucous membrane; 
in diphtheria, the exudation extends into and involves the epithelial layer 
of the mucous membrane, and the neighboring vessels, especially the lympha- 
tics, are crowded with bacteria. Swelling of the sublingual and submaxillary 
glands accompanies various faucial inflammations, but in diphtheria the chain 
of lymphatics lying under the sterno-cleido-mastoid muscle is involved, while 
it is not in croup. As respects the constitutional state, the adynamia is much 
more strongly marked in diphtheria than in croup, and bears no proportion, 
necessarily, to the extent of the exudation in the fauces. No sequel* follow 
croup. When the local process in the air passages ceases, the disease is at an 
end. On the other hand, in diphtheria, various sequel* follow—albuminuria, 
paralysis, etc. Donders, in his Anomalies of Refraction and Accommodation 
of the Eye, makes the capital observation that the ocular and other paralyses 
which follow diphtheria are not determined by the amount of the faucial exuda- 
tion, and often follow in cases which were supposed to be ordinary cases of sore 
throat, and in which no exudation had been observed. The contagiousness of 
diphtheria appears to be well established. If this be admitted it constitutes a 
fourth means of diagnosis. 
Dr. T. L. Maddin, of Tennessee, said :—ln a recent number of the British and 
Foreign Medico-Chirurgical Review, the unity or duality of croup and diph- 
theria are fully considered: and from this it appears that recent authors of 
merit, treating upon the subject, leave the question in doubt. Thus it is evi- 
dent that in the minds of many there are intimate links of connection between 
the two affections, if indeed, they are not grades of the same disease. With 
a large clinical experience, my convictions are clear that pathologically they 
have no kinship. Croup is a local disease, and its fever symptomatic; its 
etiology is various, even a common cold often causing it; its nature a local 
inflammation, with a false membrane strictly on the surface, and never under- 
going necrosis. Diphtheria has a specific etiology, and is an essential fever. CROUP AND DIPHTHERIA. 
365 
Ds false membrane, occurring mostly in the pharynx and tonsils, often invades 
the nasal, laryngeal, and bronchial mucous membrane. It penetrates the mu- 
cous and often the submucous structure, and undergoes septic decomposition. 
D may form on any portion of the body where there is a lesion, ihe lever is 
and the convalescence slow. Albuminuria is present as in scarlet 
fever. The treatment of the two is totally different. I am, therefore, clearly 
of the opinion that croup and diphtheria are distinct diseases widely separated 
from each other. , , , 
Dr. H. P. Ayres, of Indiana, said:—l have seen croup prevail largely, and yet 
110 diphtheritic symptoms accompany it; but I have never yet seen diphtheria 
Prevail without croupy symptoms attending it. Ido not think tne disease is 
e°utagious, although it may be classed as such. I have seen cases m which 
°ne of a family was attacked and died, while the others escaped. Had the 
disease been contagious more than one would have been affected. 
Dr. C. C. Hamilton, of Nova Scotia, said I have had experience with both 
diphtheria and croup, and think there cannot be any very great similarity be- 
tween the two. I have had one or two cases which would tend to prove that 
Croup is contagious, but as a general thing it is not. I haw observed that 
since diphtheria has prevailed croup has been a much rarer affection than 01- 
merly. 366 
DO THE CONDITIONS OF MODERN LIFE FAVOR SPECIALLY 
THE DEVELOPMENT OP NERVOUS DISEASES ? 
BY 
ROBERTS BARTHOLOW, M.A., M.D., 
PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE IN THE MEDICAL COLLEGE OF OHIO. 
The weai and tear of our modern civilization,” is a current phrase 
which indicates the general belief, lay and professional, that the struggle 
toi existence in our time imposes an excessive and consequently injurious 
labor on the brain and nervous system of man. That the injury thus 
done manifests itself in an increased production of nervous diseases, 
seems to be generally conceded. Without having bestowed much reflec- 
tion on the subject, I had accepted this popular view; but when I came 
to investigate the tacts which are available for the solution of the prob- 
em, in piepaiation for this paper, I felt obliged to change my opinions. 
To the question “Bo the conditions ot modern life favor specially the 
development ot nervous diseases ?” I reply in the negative. 
At the outset, it must be admitted that the evidence is largely pre- 
sumptive. Ro statistical data have descended from ancient times, and, 
indeed, as lespects so recent a period as the last and the present century, 
an exact numerical expression of the relative prevalence of nervous dis- 
eases, is not possible. In the absence of statistical evidence, the inquiry 
must be directed into other channels. An approximation to the decree 
of current familiarity with mental and nervous maladies, may be made 
y a study ot the references to such diseases in the ancient secular 
writers. The actual state of knowledge of mental and nervous maladies, 
as compared with other diseases (of women, for example) will be exhib- 
ited by the ancient medical writers. 
Insanity is distinctly portrayed in some of the characters of the Greek 
drama. Ihe tragic story of Orestes furnishes the material for two of the 
most powerful dramas of the Grecian stage. Both by AEschylus and Eu- 
ripides, is the hero, Orestes, made to become insane by remorse after the 
death ot Clytemnestra. _ The form of insanity which they depict is acute 
mania, and after a certain period reason is restored. Probably the best 
picture of mania which has descended to us from the ancient world, is 
the Ajax of Sophocles. This is delineated with a master hand, familiar 
with the malady described. Indeed the three dramatists exhibit a decree 
of familiarity with the salient features of an acute maniacal attack, 
which could only have been obtained by a personal study of the paroX' 
ysms. We obtain glimpses from the comedies of Aristophanes, that 
cases of senile dementia were not unfrequently subjects of judicial inves- 
tigation. In his comedy of “The Clouds,” which was directed against 
the sophists, and especially against Socrates, it is indicated that the young 
men ot Athens employed such means to be rid of troublesome seniors. 
It is an historical fact that Sophocles in his old age was the subject of au 
inquiry into his mental condition, instigated by his sons who wished 
to obtain possession of his property. Even Socrates was the subject of a 
delusion his inward voice, dcemonium—which guided all his actions, MODERN LIFE AND NERVOUS DISEASES. 
however trifling, and to which he invariably deferred. The dcemonimu 
°f Socrates has-been the subject of an immense deal of speculative sub- 
tilty. Without presuming to decide a question so surrounded with dif- 
ficulties, X may at least express an opinion formed after an examination 
d all the sources of information within my reach; To me, this voice, in- 
ward mentor, conscience, or doeinonium, appears to be a hallucination. It 
should be remembered that Socrates was given to introspection, and had 
a character full of eccentricities. . 
Id Grecian and Roman mythology, madness is frequently inflicted for 
disregard of the commands of divinities, in accordance with the popular 
notion that the anger of the gods is thus visited on man. Bacchus was 
one of the divinities who most used this means of punishment. He thus 
afflicted Lycurgus, of Thrace, and the three daughters of Prsetus, be- 
cause they decli ned to worship him. These are represented 
W have wandered in the fields like cows, and, quite in accordance with 
what we now know of the contagiousness of imitation, 
Dien went mad and did the same thing. The “heaven-inspired Cassan- 
dra” was doubtless insane, as the Trojans believed. It is a very old trick 
feign insanity ; Ulysses was the first on record to attempt it. 
In the ancient secular writers references to the “ sacred disease aie 
Very numerous. Herodotus chronicles the fact that Cambyses was afflicted 
with this malady, and, very remarkably, he attributes the cruelties prac- 
tised by this ruler to the mental state induced by the epileptic paroxysms. 
Qallius and Macrobius quote from Hippocrates in regard to the “ sacred 
disease.” In the former occurs the curious statement (attributed to Hip- 
pocrates) that the sexual congress is a condition of the body not unlike 
the epileptic paroxysm. Horace, in his epistles, describes melancholy 
aild paralytic tremor. 
. Erb infers that neuralgia must have been comparatively rare in ancient 
tunes, because “ Aretmus is the first who gives a recognizable description 
of it.”l Yet Socrates, in the Phredo of Plato, is made to utter some remark- 
able thoughts on the relationship of pleasure and pain. “ "What an unac- 
countable thing, my friends, that seems to be, which men call pleasure; 
aad how wonderfully it is related towards that which appears to he its con- 
trary, pain ;in that they will not both be present to a man at the same 
finie ; yet if any one pursues and attains the one, he is almost always 
compelled to receive the other, as if they were both united togethei fioin 
°De head.” These observations do not, it is true, prove the existence ot 
Deuralgia in ancient times, but they show that the acute-minded philoso- 
pher had reflected profoundly on the nature of pain, anticipating, in his 
conclusions, modern knowledge of the functions and attributes ot the 
sensory nerves. These examples from the secular writers must suffice, 
doubtless most of the members of this learned body will recall other 
and, it may be, more pertinent instances; but I must pass to consider the 
state of knowledge of nervous diseases shown by the medical wnteis ot 
antiquity. 
Ihe writings of Hippocrates furnish us with numerous lefeiences to 
the more important nervous maladies. In the Prognostics, is delineated 
with admirable fidelity and brevity that form of delirium in which the 
Patient picks at the bedclothes and objects in the air. In the Regimen 
ln Acute Diseases, there is a distinct allusion to trembling delirium due 
to vinous excess. In the book of Epidemics, cases of “ phrenitis” are 
1 Ziemssen’s Handbook, vol. xi. 368 
BARTHOLOW, 
given, the main features of which are much like those of modern cerebro- 
spinal meningitis. The earlier writers made no attempt to differentiate in 
the forms of intra-cranial inflammations, for reasons which are perfectly 
obvious; although under the term sphacelus of the brain Hippocrates 
probably meant ramollissement. In the Aphorisms, we find a great many 
very acute observations on the signs and symptoms of many nervous 
affections. The sleep which approaches coma, and the sleep which puts 
an end to delirium, are described, and the prognostic value of sopor and 
insomnolence clearly stated. The insensibility to pain manifested by 
the insane is recognized. Hippocrates declares that the prognosis of 
insanity is more serious after forty years of age, a fact which, we must 
admit, is generally true. “It is better that a fever succeed to a convul- 
sion, than a convulsion to a fever,” is an undoubted truth, which indi- 
cates that Hippocrates recognized the clinical difference between those 
convulsions which announced the onset of a fever, and those which came 
on at the termination ot an acute intra-cranial inflammation. He indi- 
cates his acquaintance with aphasia in various aphorisms which refer 
loss of speech to injuries of the head, vinous excess, etc. He frequently 
alludes to vertigo, apoplexy, and tetanus, and is minute on the subject of 
epilepsy, the prognosis of which, he informs us, is more favorable when 
the disease occurs in the young than when in the old. In a description 
of the effects of venery, Hippocrates draws a picture of nervous symp- 
toms not unlike those belonging to the first stage of spinal sclerosis. It 
is known to all here present how pronounced are the sexual symptoms 
in Duchenne’s first stage of progressive locomotor ataxia. 
Some of the medical writers subsequent to Hippocrates are more 
minute and systematic in their descriptions of nervous diseases. Are- 
tseus, who was most probably a contemporary of Galen, describes tic dou- 
loureux (On Cephalaea), vertigo, and the vertiginous sensations which 
accompany various intra-cranial diseases, epilepsy, melancholy, mania, 
ecstasy, apoplexy, paraplegia, hemiplegia, and paresis, and mentions dis- 
turbances of the functions of the cranial nerves such as are produced by 
intra-cranial tumors. The most complete account of nervous diseases 
that has descended to us from the ancient world is found in Galen.1 The 
different varieties of headache are very admirably depicted by this wri- 
ter, and he indicates his acquaintance with the fact that the symptoms 
are associated with various intra-cranial lesions. He treats of abscess, 
meningitis, coma-vigil, catalepsy, hysteria, melancholia, mania, imbe- 
cility, senile dementia, vertigo, epilepsy, apoplexy, paralysis, local para- 
lyses, spasms, tetanus, paralytic tremor, etc. Writers subsequent to 
Galen, for many centuries, as is well known, adopted his descriptions. 
It would occupy too much time to give a detailed account of the opinions 
ot other and less authoritative ancient medical writers. It must suffice 
to state that Aetius, Oribasius, Alexander, Cselius Aurelianus, Celsus, 
Avicenna, and Rhazes, besides other less important ancient physicians, 
treat of nervous maladies at very much the same relative length. It is 
quite evident, then, that various diseases of the nervous system were per- 
fectly familiar to the writers of the ancient world. 
If we compare the manner in which the ancient medical writers dis- 
cussed the various diseases with which they were acquainted, we find 
that affections of the nervous system occupied as much space in their 
works as the diseases of other parts. Probably the knowledge of the 
1 De Compositione Medicamentorum secundum Locos. MODERN LIFE AND NERVOUS DISEASES. 
369 
ancients, as compared with modern acquirements, was more full and 
®xact on the subject of the diseases of females than of any other gioup 
°f maladies. Some instruments of precision which have contributed so 
largely to the development of gynaecology, were known to and 
the most ancient practitioners of whom we have any knowledge. The 
speculum, the uterine sound, and the pessary, were, as is well known, 
only rediscovered in modern times. An attentive examination of the 
ancient books on female diseases must convince any one that women 
have always suffered from the physical infirmities to which, in our day, 
they seem to be specially liable. The ancient physicians had every oppoi- 
tunity, we may suppose, to become practically familiar with female dis- 
eases, and the information conveyed to us in their writings is maiked by 
the accuracy of detail only secured by faithful observation. When we 
compare the amount of space devoted to nervous and diseases, 
Aspectively, it is evident that the former are treated with as full detail 
as the latter. If we take the works of Paul us AEgineta, who, according 
to his own statement, u compiled his collection from the works of the 
ancients,” without omitting “ any one distemper,” we can see that affec- 
tions of the nervous system occupy quite as much space as diseases of 
tvornen, and are treated as intelligently. _ . 
"W hen the ancient writers allude to the causes of diseases affecting the 
Uervous system, they are said to be heat, cold, injuries, and excesses in 
eating, drinking, and venery—just such causes as in modern times aie 
held to be influential. The most superficial survey of ancient society 
diust convince any one that the nervous system of man was, in those days, 
exposed to extraordinary trials. The writings of Aristophanes, of Lu- 
c'an, of Athenseus, amongst the Greeks, of Martial and of Juvenal amongst 
fhe Romans, give us hints of a licentiousness to widely the most debased 
B°cieties of modern times afford no sort of parallel. Ihe political status 
°h the ancient civilized communities was never permanent, vvais and 
characterized by the greatest atrocities, occupied the icstless 
eitizens of the Grecian and Roman States. At home, games, public 
constantly recurring political excitements, the woiship of 
Venus and .Bacchus with their attendant orgies; abroad,wars, conquest, 
and plunder, were the occupations of Athenian and Roman citizens. 
The minute subdivisions into which the medical art was parcelled 
‘Diiongst the ancient Egyptians, and later amongst the Romans, indicate! 
in those times diseases were very rife. In Cicero’s age1 the only 
divisions were three—physicians, surgeons, and oculists; but when Ga en 
2 the bad example of Thessalus had filled Rome with a great crowd 
°f hungry specialists in every possible field of medical practice. I lime 
''vere specialists in remedies, as well as in diseases, and in the diseases of 
every known organ of the body. There were specialists for the globes 
the eyes, and for the eyelids ; for the uvula, and for the tonsils; for 
the external ears, and for the internal ears; for palsy, dropsy, stone, and 
skin diseases; for children, and for old people. There weie apostles of 
he movement-cure, or those who treated rheumatic and paialy tic tumbles 
y gymnastics, massage, and frictions. Galen contemptuously styled 
hese multitudinous charlatans, the asses of Thessalus ; foi this magnifi- 
ed, impudent, and successful quack had declared that he could teach 
doctor in six months all that he needed to learn. We obtain from 
hiy a lively picture of the ignorance and rapacity of these specialists 
1 De Oratore. 
24 
2 Metliodus Medendi. 
3 Ilistoria Naturalis. 370 
BARTHOLOW, 
“I will not speak of their avarice, their swindling bargains made with 
patients in an extremity, the imposition laid on suffering, the earnest 
money, so to speak, of death, the secret retainer fees,” etc. Alluding to 
the same class, Galen affirms that the doctors in Rome differed from 
highwaymen only in the fact that the former lived in the city, and the 
latter camped out in the mountains. 
These facts indicate, I think, that the diseases incident to Roman life 
were very numerous, and hence the demand for physicians; otherwise 
the supply had not been so abundant. In this strange medley of special- 
ists, there seem to have been as many, comparatively, devoted to mala- 
dies of the nervous kind as to other diseases, and certainly during the 
times of Galen and Pliny there were in the social and political condition 
of the Roman people powerful causes in operation to produce these affec- 
tions. 
From the thirteenth to the sixteenth centuries, there occurred in Eu- 
rope epidemics of purely nervous maladies such as the world had never 
before witnessed. In the graphic pages of Hecker, we learn that the 
dancing mania, in Germany and Holland, tarantisrn in Italy, and the 
malady of the Convulsionnaires, in France, involved great numbers in the 
wildest excesses. Such moral epidemics are possible only in such a state 
of society as existed in the mediaeval times—an age of faith and rev- 
erence, but ignorant and superstitious. During the same period great 
epidemics of cerebro-spinal meningitis devastated various parts of Eu- 
rope, notably near the close of the fifteenth and at the beginning of the 
sixteenth centuries. Ro additions during the middle ages appear to have 
been made to the knowledge of Galen. In a voluminous work on “ The 
Generali Practice of Phisicke,” “compiled and written by the most 
famous and learned Doctor Christopher Wirtzung,” and published near 
the close of the sixteenth century, the descriptions of Galen are closely 
followed. In his commentary on “the braines and all that concerneth 
them,” the learned Doctor includes loss of memory, vertigo, phrenitis, 
mania, melancholia, dementia, palsy, tremor, spasm, incubus, epilepsy, and 
sciatica. It is perfectly obvious that the state of medical knowledge 
then existing did not admit more accurate differentiation in nervous 
maladies. 
The present condition of neurological medicine has been reached only 
since the physiology of the nervous system has been adequately studied 
within the last fifty years. Until Bichat had laid the foundation of gen- 
eral anatomy, physiology had scarcely existed. The brilliant results 
attained by the study of the nervous functions by the modern methods of 
research, and the great development of morbid anatomy, have stimulated 
investigation of the diseases of the nervous system, and to the operation 
of these causes must be attributed the remarkable advance in neurological 
science. Diseases of the nervous system have been accurately differen- 
tiated, and have been elaborately studied both from the clinical and patho- 
logical standpoint; but it is more than doubtful if any have been actually 
discovered in modern times. Yarious attempts have been made in France, 
England, and the United States, to determine, by the statistical method, 
whether an actual increase in the number of insane, relatively to the 
growth of the whole body of the population, has taken place in modern 
times. It is extremely difficult to make a thoroughly exact census of the 
insane. Each succeeding registration is probably more exact than those 
which preceded it; but even in England it is not claimed that the re- 
turns are more than an approximation to exactitude. It is undeni- MODERN LIFE AND NERVOUS DISEASES. 
371 
kble that in each decade a small increase in the number of insane has 
been noted ; but it is conceded in every report on the subject that the 
registration, becoming more and more exact, makes an increase which is 
merely apparent. Moreover, a more humane and abundant provision foi 
fbe insane, and the increased facilities tor communicating with asy- 
kims, induce the friends of these unfortunates to entrust their keeping to 
the great institutions now provided for the purpose. 
If the kind of evidence which I have submitted has any value in 
deciding a question of this kind, it must be admitted that the various 
forms of nervous disease, including insanity, are not more numerous, 
relatively, now than in ancient times. If, as is probable, nervous dis- 
eases are not more numerous than they have always been, an inquiry 
into the conditions of modern life supposed to have increased them, may 
appear to be unnecessary. A candid examination of those conditions 
'will demonstrate, I think, that their influence has been greatly exagge- 
rated. The abuse of stimulants and narcotics, although not unknown 
the ancients, is commonly held to be more extended in modern times. 
Certain poisons, dye-stuffs, cosmetics, and deleterious metals of various 
kinds, enter more largely into domestic use than was the case in foimei 
ages. Our modern means of intercommunication by railways, subject 
111e nervous system to a degree and kind of concussion unknown to the 
People of ancient times. Modern habitations, with their appliances for 
beating and lighting, social customs, diet, and all the methods of an 
enlightened hygiene, are very different from those used in the most 
Polished periods of Egyptian, Grecian, or Roman life. 
It is probably an error to suppose that alcoholic excess is more com- 
mon in our day. Wine was the beverage chiefly used in ancient times, 
as it is now in the wine-growing countries bordering the Mediterranean. 
lAunkenness is an uncommon vice in those countries to-day. The feasts 
°f Bacchus, in ancient times, were scenes of extraordinary drunkenness 
mid debauchery, which must have initiated thousands into habits of in- 
toxication. The god visited madness on those who refused to engage in 
fbe bacchanalian rites. The symposia and orgies, in which the uppei 
Masses, Grecian and Roman, engaged, consisted in an abandonment to 
the vinous intoxication. That such indulgences brought upon the vic- 
tim the usual punishment, is evident from the references in Hippocrates 
to delirium tremens and aphasia from vinous excess. It cannot be do- 
med that the chief factor in the causation of insanity, and an influential 
mie in the production of other nervous maladies, in our day, is alcoholic 
excess, but it must have been equally so in ancient times. _ 
Although the properties of opium were certainly known in the first 
century, it was not used as a means of intoxication until the second, and 
then, certainly, to a very moderate extent. Its systematic use in civi- 
Uzed communities is a comparatively modern vice, and even now, 
indulged in to an extent which must awaken solicitude, is as 
I'et confined to an inconsiderable part of the population. Opium srnok- 
lng has attained to extraordinary proportions in China, and it is esti- 
mated that twenty per cent, of the population of that country is now 
addicted to it. A recent observer concludes u that disoideis ot the ner- 
vous system in a general sense, are by no means infrequent amongst the 
Chinese, . . . &the probabilities are that the prevalence of diseases of 
the general nervous system in China bears some proportion to the preva- 
cnce of the same disease in Europe, and other regions, . . . but 
mat cases of alienation of mind, idiocy, lunacy, fatuity, and generally 372 
BARTHOLOW, 
speaking, insanity, are strikingly few, if we leave suicides out of the 
reckoning.”1 
Tobacco has now been used by civilized peoples for three centuries. 
The greatest evils were supposed to be produced by it when Sir Walter 
Raleigh and his companions first made it the fashion. The large expe- 
rience and observation of its effects which have been acquired, demonstrate 
that its moderate use produces no ill results, and that the evils which 
come of immoderate indulgence are quickly recovered from when the 
narcotic is suspended. As the disturbances in the nervous system in- 
duced by tobacco are functional, we have in this fact an explanation of 
the apparent freedom from injury of those addicted to its habitual use. 
Various modes of contamination by poisonous metals—lead, copper, 
mercury, etc.—are possible by reason of the employment in domestic 
life of articles of necessity and luxury, containing them, and by the va- 
rious applications of these metals in the industrial arts. Individual ex- 
amples of deleterious results—affections of the nervous system—are not 
uncommon, but no general or diffused injury has occurred, or probably 
can occur. 
The daily railway travel of a considerable portion of the population 
of civilized countries, has been supposed to exert an injurious influence 
on the nervous system. The jar and concussion, the deafening noise which 
assails the ear, and the rapid movement of objects which fatigues the 
eyes, are supposed to impair the integrity of the nerve centres. One of 
the diseases alleged to be caused by railway travel is progressive locomo- 
tor ataxia. If ill results are thus produced, they ought to be seen in the 
locomotive engineers. On the contrary, the Brotherhood of Locomotive 
Engineers is a body of men who are remarkably free from nervous ail- 
ments, and who are indeed distinguished for their vigorous health. 
As respects the social and domestic conditions of modern life, it can 
hardly be disputed that modern man is in every respect more favorably 
situated than was his ancient prototype. If statistics are worth anything, 
it must be admitted that the improved hygienic conditions of modern 
society have lessened the sickness and mortality rates, and have increased 
the longevity of man. The epidemics as described by Hippocrates; the 
plague as depicted by Thucydides; the black death of the middle ages; 
the ravages of smallpox in the last century, have been imitated, but not 
at all equalled by the Asiatic cholera in this century. Those great epi- 
demical waves of cerebro-spinal meningitis which formerly overflowed 
Europe are no longer possible. A great moral epidemic, like the dancing 
mania, would be as much a solecism in this nineteenth century as a 
revival of the crusades. 
The Geneva vital statistics, with the observation of four centuries, and 
the experience ot the great life-assurance societies, based originally 011 
the Carlisle tables, seem to have established the fact of the increasing 
longevity of man. If man is living under more favorable hygienic con- 
ditions, and is less vulnerable in his bodily constitution, it must be ad- 
mitted that he is improving rather than degenerating. Is it not to the 
last degree improbable that one system of the body should manifest signs 
of premature decay, and the rest exhibit unwonted vigor? Such a sup- 
position is all the more incredible when we come to reflect on the impor- 
tant position which the central nervous system holds in respect to the 
nutrition and healthy functional activity of other parts of the body. R 
1 Dr. George Hearn, Journal of Mental Science, April, 1875. MODERN LIFE AND NERVOUS DISEASES. 
373 
is as little likely that more men, comparatively, are bald in our day than 
were so in ancient times. These facts seem conclusive against the views 
of those pessimists who maintain that the nervous system of man is 
degenerating under the teasing influences of our modern civilization. 
Instead of degenerating, it seems highly probable that the brain of 
naan, like his bones and muscles, is capable of more work than formerly. 
Modern thinkers rival the metaphysical subtlety of Aristotle, and an 
oi'dinary man requires to carry an amount of material as the usual furni- 
ture of his brain which would have conferred immortality on an Athe- 
nian. The brain in its state of functional activity, indeed, illustrates 
niost aptly what has been styled the principle of least action. A large 
part of our mental processes are carried on without our consciousness—a 
state of functional activity to which it is the fashion to apply the term 
“ Unconscious cerebration.” So nicely adapted is the organ to the work 
}t has to perform, that it accomplishes its tasks without any jar, without 
indeed disturbing its very sensitive tenant, the Ego. The wear and tear 
°f our modern civilization no more affects the integrity of this organ 
than the’discussions in the groves of the academy, nor than the political 
dissensions of the Grecian and Roman states. 
The following conclusions seem to be warranted by what has gone 
before;— 
I. Rervous diseases, in the most common forms, have been distinctly 
recognized by lay and medical writers from the earliest periods. 
11. They appear to have been as prevalent, relatively, in ancient as in 
modern times. 
111. The sickness and mortality rates having lessened and the lon- 
gevity of man having increased in modern times, it is highly improbable 
that the nervous system of man has become more vulnerable. 
IV. In modern times nervous diseases have been more accurately 
studied and differentiated.1 
Discussion on Dr. Bartholow’s Paper. 
After the reading of the preceding paper, Dr. Traill Green, of Easton, 
Pennsylvania, said :—No doubt the ancients were well acquainted with nervous 
diseases. Apoplexy was well known in Scriptural times, and we find that 
111 any characters in Biblical history suffered from it. When a man is attacked 
by apoplexy now, people are apt to say that he has suffered from oveistrain. 
But we find that the ancients suffered from the same affection, and they had 
11 ot the business strain of the present day. Statistics compiled by men familiar 
M'ith the subject, and endorsed by mathematicians, show that there is an appa- 
rent increase in deaths from nervous diseases among the policy holders of insu- 
rance companies; but this is attributed to the fact that more old people insure 
n°w than formerly. The percentage of insanity is just DA of one per cent., 
the number of apoplectics is not large. 1 have closely observed nervous 
diseases in my own neighborhood, and out of about fifty persons whom I have 
<n°wn to die or suffer from apoplexv, or palsy, not one could be said to have 
°Wed his attack to the result of overstrain. The ages of these patients varied 
thirty minutes was the limit fixed by the executive committee for the length of papers 
lead in the sections. The writer regrets that he was not aware that deviation from this 
hmit would be permitted, for he would otherwise have presented his argument more in 
©tail, and would have entered more fully into the statistical data which exist as to the 
c°mparative prevalence of nervous diseases in the first and latter halves of the nineteenth 
century. 374 
BARTHOLOW, 
from 58 to 92 years, at the time of attack, and they were from all walks of 
life. 
Dr. Henry Gibbons, of San Francisco, said :—There is nothing in the records 
of antiquity nor in modern statistics to settle this question. The statistics ot 
insurance companies, derived from selected subjects, are of no avail for the 
purpose. Mortuary statistics refer only to deaths, and not to the prevalence 
of diseases. Even if it were proved that nervous disorders caused as great a 
proportionate mortality in former times as now, it would not reach the ques- 
tion ; for with the great advance in pathology and treatment, the mortality 
ought to diminish. If Dr. Bartholow were to reside a year or two in Califor- 
nia, he would change his mind as to the increase of nervous disorders in that 
quarter. The increase is conspicuous, and there are causes operating there 
which must have that effect. With a large portion of the population, the home 
and family influences are wanting, and men in trouble and difficulty are adrift 
in the world—no wife, no parents, no children to anchor their troubled spirits. 
Passions of all kinds get control. Yery recently the wild speculations in 
mining stocks, by which fortunes are made or lost in a day, have developed a 
notable number of cerebral cases, ending in suicide or insanity. Whether 
modern society in old and settled communities exhibits any increase df nervous 
disorders, I am not prepared to say ; but as like causes produce like effects, 
and as there is every reason to believe that moral and physical causes of a dis- 
turbing character are more abundant in modern times than formerly, we might 
reasonably infer that disorders of the nervous system would be more frequent, 
though their aggregate mortality may not be greater. It must be conceded, 
however, without qualification, that in newly-settled countries, and all around 
the outskirts of the old civilization, in all parts of the world, the circumstances 
of society are more or less similar to those I have pointed out in California, 
and that they must lead to similar results. 
Dr, Wm. B. Neetel, of New York, said :—I have no doubt that the causes of 
nervous diseases have increased in modern days. The subjects of these affec- 
tions transmit them to their descendants in an aggravated or modified form. 
We must also consider the law of development. The brain’s intellectual sphere 
has been enlarged, and, with increased mental activity, we have greater liability 
to nervous diseases. The common use of alcoholic stimulants at the present 
day, is, both directly and indirectly, a cause of nervous affections. Syphilis, 
another cause of nervous diseases, is not found to have existed in former times, 
while now it is very common. The records of the Pathological Institute of 
Berlin prove conclusively that many fatal diseases of the brain are due to 
syphilis. 
Dr. Thomas L. Maddin, of Nashville, Tenn., said :—I agree with the author 
of the paper that there are no new diseases to which man is subject, for all dis- 
ease is but an error of the tissue or function of an organ. But because of edu- 
cation and the surroundings of modern life we may have new modifications of 
disease, and we often have a physical basis on which to rest those modifica- 
tions. The exercise of any organ of the body will increase its size and struc- 
ture, and in that way may modify the diseases of an organ. For instance, a 
man living luxuriously, and constantly using stimulating condiments and alco- 
holic drinks, will in the course of time have his liver in an abnormal condition, 
and then there is a physical basis for organic and functional hepatic disorder. 
He is predisposed to diseases which another man, living on frugal, plain diet, 
while subject to the same affections, is not so likely to have developed. People 
are different now from what they were two thousand years ago, or in their 
primitive state. People in civilized life differ from savages in reference to the 
development of the nervous system. Take a man on a plantation, with no 
education, and no elevation of thought, and take another who has been preco- 
ciously educated from childhood ; the brain of the latter is in a state of hyper- 
remia; his nervous condition has been stimulated from the beginning; and 
there is an abnormal condition of his entire nervous system. It is educated MODERN LIFE AND NERVOUS DISEASES. 
375 
out of relationship to the other organs of his body. It has obtained an 
ascendency over his system which influences the functions of the othei oigans. 
Thus the highly educated and civilized man is more subject to nervous disor- 
ders than the quiet countryman. 
Hr. A. B. Arnold, of Baltimore, said:—The etiology of all diseases is obscure, 
but particularly so that of diseases of the nervous system. I believe that the 
idea that nervous diseases are more prevalent now than formerly has ongi- 
nated with specialists. I have practised for thirty years, and am not aware 
that I have seen more cases of nervous disease during the latter than dunng 
the former half of that time. If the increase spoken of exists, it must be 
attributed to the progress of civilization, to the wear and tear of body and 
blind, and to the race for wealth. Intellectual men arc generally long-lived, I 
believe that shocks are more detrimental than hard study, and, as pointed out 
by the reader of the paper, war and turmoil with all their attendant evils were 
ihe almost natural conditions of former times, while now they compaia- 
tively rare. In modern civilization, the mind is better trained and disciplined. 
It is not so demonstrative in joy, nor so depressed in trouble. Discipline pie- 
vents the mind from being affected with shocks. I believe, although it is 
father Darwinian to think so, that the nervous system accommodates itselt to 
tile strain put upon it—an accommodation of the inward condition to exter- 
nal influences, which is in favor of the present time. lam not aware that even 
special writers on the subject particularly ascribe insanity to a syphilitic con- 
dition; in fact, the subject is so extremely obscure that it is hazardous to 
express an opinion upon it. Again, medical men allow themselves to be too 
ttuich influenced by the hue and cry of protessional temperance oiatois. It 
cannot be scientifically proved that alcohol in the form in which it is at present 
“sed has a very marked influence in the production of nervous disease. I 
believe that, instead of drunkenness being a cause of mental disease, it is in 
Line cases out of ten only the first warning ot its appioach. 
Dr. NS D avis, of Chicago, said This question is one of very wide scope, 
bnd one which it will be extremely difficult to determine with any degree of 
certainty, with our present knowledge. Even in this discussion, the fact has 
been brought out that in certain conditions of society there is to be round a 
Harked increase of particular nervous diseases. The gentleman from the 
Pacific coast has indicated a condition of modern society which has a tendency 
to develop that form of nervous derangement that leads to _ Do 
back to the days of the Crusades, when all Europe was aroused by a religious 
Hania, and was led forth to the battle field by hundreds of thousands, and you 
'DU find conditions which were likely to, and which doubtless did, Produce 
special tendencies towards the development of mental disease. People talk 
about mental strain being a cause of mental disorder; about the intensity ot 
°Ur work : I have been led to think that very few brains ever wear out by 
w°rk. The physiological law is growth ; strength ; compactness. If there is 
n°t some corroding influence to interfere with the law, you will seldom wear 
o,ff your brains with work. Rush tells us of the ten years before the Kcvolu- 
Don, when a large part of the male population of Philadelphia was aggregated 
ln social clubs, eating four meals a day, and drinking intoxicating liquors at 
eaeh; and he lived to see almost every member of those clubs go to Ins grave 
ll‘°m the effects of apoplexy, paralysis, or dropsy: there was a development ot 
nervous disease. The Revolution followed, there was excitement and war; 
Ibe people were stripped of their property, and were compelled to labor and 
toil mentally and physically ; and that particular class of nervous diseases 
abiiost disappeared. . , . ... , , 
. No doubt some special nervous diseases have diminished, while others have 
Decreased, The reason for this increase of particular classes of disease is not 
Hir high state of civilization, nor our extent of learning ; I doubt whethei we 
lave a student in America, to-day, who studies harder than some of the stu- 
dents of Greece and Rome, or even of the ancient Jews. I doubt whethei 376 
B A K T HOLOW, 
some of them did not think as deeply and persistently. And no doubt some 
of them suffered from mental disease, but not from thinking or study. I 
think Saul got his paroxysms of mental derangement, as a great many do 
to-day, from wickedness; not from study. It is not the hours we spend at 
books, or at business, that wear us out; much is attributable to our anxiety 
for wealth and show. When we put our whole heart on accumulating wealth, 
and the bubble bursts, it produces a severe mental anxiety. Large numbers 
of our students become lean and dyspeptic, and disordered in health, before 
they get half through college ; why ? Because they learn at an early period of 
life to go to the breakfast-table, and sip two cups of coffee and nibble a crust 
of bread as an apology for breakfast; thus endeavoring to substitute pure ner- 
vous excitation for materials to replenish blood and make tissue. It is the 
same with many lawyers and doctors, whose friends say they are killing them- 
selves, and yet who do not devote to their professional duties as much time, by 
one-third, as others do, who are perfectly free from nervous disease. What is 
the reason ? Because as soon as they take their meals they are puffing their 
tobacco, or chewing their quids, until they have their entire nervous systems 
saturated with a narcotic that cannot fail to produce retardation of molecular 
changes, thus acting upon the false notion that the retention of an old atom is 
equivalent to the evolution of a new one ; and in a few years they complain of 
being worn out. They have retained the old atoms in the form of inert fat, 
which begins to find lodgment in the brain, or liver, or heart. If an artery 
gives way, and they fall from apoplexy or palsy, you give your certificate that 
they have died from one of these diseases, when the truth is that they have 
died from long use of alcohol and tobacco. Take these two influences out of 
the community, and you will have less nervous disease than the ancients, be- 
cause the other influences are of such a nature that we can guard against them. 
We would live longer, the race would be healthier, and we would"have fewer 
diseases of any kind. These things have stepped in and filled up the places of 
some things peculiar to the ancients. No doubt causes have been operating 
all through the world’s history, sometimes making one form of mental disease 
more prevalent than another. Balance them up, and we may find that we are 
very nearly where we were in former years. Our advances in sanitary science, 
and in pathology, and in the treatment of disease, have lessened mortality 
and increased the duration of human life. If the prevalence is the same as in 
former times, then we must have more influences at work. 
Dr. R. P. Howard, of Montreal, said :—I think that previous speakers have 
established the fact that nervous diseases are more common than formerly, 
owing to the use of stimulants ; alcohol was used by the ancients, but tea and 
tobacco are modern, and are potential causes of derangement of the nervous 
system. Syphilis is another modern cause of nervous disease. One of the 
speakers has tried to ignore the importance of this, but its influence is well 
established. The undue attention of modern civilization to culture of the 
brain, over-developing it in relation to the other organs, may be another cause. 
Hereditary influences will wear themselves out, else every person would inherit 
some taint. A man may have too much work as well as too little. The men 
of to-day work faster than men in former times; everything is done in a hurry- 
The weight of evidence is in favor of the view that there is a tendency to an 
increase of nervous affections. 
Dr. H. I. Bowditch, of Boston, said -There are one or two points which 
have not been noticed. lam satisfied that the climate of this country is more 
stimulating than that of others. I infer this from the general effect it has upon 
the English race. The Anglo-Saxon race has grown thin and apparently more 
excitable than it was in the mother country. English people have found that 
they cannot safely drink to such an extent as they can in England. I have 
known cases in which Englishmen in America have been attacked by delirium 
tremens, from using quantities of alcohol which they had used with perfect 
impunity in England. Yet they were comparatively temperate men. Again, MODERN LIFE AND NERVOUS DISEASES. 
377 
there is the perpetual political excitement, affecting both our men and women, 
which has no existence in Europe. When an American goes to Europe, he 
gets into a state of quiescence which is perfectly delightful, but when he re- 
turns, even after spending six months there, the first sight of the pilot boat 
Puts him into an excitement about the latest scraps ot political news. _ 
Dr. Green said No inference can be drawn from the frequency of suicide, 
as suicides are committed from other causes than the existence of nervous dis- 
ease. The Welsh are more predisposed to mental and nervous diseases than 
pther people of Great Britain, so that the question of race should be considered 
*u connection with the subject. , . A 
Dr. W. Scott, of Cleveland, Ohio, said Olir modes of travel induce dis- 
uses unknown to our forefathers. The custom of sending children to school 
at too early an age also exercises a pernicious influence. _ Childien aie take 
fr°m school at the time when they ought to be commencing their studies m 
earnest. The medical profession ought to take the subject of education i - 
Public schools into serious consideration. Vicious systems of education are 
Die cause of many functional disorders, and often lay the foundation loi t e 
development of nervous disease. Another feature ot our modern civilization is 
D‘e want of vigorous development, and this is more fruitful ot ne?ous 
Dons than chewing tobacco or drinking coffee. Plants require the light of the 
sun in order to grow, and our children should not be denied its blessings, 
houses, of even luxurious construction, are kept in a state ot dun- 
geon-like darkness, and children reared in such houses are not nearly so vigor - 
°us as the children of a country clown, who have at least the benefits or a 
Siißcjiiiip • 
Dr. Bartholow, in reply, said .—I think that the statements of specialists 
should be taken with a great deal of allowance. They seem to base the opinion 
that nervous diseases are increasing, upon the fact that they see rnoie cases 
Dian formerly ; but that is only the result of their individual business increas- 
ing, as they become settled in practice. Doctors never see rnany cases m 
‘heir first years of practice as subsequently. It lias been asse te l that syplnhs 
* * modern disease; that is doubtful. Many causes of syphilis existed for 
Kierly and there is no proof that the disease did not exist too. Mj gie< t 
answer to all the arguments which have been adduced is that menwe laigei, 
stronger, and better in every way than in former times. A E.| 
man cannot put on the old armor. The body is stronger and stoutei than it 
and’men are able to do more intellectual work If the Geneva statistms 
** worth anything, they prove that the longevity of man has doubled within 
three centuries. As to the effect of the climate ol America, it is found that 
longevity is greater here than in England. 378 
CONTRIBUTION TO THE ETIOLOGY OF EPILEPSY. 
BY 
WILLIAM B. NEFTEL, M.D., 
OP NEW YORK. 
The remarkable progress made in our knowledge of epilepsy com- 
mences with the classical researches of Brown-Sequard in 1850.1 As 
the results obtained by him are well known to the profession, I shall 
merely mention here a few of the more important points. After the 
division of one half of the spinal cord, or of one sciatic nerve, in the 
guinea-pig, the animal becomes epileptic in the course of several weeks, 
exhibiting on the injured side the so-called epileptogenic zone. This 
zone is characterized by a lowered sensibility, and is situated below the 
eye, especially at the angle of the lower jaw, and extending toward the 
neck and scapula. If the section be made through the entire cord, or 
through both sciatic nerves, the epileptogenic zone appears on both 
sides, and if the pedunculus cerebri be injured, the epileptogenic zone 
appears on the opposite side. The epileptic attacks sometimes occur 
spontaneously, but they can be called forth at any moment by irritating, 
or even touching, the epileptogenic zone. The artificially produced epi- 
lepsy is transmitted by inheritance to the descendants of the animal on 
which the experiment has been performed. 
These facts are of immense importance for the study of epilepsy in 
general, though as yet they do not admit of a direct application to 
human pathology, with the exception of the hereditary disposition, 
which, however, had been already previously established. It is easy to 
presume that epilepsy can be brought on by injury of a sensitive or of a 
mixed nerve, and therefore also by injury of the sciatic nerve, or of the 
spinal cord, but if is not in accordance with the daily experience of 
physicians that affections of the spine or of the sciatic should cause epi- 
lepsy, with an epileptogenic zone. Thus amputation of the thigh (sec- 
tion of the sciatic) is not followed by epilepsy, with an epileptogenic 
zone. Again, W. Muller2 has published a case in which the injury of 
the cord in the human subject much resembled the experiments of 
Brown-Sequard on guinea-pigs. A man received a wound in the back 
from a knife that penetrated through the cord ; the patient lived forty- 
three days, exhibiting all the symptoms of injury of the cord on one 
side, but having no convulsions whatever, though at the autopsy it was 
found that the entire left side of the cord had been perfectly divided.3 
1 Brown-Sequard, Researches on Epilepsy, etc., Boston, 1857 ; also Journal de la Physi- 
ologic des Homines et des Animaux, 1868-1860 ; Archives de Physiologic normale et patho- 
logique, 1868-1872. 
2 Wilhelm Muller, Beitrage zur pathologischen Auatomie und Physiologic des nien- 
schlichen Rftckenmarkes. Leipzig, 1871. 
31 omit giving here examples of epilepsy caused by injuries of sensitive nerves, and will 
only mention that it remains as yet undecided whether the epilepsy in these cases is caused 
by neuritis ascendens, or by purely functional centripetal excitations. Thus in the case 
described by Yirchow, the epilepsy was caused by an injury of the median nerve (neuritis 
iuterstitialis prolifera), and in Bcheverria’s case by a lesion of the ulnar nerve (neuritis]- ETIOLOGY OF EPILEPSY. 
In 1871, Westphal,1 in repeating the experiments of 
pilose conclusions he confirmed in all particulars, found that guinea- 
co*uld be made epileptic by producing a commotion of the brain. 
knocking the animal’s skull against a solid object, or by inflicting with 
a small hammer (such as that used in percussion) one or several blows 
Upon its head, the animal is seized with general tonic and clonic convul- 
lQns, quite identical in character with the epileptic attacks exhibited 
the animals treated by Brown-Sbquard’s method. If the commotion 
‘ very intense, the blow being too violent, the convulsions are generally 
_ (owed ky Ike death of the animal from paralysis of respiration, the 
Motion of the heart still continuing for several minutes. If, however, 
16 blows are moderate, the animals entirely recover from the first 
‘ tack, but after the lapse of several weeks exhibit the epileptic state 
the epileptogenic zone on both sides, exactly like the animals arti- 
t Ojally made epileptic by a bilateral section of the cord or of both sci- 
lc nerves. In young animals an attack is called forth by a few slight 
Percussions with the hammer, while in grown, vigorous animals a con- 
fer able amount of force is required to produce the same effect. 
• " hen the blows are very slight, no real epileptic attacks follow, but, 
lstead of them, what may be called abortive attacks, consisting of 
| eculiar reflex movements. If one of the epileptogenic zones be pinched 
.’ such an animal, it scratches the place with the corresponding extrem- 
is and, closing the eyes, turns the head toward the same side, Ani- 
nils exhibiting abortive attacks can easily be made epileptic by repeat- 
rl? the same operation. The epileptic state and the epileptogenic zones 
appear generally four or five weeks after the commotion, and may last 
!* ’nontbs or longer, after which they gradually disappear, though a 
JSht blow on the head can easily bring them on again. Sometimes 
'le attacks manifest themselves spontaneously, but they can always be 
;l|led forth by mechanical irritation of the epileptogenic zone on each 
ne. The epilepsy artificially produced by cerebral commotion is also 
’aiisrnitted by inheritance, 
in order to ascertain the anatomical lesion which caused the epilepsy 
’Gr these experiments, Westphal removed the skin and periosteum, 
inflicting the blows directly on the bones of the skull, obtained the 
anie result, viz., an immediate attack, followed later by the epileptic 
.ate and the epileptogenic zones. This shows conclusively that the sen- 
, lve nerves of the skin or of the periosteum have nothing to do with 
,lese phenomena. Moreover, the autopsy made by Westphal immedi- 
after'the first attack following the blow, did not reveal any lesion 
i her of the skull, or of the cerebral hemispheres, or of the cerebellum. 
OnQ0nQ found oidy capillary hemorrhages in the gray and white substances 
’ the medulla oblongata and of the upper cervical portion of the cord. 
.10«gh the experiments of Westphal apparently have some similitude 
ith traumatic injuries of the head, in man, yet he rejects any applica- 
-011 ot the results of his experimental researches to human pathology. 
by . °^ier hand, in Billroth’s case there was no neuritis, though the epilepsy was induced 
may traumatic cause affecting the sciatic nerve. In the same way wounds and cicatrices 
Sch ln* Uce epilepsy by the irritation of sensitive nerves. Thus in a case described by 
ci f66’ the epilepsy was brought on by a wound of the head, which left a very sensitive 
r]jSa rix the slightest touching of which would call forth an epileptic attack. The epilepsy 
tlk PPeared after the excision of the cicatrix, in which microscopical examination revealed 
i Thence of neuritis. 
Klin ■ Ueber kiinstliche Erzeugung von Epilepsie bei Meerschweinchen: Berk 
Q' Wochensch., 1871, No. 38, 39. 380 
NEFTEL, 
He says: “lam not acquainted with a single observation of cerebral 
commotion (in the human subject), in which convulsions are mentioned 
among its symptoms.” 1 
Hitzig2 has also produced epileptiform convulsions, in dogs, by injur- 
ing the cerebral cortex. There is no doubt that epileptiform convulsions 
can be called forth in various ways, especially by injuring sensitive parts, 
among others therefore some central nervous structures. JBut the epi- 
leptiform convulsions thus produced are by no means identical with 
epilepsy, which, besides convulsions, requires the presence of the so-called 
epileptic state. In speaking therefore of real epilepsy, we must exclude 
such convulsions as are caused by the sequelae of injuries of the cortex 
(hemorrhages, inflammation, softening, etc.), as in the experiments of 
Hitzig, or in the cases of Hughlings-Jackson.3 These latter seem also to 
have depended on lesions of the cerebral cortex, whereas the genuine 
epilepsy may exist without any palpable textural changes of the"brain. 
The following case, lately observed by me, presents unusual interest, 
inasmuch as it resembles in many respects the experiments on animals, 
and has besides the great advantage of giving in a precise manner the 
subjective feelings ot the patient. It is not only interesting as regards 
symptomatology and treatment, but especially so as throwing some light 
on the etiology of epilepsy. 
Mr. H. W. K., lawyer, 24 years old, of a healthy family, without any heredi- 
tary neuropathic disposition, was formerly quite well, intelligent, industrious, 
and very regular in his habits. During a'riot in Washington, in July, 1869, a 
negro struck him with a loaded cane on the head. The first terrible blow 
brought him senseless to the ground, where he received several additional 
blows on the head. He was carried to his house in an unconscious state, and, 
according to the opinion of the attending physicians, remained during three 
days and three nights in a comatose and hopeless condition. The first blow, 
which rendered him senseless, was struck on the right side of the forehead, iu 
the direction from the tuber frontale toward the right crista frontalis externa 
and linea semicircularis. Fortunately the patient had long hair at that time, 
and wore a straw hat, which undoubtedly weakened somewhat the force of the 
blows. To the same circumstance must be ascribed the absence of any injury 
to the skull, on which no marks of contusion were noticeable. The greatest 
danger that threatened the patient’s life was the exceedingly feeble, scarcely 
perceptible respiration, which at times seemed entirely extinguished. The 
action of the heart was also very weak (pulse 20 in a minute), and immediate 
death was undoubtedly prevented only by the strenuous efforts of Surgeon- 
General Barnes, who remained day and night at the patient’s bedside, ener- 
getically using all possible means of excitation and derivation. 
On the fourth day the consciousness gradually returned, though the patient 
still remained motionless, and therefore "was still considered unconscious. He 
could, however, hear and understand everything, and felt the greatest fear of 
being buried alive, hearing the physicians express their opinion of his hopeless 
condition, and of the fatal termination which must necessarily soon take place- 
At the end of the fourth day, he felt in the extremities a pricking sensation 
(formication', which gradually extended all over the body, and slowly disap- 
peared on the fifth day. At the same time he began to "make feeble move- 
ments with the extremities, and soon was able to contract all other voluntary 
muscles; but he could not swallow or speak until the end of the first .week- 
During the second week after the commotion, the patient experienced the 
1 Loc. cit. p. 462. 
2 Hitzig, Untersuchungen über das Gehirn. Berlin, 1874, S. 270. 
311 ughlings-Jackson, West Riding Lunatic Asylum Medical Reports, vol. iii., 1873. ETIOLOGY OF EPILEPSY. 
381 
Stalest inclination to sleep, and could not awaken spontaneously. Accoiding 
lo the advice of bis physicians, he was awakened at times, and prevented iiom 
sleeping continuously. He was extremely sensitive to noises, easily felt ex- 
I'austed, and after the slightest exertion would become unconscious, and re- 
Wiain so during ten minutes, exhibiting at the same time convulsive move- 
ments. He remained in bed during three months, having the epileptic attacks 
first very often, and then once in two or three days. At last his health 
Commenced to improve, he had a better appetite, and could exercise in the 
°Pen air. But even in the street he was seized several times by an attack, 
" Ith pallor, loss of consciousness, and epileptic convulsions. 
I'he most distressing symptom the patient suffered from was an intense 
leaclache, which commenced with the return of consciousness aftei the com- 
motion, and has scarcely ever left him during six years. The seat of the pain 
ls the right side of the forehead and the right eye, the spot of the inteusest 
Pain corresponding to the right crista frontalis externa, wheie it passes into 
ffie linea semicircularis. The pain at times increases spontaneously, and be- 
anies unbearable, continuing so for days and even weeks, with but short re- 
missions, and finally disappearing almost entirely. At the height of the par- 
°xysm, the rbdit eye becomes absolutely blind (the patient not being able to 
c°u>it fingers)” the slightest touch of the painful zone is unbearable, and press- 
m'e Up on” it calls forth loss of consciousness, and convulsions, considered as 
eP'leptic by physicians who have witnessed them. Occasionally such fits 
m^cur spontaneouslv, without any pressure upon the painful zone, and the pa- 
tl(mt sometimes feels the approach of the attack, and has time to lie down 
though more frequently it comes on suddenly, and the patient falls 
'Hthout bavino- taken any precaution. All the time the patient sulfeis fiom 
te violent headache, there is a complete analgesia of the painful zone, and the 
Mioje forehead appears pale and cold. 
d hen the pain is severest, the patient lies motionless, suffering from nausea 
vomitino-, and scarcely able to eat anything, as these symptoms aie in- 
Vai'iably increased by food. The patient passes sleepless nights through the 
VvJ'ole duration of the paroxysm, only getting occasional short naps, from 
Avaich he awakens with increased pain. At last, under the constant use of hot 
aPplications to the head, the pain gradually disappears and the patient slowly 
1 He then remains in a comparatively healthy condition for days, 
''eeks, or even months, with good appetite and the power of sleeping, and with 
fie vision of both eyes normal. Nevertheless the painful zone remains sensi- 
;lve, even during the intervals between the paroxysms, and the slightest 
folmh, and especially pressure, can bring back the paroxysm of pain with all 
lts distressing symptoms, the fainting, and the epileptic convulsions. The 
Patient has always to avoid touching the painful zone, even while washing Ins 
mce or wearing his hat. He can hardly read, his head and eyes often feeling 
U(Jav.y; he has'also to avoid the rays of the sun, and every physical and mental 
rf„erti°n, and as a consequence, has been obliged to give up every occupation. 
late the paroxysms of pain have become more frequent; his memoiy, uhat 
ased to be excellent, has begun to fail; he cannot always control his ideas 
yth the former precision, and at times they appear so confused that he fears 
■le development of insanity. In the course of the last three years, though he 
Uls been treated by many able physicians, and has used among other remedies 
jl great deal of bromide of potassium and narcotics, nevertheless there has 
'Geo a progressive aggravation of the disease, especially as xegaids the intel- 
Gctual sphere and the frequency of the paroxysms of spontaneous pain. 
rl Present condition : May 29,1816. The patient is of middle size, with a well- 
eloped skull and chest, and moderately developed muscles and panniculus 
atlJPosus; the color of the skin and of the visible mucous membranes is rather 
Pa G 5 the thoracic and abdominal organs are normal ; pulse f 0 ; respiration 18 ; 
Gunperature 37° C. He is now suffering from a comparatively mild attack of 
sP°ntaneous pain, and has scarcely slept or taken any food during several days. NEFTEL, 
The painful zone extends over the right half of the frontal bone, the anterior 
lower portion of the right parietal bone, the upper portions of the greater wing 
of the sphenoid bone, and of the squamous part of the temporal bone, the right 
eyelids and eye. The slightest touch of this region cannot be borne, and the 
patient involuntarily shrinks from the approach of the exploring finger. Th0 
centre of the intensest pain (spontaneous, as well as produced by pressure) is 
the upper portion of the crista frontalis externa, and the adjoining lower por- 
tion of the linea semicircularis, extending about four centimetres in length, and 
half a centimetre in width. The right tuber frontale is also more tender than 
the rest of the painful zone, but there is no particular tenderness over the fora- 
men supraorbitale. The painful zone does not extend below the eye. The 
patient is unwilling, for the sake of an experiment, to have the slighest pres- 
sure made upon the painful zone, but assures me that it has been done many 
times by mistake or carelessness, and has always been immediately followed 
by the intensest pain, with pallor of the face, loss of consciousness, and epileptic 
convulsions. The skin of the forehead is cooler than the rest of the face, it Is 
quite pale, and analgesic; a prick with a needle is not felt. The right eye 
looks smaller than the left, and is almost blind. (Only quantitative light can 
be ascertained.) The right pupil is somewhat larger than the left, and reacts 
sluggishly ; the right retinal vessels are narrower than those of the left side* 
The patient speaks very little, and almost without contracting the facial mus- 
cles, or moving the eyes ; it seems as if he preferred to turn the whole head, 
instead of contracting the mimical and muscles. His physiognomy there- 
fore lacks expression, or rather expresses stupor, though it is evident that he 
keeps the facial muscles immovable in order not to increase the pain. Tho 
patient has passed a perfectly sleepless night, and complains of nausea, general 
prostration, and heaviness of the head and eyes. 
As every kind of medication that had been resorted to had utterly failed 1° 
benefit the patient, I decided to make a careful trial with the galvanic current* 
1 applied the cathode of a weak current (two elements of Siemens) to the napo 
of the neck, and wanted to apply the anode to the painful zone, but the patient 
immediately turned away his head, before the electrode had touched the skin- 
Leaving the cathode at the same place, I then applied the button-shaped anode 
to the right auriculo-maxillary fossa, and, without interrupting the current, 
gradually increased its intensity. When six Siemens’s elements had been 
introduced into the circuit, the patient remarked that the pain in the forehead 
began to increase, whereupon I slowty diminished the intensity of the current, 
the whole sitting lasting a little over a minute. He felt somewhat better aftol 
the treatment, and slept that night until 3 A.M., when he awoke with headache 
and nausea, the right eye being perfectly blind. 
May 30. I tried again the galvanic current, but this time avoiding, as much 
as possible, fluctuations of the current-intensity by means of a rheostat, inter- 
calated as an accessory current. The current was derived from ten Siemens s 
elements, the flat cathode being applied to the nape of the neck, and the button- 
shaped anode to the right auriculo-maxillary fossa; the resistances were gra~ 
dually augmented in the rheostat, until the full current-intensity had passer 
through the body during fifteen seconds, after which the current was again 
slowly diminished by means of the rheostat, and imperceptibly broken. Th® 
effect of this treatment was quite surprising. As soon as the current began to 
flow with full intensity, the patient exclaimed that the pain had entirely lo* 
him, the head felt quite free, and the eyes became clear. The sitting had laste 
about two minutes. The patient was quite overcome b}r the sudden disappeal' 
ance of all the morbid symptoms; his features became movable, and the blind- 
ness vanished. He felt quite well the whole dajq had a good appetite, conn 
walk a great deal, and slept six hours. Though lie awakened without Pain) 
still, the next day, the head and eyes were heavy, and he felt the premonitoi} 
S3Tmptoms of an approaching paroxysm. 
May 31. I repeated the same treatment, and with the same result; ti ETIOLOGY OF EPILEPSY. 
383 
Patient feeling invigorated, as if, according to his own expression, awakening 
horn a long and refreshing sleep. I found on examination (which I had 
knitted the" previous day), after the treatment, the following facts: Slight 
touching of the painful zone, with the exception of the most sensitive part 
(urista frontalis, etc.), could be easily borne ; there was no trace of anaesthesia 
f)1" analgesia in this region, but, on the contrary, a prick with a needle was most 
Painfully felt (hypersesthesia). It was quite surprising to find complete anses- 
toesia and analgesia of the left (healthy) side of the forehead, extending exactly 
to the median line. Moreover, on tins side differences of temperature could 
M°t be distinguished by the patient, and on applying a piece of lint dipped in 
hot water, and another in iced water, he felt no difference on the left, healthy 
tole, and could easily bear them both; whereas, on the painful zone, he could 
lnstantly and with great precision discover the least difference of temperature, 
the extremes of which were felt most unpleasantly. I ascertained, besides, 
toat the left frontal muscle was paralyzed, the skin of the left (healthy) side 
totnaining smooth when he wrinkled the forehead 5 also,\ that the lelt upper lid 
c°ulcl not be perfectly closed. 
Jtine 1. I re-examined the patient, and convinced myself again of the correct- 
fess of the above-mentioned facts. I repeated daily the above-described 
leatmerit, applying in addition the button-shaped anode also to the left fossa 
laris. 
. June 20. The patient slept ten and a half hours, last night, and the foregoing 
nights, Six or seven hours, which for years he has been unable to do. He feels 
3uUe well and strong, and has no pain ; the head is clear, the vision of both 
normal, and he can read very wTell, has a good appetite, and is able to 
Walk considerable distances. On examination 1 find both eyes equal in every 
iespect, and the vision normal. The painful zone admits of a moderate pres- 
and even the most sensitive spot can be touched, though only very gently, 
he sensibility and sense of temperature in the painful zone still remain exalted 
(hyperesthesia), and there is no trace of analgesia. However, a stronger pres- 
Ju'e cannot be borne, especially by the most tender portion of the zone, and 
le patient still wears his straw hat obliquely toward the left side of the fore- 
leacl, thus leaving the right side uncovered. The left side of the forehead 
to'urot be corrugated, and is still analgesic, though a slight touch with the 
nnger can be felt; differences of temperature cannot yet be distinguished. 
, fbe galvanic treatment was continued daily as before, viz.; flat cathode at 
‘e nape of the neck, and button-shaped anode at first to the right, and then to 
. e left, fossa auriculo-maxillaris. Current-intensity seven to ten Siemens s 
ernents, increased and decreased cautiously, though of one 
? enieut could now be easily' borne. Current-duration about one minute, 01 
°ne minute and a half, for each side. 
July 3. qqie painfui ZOne can now bear a considerable pressure, and even the 
sensitive portion can be touched. The left side of the forehead can be 
toinkled, though less than the right side, and the left eyelid can be peifectly 
closed. The senses of touch and temperature on this side have considerably 
1111 proved, but are not yet restored. The analgesic area has been progressively 
oritracting; the patient at first could feel the prick of a needle only at the 
°wer part of the median line, then at the arcus superciliaris, and now the 
egion of the left temple alone remains analgesic. The patient complains of 
10 pain ; all his functions are normally discharged ; and his geneia health is 
quite satisfactory.1 
-p I shall not enter into an analysis of the above described symptoms, as 
tod not the opportunity of observing the patient at the time ot the 
accident, nor immediately after. Although the intelligent patient de- 
Scubed with great minuteness all his subjective feelings, and as much as 
A After thirty-one sittings of galvanic treatment the patient suddenly and unexpectedly 
lscontinued his attendance. NEFTEL, 
possible gave the opinions of the physicians who then attended him 5 
still we entirely miss the result of an objective examination as regards 
sensibility and motility ; the ophthalmoscopic appearances; the condi- 
tion of the pupils; the presence of sugar, albumen, or blood in the urine, 
etc. The patient did not even know during six years that the left 
(healthy) side of the forehead was anaesthetic and analgesic, with loss of 
the sense of temperature and with impossibility of wrinkling it (paraly- 
sis of the frontal muscle). On the contrary, he considered the painftd 
zone as being analgesic, which may have been the case during the parox- 
ysms of spontaneous pain, though during the intervals I always found 
this zone hyperaesthetic. 
There can be no doubt, however, that the injury produced a cerebral 
commotion of the gravest kind, which threatened to terminate with 
paralysis of respiration, exactly as in the experiments of Westpbab 
when the blow on the head was too violent. This termination was pre- 
vented in our case merely by the energetic and successful interference 
of the attending physician. Whether with the cerebral commotion 
some transitory affection of the brain had taken place, cannot be decided 
with certainty. Thus the vaso-motor phenomena might have been 
ascribed to a lesion on the surface of the cerebral cortex, in which 
Hitzig1 and Eulenburg and Landois2 have quite recently discovered the 
existence of vaso-motor apparatus. Again, the existence of pachymen- 
ingitis might have been assumed with still greater probability in conside- 
ration of the somnolence of the patient during the second week aftet 
the accident, and the diagnostic value which Griesinger3 attaches to tin9 
symptom, especially when it is found in conjunction with stupor, con- 
tracted pupils, and headache. On the other hand, the sudden and almost 
complete disappearance of all the morbid symptoms after galvanization, 
and their periodical absence, make very plausible the assumption that 
no permanent or grave lesion of the brain had been caused by the acci- 
dent. This supposition is supported by the researches of Fischer,4 who 
has shown that a mere traumatic reflex paralysis of the cerebral blood- 
vessels is sufficient to produce the phenomena of commotion of the 
brain. From the history of the disease, we have every reason to pi’6' 
sume in our case the existence of such a reflex paralysis of the cerebral 
bloodvessels and not a permanent structural lesion of the brain. 
This case therefore elucidates a most important fact, namely, that 
epilepsy can be produced in a perfectly healthy person (having no hereditary 
neuropathic disposition), by an injury of the head causing commotion with' 
out any structural lesion of the brain. 
Although the analogy of our case with the experiments of Westpha' 
is very striking in many particulars, yet there are also apparently some 
differences. Thus we find a zone in our patient, the mechanical irrita- 
tion of which calls forth at any moment loss of consciousness with epi- 
leptic convulsions, and though this zone is here hyperaesthetic, while it 
is anaesthetic in the animal, yet during the paroxysms of spontaneity 
pain it also appears anaesthetic and analgesic. We must bear in mim 
that we generally judge of the presence of anaesthesia in animals by the 
absence of expression of pain (screaming); but this was also the case 
1 Hitzig, Centralbl. fiir d. med. Wise., 1876; No. 18. . 
2 Eulenburg und Landois, Ueber thermisehe von den Grosshirnhemispharen ausgeheno 
Einfiusse ; Centralbl., 1876; No. 15. 
3 Griesinger, Arcliiv der Heilkunde, 1862, 
4 H. Fischer, Ueber die Commotio Cerebri; Sarnrnl.klin. Vortrage, Leipzig, 1871. ETIOLOGY OF EPILEPSY. 
385 
with the patient, who, though suffering intensely when the painful zone 
Was touched, never manifested any sign of pain, but only became pale 
aild lost consciousness. Possibly animals artificially made epileptic, 
suffer also from paroxysms of pain similar to those of our patient, but 
which have escaped our observation. Again, the blindness during the 
Paroxysms of pain (probably a vaso-motor phenomenon) has not been 
Noticed in the experiments on animals. Furthermore, the painful zone 
*N our patient was above the eye, whereas in the animal the epilepto- 
genic zone is situated below the eye. These differences, however, do 
not seem to be of great importance, and may depend on the incomplete- 
ness of the observations, on some unknown anatomical variations, or on 
differences in the localities to which the traumatic irritations are applied. 
Of late, cases of epilepsy have been published, in which an epilepto- 
genic zone has been observed, though in by far the great majority of 
puses this zone is not present. I treated a patient affected with epilepsy, 
111 1868, who in several respects resembled the one described in this 
paper, especially as regards the blindness and headache.1 I regret not to 
have paid at that time the necessary attention to the existence of an 
epileptogenic zone. Subsequently I received additional information 
h’om this patient, who is now in perfect health, that in his case there 
Was also great tenderness in the region of the temples, which could not 
he touched, and that the affection originated from an injury of the head. 
I may add that, in this case too, the "disease, which did not yield to the 
different remedies employed, nor even to a fortnight’s galvanization of 
the head, was successfully treated by a method similar to the one above 
described. It seems likely that the cases of epilepsy with an epileptogenic 
zpne are of traumatic origin, and it is therefore advisable in every case 
°t epilepsy to look carefully for an epileptogenic zone. Of course, in 
the human subject the place of this zone may not always correspond 
tff that observed in animals. It is also probable that in the course of 
time the epileptogenic zone becomes reduced, and finally disappears, thus 
leaping further observation. 
We are now led to inquire whether, in the majority of youthful epi- 
eptics, the disease has not been caused by frequent injuries (falling upon 
the head), in childhood, especially in individuals with a hereditary 
Neuropathic disposition. From this point of view it would seem surpris- 
ing that comparatively so few are affected with epilepsy and petit mal. 
the experiments on animals teach us, however, that not every blow upon 
the head even in the guinea-pig—this neuropathic animal par excellence— 
liable to produce epilepsy. For the same reason, in the child, the 
favorable conditions for producing epilepsy are comparatively rare: it 
Would possibly be requisite to have the head fixed to a solid immovable 
°hject, striking it repeatedly with a certain force, and perhaps even at a 
certain region. If we admit the traumatic origin of epilepsy, we are 
then enabled to explain satisfactorily many phenomena which accompany 
his disease, as for instance the prevalence of epilepsy in youth, the 
ereditary transmission of the disease, the negative results obtained 
'em the pathologico-anatomical investigation of the brain (at least the 
absence of structural lesions of the brain), the vaso-motor and other 
Phenomena which epilepsy has in common with cerebral commotion, etc. 
■lastly, I should like to direct the attention of the profession to the above- 
1 Neftel, Galvano-Therapeutics. New York, Appleton, 1871, p. 113. 
25 386 
NEFTEL, ETIOLOGY OF EPILEPSY. 
described method of treatment, which may possibly be also found useful 
in other cases of epilepsy. 
To conclude, I shall sum up what has gone before in two propositions:— 
I. It is made evident by the case described, that in a perfectly healthy 
person, free from any hereditary disposition, epilepsy can be brought on 
by traumatic influences upon the head, causing cerebral commotion with- 
out any structural lesion of the brain. 
11. Further investigations will be needed to prove that such traumatic 
influences during childhood may constitute a most frequent etiological 
factor in the production of epilepsy. 387 
the influence of high altitudes on the progress 
OF PHTHISIS. 
BY 
CHARLES DEHISOH, A.M., M.D., 
. It is assumed that this occasion calls for something suggestive, lead- 
lng an inquiring mind to look at an important subject in a new light, 
aud seeing the errors of former beliefs through a change in the channels 
of thought. How desirable then, if we are not now perfect (and I 
believe the hopeful mind of to-day has more to expect from what we are 
to learn, than from what we now know), that a controversy of opposing 
Hews should here he stimulated in friendly discussion. Believing that 
°Ur profession as a body is proving itself an insufficient barrier to “the 
progress of Phthisis,” and having convictions which persuade me to 
differ from many of the authors1 who have written on the subject of 
and consumption (and I have endeavored to consult them all), I 
may be excused for seeking to introduce this discussion by occasionally 
ernphasizing these differences of opinion. 
The subject assigned me is one of the most interesting and important 
fbat can claim our consideration, and all the more so because it has not 
hitherto received any special attention from our profession at As 
t° the disease itself—this great and persistent destroyer ot mankind 
finable results have of late accrued from the constant inquiry and patho- 
9gical research of eminent medical men. Thus this disease has come, 
through the critical analysis of a transitionary stage in professional 
ffi'inion, to include, under the one name of Phthisis, various and widely 
differing abnormal conditions. 
OF DENVER, COLORADO. 
Climate and Consumption. 
We can define Pulmonary Phthisis as slow death commencing in the 
yir>9s, or, going back of the local affection to the dyscrasia or abnormal 
H°od state which precedes or accompanies its progress, we can enlighten 
°TU’selves as to the various pulmonary and other defects which have till 
0 fate been considered as one disease. However, the scope ot this 
Jeport, and lack of time, make the minute consideration ot this subject 
tUI unwarrantable digression, so that we will content ourselves with the 
generally accepted significance of the term Phthisis in its broadest sense, 
lllcluding those morbid conditions (chiefly inflammatory2) which tavor 
t]i' Dr. Hermann Weber and Dr. Archibald Smith, late of Lima and elevated resorts in 
2 Peruvian Andes, are notable exceptions. 
, Hermann Weber, in the Medico-Chirurgical Transactions, vol. lii. (Treatment 
Phthisis by Prolonged Residence in Elevated Regions), gives the credit of first promul- 
°atlng these views to"the late Dr. Thomas Addison, “whose teaching, that inflammation 
the great instrument of destruction in every form of phthisis, was for a long 
lnie either ignored, or regarded as erroneous, by most ot his contempoi’aries.” (On the Pa- 388 
DENISON, 
weakening or a breaking down of pulmonary tissue ; and refer to special 
phases of the disease as the illustration of our thought may seem to 
demand. 
In considering the climatic treatment of Phthisis, it is not essential to 
dwell upon the first experiences of our medical fathers in this matter. 
The conclusion of Dr. Walshe, that “climate takes its occasional share in 
bringing about the nearest approximations to real cure therapeutically 
obtainable,”1 has at length come to be very generally held by medical 
men. Even before the disease was well understood, while the failure of 
medicine to cure or check it was slowly being realized, the considerable 
benefit derived from even mild changes of climate must have strongly 
suggested a climatic cure. So if the remedy of high altitudes had not 
long been utilized, as we now learn it has been in the Peruvian Andes, 
the first two cases mentioned by Dr. Hermann Weber, in his excellent 
paper “ On the Treatment of Phthisis by Prolonged Residence in Elevated 
Regions,”2 would have suggested this most potent means of cure to every 
reflective mind. These cases occurred in natives of elevated localities, 
who had become residents of London. Prostrated by acute phthisis, 
they returned to spend the remainder of their probably short lives h1 
their early homes, the one to the Black Forest, in Germany, at an eleva- 
tion of 2800 feet, and the other to Switzerland, 5000 feet above the sea- 
level, and in both the disease was quickly arrested. The evidences of the 
therapeutic value of high altitudes are, however, comparatively recent. 
Thus it is not strange that, having no better experience to trust to, 
the medical profession has hitherto placed confidence in the scattered suc- 
cesses furnished by Mediterranean, low continental, maritime and English 
health resorts. In England, and on the continent, the description and 
classification of favored health resorts have been carried to an exactness 
which has hardly been reached elsewhere.3 But it is a question, in my 
mind, if these analyses are not sometimes made to the exclusion of im- 
portant data, notably the moisture of the air, and with undue import- 
ance given to less vital points, such as the precise degree of temperature 
and the daily variation. Then again the author so often feels it incumbent 
on himself to tell you how to get away from a place, if you are not suited, 
that often no relief would seem to be expected; while the poor invalid, 
usually in some doubt, ekes out a six months’ health trip at as many sepa- 
rate resorts. This guessing at the answer to the invalid’s conundrum, 
“where can I best find relief,” is far from the certainty and confidence 
in the course to be pursued, which should characterize the climatic treat- 
ment of phthisis. There may be some physicians who are so specially 
gifted in the adaptation of these low climates to the consumptive’s needs 
as to gain very fair apparent success. After studying the descriptions m 
numerous low, inland, and seaside Mediterranean health resorts, with ad 
the phases and symptoms of phthisis so nicely met by the appropriate 
thology of Phthisis, by T. Addison, M.D., Guy’s Hospital Eeports, 2d Series, No. N-, 
1845.) The same has recently been emphasized in the works of Dr. Felix Yon 
and among others by Dr. Ludwig Buhl (Inflammation of the Lungs, Tuberculosis, an 
Consumption, New York, 1874). 
1 Diseases of the Lungs. W. H. Walshe, M.D. London, 4th edition, page 585. 
2 Loc. cit. 
3 Climate, in Williams’s Pulmonary Consumption ; Lettsomian Lectures, on the in flu earn 
of climate in the treatment of pulmonary consumption, by C. T. Williams, M.D.; Con- 
sumption, its early and remedial stages, by Edward Smith, M.D.; Diseases of the 
by Dr. Walshe, 4th edition; The effects of climate on Tuberculous disease, by Ldwi 
Lee, M.R.C.S., one of the Fiske Fund Prize Essays. INFLUENCE OF HIGH ALTITUDES ON PHTHISIS. 
389 
climatic remedies, I must confess to a slight feeling of hesitation. It is 
'vell for us to ask ourselves how certain we are of any permanent reliet 
peing obtained by consumptives in low humid climates. Though there 
18 no lack in the number of “ watering places,” the field is so small (with 
elevation left out) that one might almost as well think of supplying all 
climatic needs of consumptives within the boundaries of the little 
of Massachusetts. If in these low and narrow limits favorable 
qualities are found, then efficiency in the climatic treatment of phthisis 
Remands more decided proportions of these same qualities, which we 
h°po to show are to be found, together with additional advantages, at 
Bultable elevations.1 
Low Climates.—As I am going to speak positively in favor of the utility 
cf high altitudes, where not specially contra-indicated, and shall ask you 
0 concur with me in this favorable opinion, it is well to make mention 
the grounds I have for feeling less confidence in low climates. As 
Thl be apparent when we come to discuss the humidity of the air, we 
aJ'.e deprived of important data with regard to the undesirableness of low 
pi mates, in that we have few positive records of the relative or absolute 
Urffidity of these places in Europe. They all, however, represent more 
?v less moist climates. Of climates in England, Dr. C. T. Williams, hi 
his very carefully prepared Lettsomian Lectures, gives valuable statistics 
several localities, mainly along the southern shore of the Island, and 
fern arks upon the favorable results of 386 winters spent at those places 
y 243 consumptives. “Bear in mind,” he says, “ that these general 
assign the largest amount of benefit to the most easterly stations, 
follow a course exactly the reverse to that of the warmth of the 
Realities; Hastings, the coldest, being at the top of the list, and Tor- 
the warmest, being at the bottom,” Yentnor and Bournemouth 
Aing between these. This result will be claimed as an argument for 
I]B>h altitudes, when we come to consider that a cooler temperature, as 
*ell as decreasing humidity, are found to be the natural attributes of 
£Yat elevations. 
Ou the continent, there are also warm, moist clirantes, called sedative, 
an<l more exhilarating resorts, termed stimulating,2 which, like Hastings 
ln England, begin to partake of the best qualities of high altitudes, and 
. show, according to Dr. C. T. Williams’s excellent tables, a proportionate 
1 prove men t for the winters there spent by consumptives. Of the former 
Sr°up there is Pan, remarkable for the stillness of its climate, where, as 
We are informed, a plentiful amount of rain “ falls perpendicularly.”3 
an i ur°pe, a reason has seemed to exist for sending south to the warm shores of Italy 
k a t° the south of France those consumptives who, from feeble stomachs, are unable to 
W the quantity of food necessary to supply the waste caused by the greater amount of 
ygen inspired in the colder regions of the north. In the warm, moist climate, less car- 
ta**11 j is given off*, and less heat required, so that the feeble digestion is not so heavily 
as in the severe climate of England. The plan works well, chiefly as a palliative 
asure; but as warm weather comes on it is reasonable to believe that the scales must be 
a lle(I and that the indigestion and enervation felt at the South may be much relieved by 
V etum to the cool climate of the North. So the consumptives who have shunned a harsh 
to*3'' spring, by a sojourn in Florida, hasten back, as warm weather approaches, 
seaside and countrv resorts, and are kept constantly on the move, with considerable 
a Querent benefit. This idea of allowing the digestive capacity to decide to what climate 
nrflo!lSUmPtive should go, may often seem to result in good, but it founded on uncerta n 
to i?1868’ and lacks much desired definiteness in results. Like much ol the theorizing as 
to 16 reafment of phthisis indulged in by authors for many years, it is not radical enough 
cL.fnswer our needs in the war we have towage against one of the greatest of human, 
estroyers. 
'Wlshe, op. cit. 3 0. T. Williams, op. cit. 390 
DENISOjST, 
There is Valencia, in Spain, which Dr. Walshe characterizes as “ probably 
one of the warmest, most humid and depressing spots in continental 
Europe;” Pisa, a once populous city in Italy, of which the same author 
says that it has “ completely lost its quondam prestige as a sanitarium, 
though, as we fail to notice positive climatic qualities to greatly recom- 
mend it, we are surprised with the further assertion that this “ changed 
opinion is the result of sheer medical caprice;” and Venice and Rome, 
the latter of which Dr. Williams1 represents to have “had formerly & 
great repute, though for many years its unfitness as a shelter for invalid 9 
has been recognized, and it is now mainly resorted to for pleasure, and 
not for health.” Among the latter group (“stimulating”), we find 
Hyeres, Cannes, San Remo, and Rice (representing the Riviera), Barce- 
lona, Gibraltar, Malaga, Lisbon, and the Mediterranean islands (as Sicily, 
Sardinia, Malta, and Majorca), which, as before remarked, partake cd 
more favorable qualities, and are notably less moist, than the “sedative 
group, or which have some peculiar attributes; thus Dr. Edwin Lee say 9 
of Raples, “The frequent variations from dryness to moisture, and from 
warmth to coldness, promote the disengagement of electricity.”2 
There are marine climates which, being wholly surrounded by salt 
water, I fancy confer some of the advantages of sea voyages, in that the 
air is constantly in motion, and the insensible activity of the skin thereby 
promoted, while the air is always pure and bracing, considering the tem- 
perature. Ho that these may be considered better than the moist climates 
on the continent of Europe ; and yet Dr, Walshe says of Madeira, “ much 
of this promising character turns out to be practically delusive. The 
damp is so extreme that changes of temperature thermometrically small 
—of three or four degrees—prove sensationally great; a temperature of 
58° indoors, without being actually cold, is disagreeably chilly,” etc. 
The Canary Isles, St, Helena, some of the Mediterranean islands, the 
Bermudas, Bahamas, West Indies, etc., may also be considered in tin 9 
group. There are relatively very dry climates, as Egypt and Syria, whose 
enervating quality is the high temperature which would hardly be beat' 
able, were the dryness absolute,4 
Of American climates, we have the characteristic low resorts of 
and sedative Florida ; the balsamic regionss among the pines in southern 
Georgia; the dry and alkaline regions of southwestern Texas, in the 
vicinity of San Antonio; and the exceedingly equable and mild Racifc 
coast, San Diego, Los Angeles, Santa Barbara, San Luis Obispo, San Jose, 
and San Rafael, in California. Because of the great humidity of the 
atmosphere, these last are much like the warm moist climates in the 
Mediterranean basin. The favored low resorts in the United State9 
might be much better chosen climatically speaking, but then the attrac- 
tions have thus far been where the comforts of life are to be found. 
1 Op. cit. 2 Op. cit. 
3 A sea captain of long experience, who now lives in Denver, for the relief of asthma, 
tells me he has carried many consumptives to the Sandwich Islands, “ but brought none oj 
them aioay 
4 In America, in Southwest Arizona, and in the inland portion of Southern California 
notably in the vicinities of the Death Yalley and Fort Yuma, the winter months only ai 
comfortable, and sometimes hardly that, because of the intense radiation from the sane y 
plains. At Fort Yuma, Dr. Geo. S. Rose, of the D. S. Army, has informed me that the m 
annual rainfall has been for nineteen years only 2.95 inches, while the average annual ten 
perature has been remarkably high—about 75°. , 
5 The Pine Forests of Georgia as a Resort for Invalids; by Ezra R. Fulling, M- 
Reprint from N. Y. Med. Journ., Sept. 1871. INFLUENCE OF HIGH ALTITUDES ON PHTHISIS. 
Medium Altitudes— America is blessed with advantageous resorts for 
cases in which high altitude is not well borne, or rather not permissible. 
-Notably is this true of the medium altitudes, though the need ot them has 
yet to be sensibly felt by physicians who guide invalids, before desirable 
comforts and accommodations will be assured. Among these should be 
Mentioned the Cumberland Table Land, in the mountains of eastern 
Tennessee, more especially “ Walden’s Ridge” (elevation about 2000 feet), 
lately described by the facile pen of Dr. E. M. Wight, of Chattanooga ;x 
western North Carolina (Ashville, elevation 2250 feet);2 southwestern 
Texas (Fredericksburg, Boerne, XJralde, and Ft. Clarke, elevation 1500 
to 2000 feet, valley of Rio Grande); southern New Mexico (the Mesilla 
Valley) and western Kansas (elevation 3000 to 4000 feet), the former in 
winter and the latter in summer being comparatively warm enough to 
be placed in this group. So also northern Minnesota (St. Paul and 
Th’ainard, elevation" 1200 feet), because of its cooler temperature and 
northern situation. In Europe, examples of medium altitudes might 
be mentioned, as Silesia (Gorbersdorf, 1700 feet), Le Mont Dore (3400 
feet), Konigswarth in Bohemia (2200 feet), Black Forest (2800 feet), 
Lower Engadine (about 4000 feet), Faux Bonnes (2450 feet), Cauterets 
(3254 feet), and BagiAres de Luchon (2060 feet). In Brazil, Dr. Walshe 
desires to call attention to San Paulo (2300 feet), a short distance inland 
from the port of Santos. In Mexico, we have Jalapa (4000 feet).3 
High Altitudes.—Coming now to high altitudes proper, a few places 
will be mentioned, chiefly those which will serve for our present study, 
lying in the region of an altitude of approximate immunity from phthisis, 
which we will consider further on. In Europe we have to content our- 
selves with more unfavorable complications than obtain in the chosen 
high altitudes of America. The mountains of the Alps present, in the 
upper Engadine, such resorts as St. Moritz (6100 feet), Samaden (5500 
fret), and* Davos (5200 feet). They are high enough for their northern 
latitude, but are burdened with an excess of moisture gathered by the 
fountains, exposed as they are to the moist Atlantic currents. This is 
evidenced by Dr. Walshe’s citation from Dr. Hewlett,4 that, at St. Moritz, 
“in fourteen winter months (seven in 1866-7, and seven in 1867-8) there 
Were only fifteen clear days, while 148 rainy days, and others more than 
half clear, with their admixture of snow, sleet, and rain, made up the 
I’est.”5 This is considerably at variance with the excellent reputation 
Lr. L. Yacher gives Davos, for the five cold months ending with March, 
during which time only the stay of consumptives at this resort is recom- 
mended.6 It is here that the plan, personally investigated by Dr. Yacher 
(so novel to us who live at the base of the Rocky Mountains, though 
Partly exemplified by the invalid’s experiences in Minnesota), is presented, 
fr consists in keeping invalids in the region of continuous snow, until 
|be thawing season in the spring, when they are quickly removed to a 
lower level. Dr. Yacher gives the number of invalids seeking this resort 
1 A People without Consumption, and some Account of their Country, etc. Reprint, 
runs. Tenn. Med. Society. 
Western North Carolina as a Health Resort; by W. Gleitsmann, M.D. The Climato- 
herapy of Consumption; by S. B. Chaille, A.M., M.D.; from N. O. Med. and Surg. 
d°urnal, May, 1876. 
* Influence of Climate in North and South America; by J. Disturnel. 
Walshe, op. cit. 
® St. Moritz; by R. W. Hewlett, M.D. 1871. 
Le Mont Dore—Davos. Etude medicale et climatologique sur les cures d’air dans la 
Inthisie Pulmonaire ; par Le Dr. L. Vacher. Paris, 1875, 392 
DENISON, 
as eight, in 1865 ; 55, in 1870; 220, in 1873 ; and 400, in 1874; which 
ratio serves to show the increasing favor which the results of the treat- 
ment have warranted, as well as the comparative newness to Europeans 
ot the special efficacy ot high altitudes, I shall have many occasions to 
refer to the experiences furnished by Davos. In Asia, the elevated pla- 
teaux in Persia and Armenia, and those adjoining the lofty Himalaya 
Mountains, together with other elevated inland and dr}7 localities, would 
seem to furnish excellent climatic combinations, but I have not the neces- 
sary data for an account of that vast section. 
In America, North and South, the great Rocky Mountain and Andes 
chains furnish, along and between their variously diverging branches, 
almost innumerable resorts of any desired elevation or latitude. From 
the north to the south,in thellnited States,the great plateaux and elevated 
basins between the Rocky and the Cascade Range, the Sierra Nevada 
and the Sierra Madre Mountains, present variations in altitude, tempera- 
ture, and humidity, which would claim our attention could we now 
spare the time necessary to study so broad a field. Generally having 
favorable climatic attributes, with unfavorable distances and local pecu- 
liarities, we pass over this vast section to mention the western slope of 
the Sierra Nevada, in California (vicinity of lakes Donner and Tahoe, in 
summer), and especially the eastern slope of the Rocky Mountains, in 
Colorado and New Mexico. (Cheyenne, in Wyoming Territory, 6100 
feet; Boulder, Colorado, 5300 ; Denver, 5200 ; Idaho Springs, 7540 ; Colo- 
Springs, 5980; Manitou, 6200; Pueblo, 4630; Canon City, 5260; 
Trinidad, 5800. In New Mexico, Santa Fe, 6850; and Albuquerque, 
5030.) 1 4 
It is in Colorado that the Rocky Mountains proper reach their great- 
est continuous height, many peaks being over 14,000 feet, and present a 
remarkable width of 100 miles. Interspersed with these lofty peaks are 
elevated plateaux, or valleys, as North, Middle, and South Parks, 8000 
to 10,000 feet; Fairplay, 9800, and San Luis Park (Del Norte), 7000 
feet. In Mexico, this vast plateau is continued, being about 1000 miles 
wide at the north, and nearly 2000 in length, and is called the Anahuac. 
It varies in elevation from 8000 feet on the east, to 4000 feet in some 
portions of the western, or Pacific, slope (the City of Mexico, 7400; 
Chihuahua, 4640), and includes most of the Tierras Frias, or cool re- 
gions. These exceedingly dry, elevated plains, including extensions to 
the north into New Mexico and Arizona, would claim much more of 
our interest and study were the habits and lives of their greasy original 
inhabitants more inviting and congenial to the cultivated American. 
The loose sand and fine lime dust, together with the rapidly increasing 
growth of the prickly and inhospitable cactus, as you go south and 
southwest from central Colorado, may reasonably indicate'the undesira- 
bleness of much of that southern region.l As exceptions to this unin- 
viting region, I note the beautiful and favorably-located southern slope 
of the mountains, toward the San Juan river, in southwestern Colorado, 
where lie the Pagosa springs (most wonderful of the hot springs in Ame- 
rica) ; a genial climate and interesting volcanic region near Fort Bayard 
1 Where the cactus prows to the size of trees, as in some parts of New Mexico and 
Arizona, Lieut. Philip Reid, of the United States army, informs me, are the most uninviting 
places imaginable for the steady abode of man. Yet here, on the advent of railroads, I 
predict will be found the extreme climatic remedy which will suit many in winter who are 
now without much hope anywhere. Such is the fight the invalid will have to make with 
his destroyer. INFLUENCE OF HIGH ALTITUDES ON PHTHISIS. 
(elevation, 6000 ft.); the foot-hills and possible favored resorts in sunny 
Uplands of Chihuahua; and the inviting surroundings of the antique 
.Ity of Mexico, almost encircled by the lofty Sierras, which inclose beau- 
tdul lakes and favored resorts, and send, among other peaks, the Popo- 
catepetl 17,785 feet above the sea, far into the regions of perpetual snow. 
The Cordillera de los Andes, which has divided in Guatemala, to 
°l'ni the eastern and western boundary of the Anahuac in Mexico, ex- 
tends into South America, to rise still higher just north and south of the 
equator. Here the Cordilleras, lying close to the Pacific coast, diverge 
*u ranges which inclose elevated valleys or plateaux from less than 8000 
le over 12,000 feet in height, while snow-clad peaks like Chimborazo in 
Ecuador (21,500 feet), and the Sorata and Illimani, in Bolivia (22,400 
and 21,250 feet), tower above.1 In the central portion of Peru the Mon- 
Cria consists of a lofty plateau, averaging 12,000 feet in height, which con- 
dos many cities and villages, possessing, according to Disturnel, “a 
ei'flie soil, amid the most magnificent scenery on the earth’s surface,” 
aud “ enjoying a temperate and delightful climate.” The considerable 
Moisture in the air, for such great elevations, as contrasting with the 
Excessively dry regions on and to the north of the Anahuac, may yet 
1,1 dicate valuable discriminations for the thousands who will seek a 
of their consuming strength in high altitudes. 
Analysis of the Attributes of High Altitude Climates. 
We have now hurriedly, and somewhat superficially, reviewed the 
c juuacteristics of low climates, and have geographically indicated me- 
’Uqn and high altitudes. In claiming our present consideration, high 
fitudes have 'positive features and effects to contrast with the uncertain- 
°f low levels. Therefore it is to be hoped that the considerable space 
Wyen to low climates may not be thought amiss; so much does our ap- 
P|Gciation of good, as in fact the enjoyment of life, come to us by con- 
■ last. I have gladly accepted the invitation to consider high altitudes 
general, rather than any one locality, though I fear that the dry 
• of so large a field will tax your patience, and be otherwise unsat- 
s actory. Let us then consider high altitudes in the abstract, and seek 
0 analyze the attributes of its atmosphere, leaving, for the present, geo- 
-Braphical and local considerations mainly in the background. 
We may form in our minds an idea of the climates which will best 
nswer the consumptive’s needs. Hot that we can fathom the Creator’s 
j.' aJis, and improve on the world he has given us, but that having satis- 
e(l ourselves of the ideal, for the majority of phthisical patients, we 
Aqy then seek the real, among the varied climates of the earth. Here 
18 instructive to remark how various are the visions indulged in by 
j.Satisfied man, of the most beautiful and desirable country in which to 
1 e- _ It is of consequence also to note that it is improbable that we 
f Asicians would agree, were we to vote now as to the average tempera- 
tijj leri d>s considered that, under the equator, the growth of wheat is not established 
Pj ,16 aPitude of 4500 feet is reached, and that sugar cane has been grown at 7500 and 
for >dria.lla at 5400 feet, it is not to be wondered at that the most comfortable existence 
thpnian d»und at a considerable elevation, and that populous cities lie high up in 
0f aioantains, as Bogota, the capital of the United States ot Colombia, 8650 feet; Quito, 
or pCiUa(!y.r’.feet; Cuzco, the ancient capital of Peru, 11,380 feet; and towns bordering 
1 a'e liticaca, between Bolivia and Peru, 13,000 feet. DENISON, 
tore, humidity, amount of sunshine, electric tension, elevation, and char- 
acteristics of wind, as to direction and velocity, etc., of our ideal cli- 
mate, for the majority of consumptives, or even for uncomplicated phases 
of the disease. The attributes of climate just mentioned are so inti- 
mately interwoven and dependent on each other, that their separate 
consideration is difficult. We will try, however, to avoid repetition by 
referring to them in the order named. 
Temperature.—The temperature of high altitudes makes life pleasant 
under the equator, and gives marked variety to climates north and south 
of that line. In general, the decrease in the temperature of the air has 
been reckoned at 1° Fahr. for each 800 feet of elevation.1 JBut the rule 
for the decrease of temperature cannot be arbitrary for all elevations, 
because of local peculiarities. For instance, the mean annual tempera- 
tures of places along the eastern base of the Rocky Mountains in Colo- 
rado, are much higher than their elevations would indicate, judging 
from the records of stations in the same latitudes on the Atlantic coast 
of the United States. The cause of this is (1) The far inland position• 
“ The sun’s rays passing through the air with but trifling loss, fall on 
land or on water. The specific heat of land being only one quarter that 
of water, it both absorbs heat and gives it out more rapidly . . . conse- 
quently the more land the greater is the heat, and the wider the diurnal 
and yearly amplitudes of fluctuation.”2 (2) The dry sandy soil. The 
plains are generally but lightly covered with grass (rivers and trees 
being very limited), and this tends to increase the difference between 
ordinary clay soil and water, and so furnishes both greater absorption and 
greater radiation of heat than the ordinary soil of lowlands. (8) The q>r°' 
tection afforded by the mountains, to the west and northwest. These break 
or divert strong winds, and gather moisture from western currents, thus 
promoting an increase of sunshine on the plains. (4) The dry and ward1 
Equatorial and Pacific winds. These prevail at all exposed points on the 
mountains, and bring pleasant weather to the plains below. 
In considering the variations of temperature referred to above, 
remark that the more rapid absorption and radiation of heat by lun(* 
than by water, explains the low fall of temperature at night, and the 
considerable rise at midday, away from the sea-coast, and shows, by pl' 
ference, the equalizing influence on temperature of moisture in the air* 
These variations are increased in high altitudes by the lessened capacity 
of the air to hold moisture, due to elevation and the resulting loss 111 
weight. The annual fluctuations, due to the changed angles with which 
the sun’s rays fall on the earth, are for the same reason affected by eleva- 
tion. Thus the following table is explained, giving the mean daily range, 
the average monthly range, the range of monthly means, the annual 
means, and the annual range of temperatures of places chosen as nearly 
as possible in the same latitudes, on the sea-coast, inland, and at the base 
of the Rocky Mountains. 
1 Under the equator it has been estimated to be l°Fahr., near sea level, for each 333 ft- > 
for each 297 feet at 10,000 feet, and for each 818 feet at 20,000 feet elevation ; while recej1 
observations, in temperate climates, have given the rule of 1° Fahr. for every 400 feet, dn 
records of Mr. Glaisheris balloon ascension indicated different strata of air, the fall in tenl' 
perature being under a clear sky 5° Fahr. for each of the first four inches of baronietn 
fall, then 4° per inch till the thirteenth inch of descent, and 4.5° each for the last thre 
inches. 
2 Parkes, Practical Hygiene, p. 417. 4th ed. Phila., 1873. INFLUENCE OF HIGH ALTITUDES ON PHTHISIS. 
395 
Table I.—Showing Ranges 
of Temperature from July, 
1874, to July, 1875.1 
Mean daily 
Mean monthly 
Range of 
Annual 
Annual 
Atlantic Stations. 
range. 
range. monthly means. 
mean. 
range. 
New Haven, Ct. 
16° 
42° 
48° 
48.6° 
91° 
Atlantic City, N. J. . 
15 
41+ 
44.1 
49.7 
89|- 
Baltimore, Md. . 
18 
44 
48 
53.9 
98^- 
Norfolk, Va. 
18 
44 
40.7 
57.3 
89j 
T Average . 
17 
43 
45.2 
52.4 
92 j 
Inland Stations. 
46.8 
51.7 
54.2 
120 
127* 
117 
Davenport, Io\Va 
Indianapolis, Ind. 
St. Louis, Mo. . 
18 
22+ 
20 
53.5 
57 
53 
68.6 
58.5 
57.4 
Nashville, Teun. 
21 
49 
49.7 
59.5 
108 
Average . 
Lleyated Stations. 
20 + 
53.12 + 
58.55 
53.05 
118$ 
Cheyenne, Wyo. 
Denver, Col. . 
31 
30 
61.5 
60.5 
48.9 
53.7 
43.6 
49.2 
136 
131 
Colorado Springs, Col. 
30 
63.5 
47.7 
46.8 
123 
Santa Fe, N. M. 
29 
49.5 
45.3 
49.2 
88 
p Average . 
30 
58.75 
48.9 
47.2 
119$ 
■Pacific Coast Stations. 
11.5 
55.5 
50 
San Francisco, Cal. . 
12+ 
31 
San Diego, Cal. 
13 
31 
5.6 
59.9 
60 
.Average . 
IH 
31 
8.55 
57.7 
55 
besides showino- the effect of inland, position and elevation on the 
daily, monthly, and annual ranges of temperature, this table makes evi- 
dent certain facts of interest both in reference to the stations separately, 
and the groups into which they are divided. (1) The fluctuations in 
temperature (notably, of course, in the annual range) decrease toward the 
South. This continues till even greatly elevated localities, near the 
equator, are quite equable in temperature, as on the elevated plains in 
the Peruvian Andes. (2) The comparatively low range of monthly 
means, at the “elevated stations,” considering the high mean daily, 
Monthly, and annual ranges (with the low average relative humidity of 
this section, about .45), indicates that there must have been a large pro- 
portion of pleasant, even weather at those stations in each month to have 
made up for those other extremes. This preponderance of pleasant, 
shnny weather is quite uniform at the base of the (o) iie 
extremely low mean range of temperature for all_ divisions of time, on 
Ihe Pacific coast, indicates the existence there of a continuous, warm, 
moist wind, which is unobstructed, and only gives up its moistuie when 
c°oled by the winter temperature of that latitude.2 _ , , .. 
, The influence of heat on the activity of several functions of the body 
mads us to prefer a cool to a warm temperature. (I) Heat is opposed to 
stimulation, so far as the nervous system is concerned. “in experiments 
Report of the Chief Signal Officer, War Dept., 1875. 
2 It is unobstructed, for otherwise there would be greater precipitation of moisture, and 
accompanying thermal changes. That it only rains in winter, is a tact known to all. It is 
a continuous wind, for otherwise terrestrial radiation and absorption would have produced 
a much more marked effect on the temperature than the records show. It may be considered 
Warm, because a cold wind could not carry moisture enough to have produced such thermal 
effects in these latitudes. It is moist, because if it was dry the daily and seasonal influences 
the sun would be greater than the records show. We are not surprised then to learn 
that the average atmospheric humidity is out of proportion to the amount of rainfall on the 
Pacific coast. DE jSTISOK, 
on frogs, when a temperature much over the natural amount is applied 
to nerves, the electrical currents through them are lessened, and at last 
stop.1 E. H. Weber’s observations2 show that for men the same rule holds 
good, the most favorable temperature being 99.5° Fahr.”3 Then a con- 
trast between the temperature of the surrounding air and that of the body 
favors the influence of atmospheric electricity, which experience proves 
to be an active agent at considerable elevations. (2) Heat in the shade 
has been shown by Rattray4 and others to have a sensible effect in 
increasing the temperature of the body, to counteract which a healthy 
activity of the skin is required, but is impeded by a coincident high 
relative humidity of the air. The experiment of entering a heated oven 
(200° to 800°) becomes more difficult when the air is moist than when 
it is dry; evaporation is hindered, and the bodily temperature is said to 
rise even 7° or 8°.5 (3) Heat lessens the number of respirations per 
minute. According to Rattray’s observations, the variation has been 
known to be from 16.5 respirations per minute in England, in winter, to 
12.74 and 13.74 in the tropica. Other observers note that the breathing 
is also less deep. Hr, Francis (Bengal Army) and Dr. E. A. Parkes0 
have both observed that the lungs are lighter after death in Europeans 
in India, than the European standard. On the other hand, a healthful 
activity of the respiratory function is favored by a cold temperature, and 
is an important feature of the high altitude cure. (4) Heat, especially 
if continuous, lessens the digestive powers. The stimulation of the appe- 
tite which cold is well known to produce, is lacking, especially for much- 
needed animal food. So the destruction and formation of tissue is 
retarded. This is also opposed to that renovation of system which is 
decidedly promoted by both cold and elevation. 
Humidity.—To continue our proof that cooZ, dry climates are better 
constituted for the needs of phthisical patients than those which are 
worm and moist, we will consider the humidity of the air, hearing in 
mind that coolness and dryness are constantly favored by increasing ele- 
vation. This brings us to one of the strongest arguments in favor of 
high altitudes. It is, however, difficult to thoroughly explain this sub- 
ject, because of our lack of familiarity with the precise laws which 
govern the various changes of the moisture in the air. 
The Signal Service Bureau of the United States Army determines the 
relative humidity of the air by the difference in temperatures given by the 
wet and dry bulb thermometers, and thus the percentage of saturation 
of the air is known. But these humidity records have not been well 
distributed, and it would seem either that the Officers of this bureau have 
little confidence in the reliability of humidity statistics, or that they 
do not appreciate their important bearings on scientific and climatologi- 
cal investigation. While the relative amount of atmospheric moisture 
is most important, as determining the healthful activity of the skin, 
the evaporation and quickening of perspiration from the surface of the 
' Eckhard, Henle’s Zeitschr., Band x., S. 165, 1851. 
2 Weber, Ludwig’s Phys., 2d ed., vol. i. p. 126. 
3 Parkes’s Practical Hygiene, 4th ed., p. 400. 
4 On the Effects of Change of Climate on the Human Economy, by A. Eattray, M.D-> 
Surgeon R. N. Proceedings of the Royal Society, 1869-1872. 
5 By inference we find here one cause of sunstroke, which in our experience does not occur 
at great elevations in America, notwithstanding that Dr. Yacher (op. cit.) speaks of sun- 
stroke occurring on the Alps. 
6 On Algide Cholera, by E. A. Parkes, M.D., p. 14 (1847). INFLUENCE OF HIGH ALTITUDES ON PHTHISIS. 
body being greatly in proportion to the removal of the dew-point and 
temperature of the air from that of the body, yet these recoids aie in a 
Pleasure superficial, simply because they are relative and not real. This, 
too, notwithstanding that a little more than halt the ratio of satuiatiou 
is shown by them on the plains east of the Rocky Mountains, to that 
Which exists in some localities on the sea-coast. rihis is proof enough 
that our temperature is not much in the suspicious company of the dew- 
point. I am, however, inclined to claim that the importance of a large 
amount-of atmospheric vapor, as a causative, and of a small amount, as 
a curative, element of phthisis, is such that the absolute rather than the 
relative amount of moisture in the air needs our special study. It to-day 
We were possessed of the knowledge of the average amount of vapor m 
a cubic foot of air in all parts of the country, I believe we would have 
°ue, if not the most valuable indication possible, of the best localities 
for phthisical patients. With some reservation as to temperature, the 
tallest ratios would indicate where consumption originates with the 
greatest difficulty, where a low ratio of relative humidity, a small 
manual rain-fall (excepting sudden and great precipitation), a large pro- 
portion of sunshine, and a favorable diathermancy of the air would be 
assured, so much do these favorable conditions accompany real dryness 
of the air. This absolute humidity would of course be shown to be 
greatest in the tropics, least toward the poles ; increased over large bodies 
of water, decreased as we go inland from the sea; increased by heat, as 
m summer and at mid-day, and decreased by low temperature, as in 
winter and in the morning. . ~ 
To more fully consider the importance of the real atmospheric humid- 
ify, it is to be noted that the air is capable of holding moisture, mainly 
according to its temperature. The expansion of air under the influence 
?f heat increases its capacity for retaining invisible vapor from about 
half a grain in a cubic foot, the limit at zero, withia ba romet ncal pres- 
sure of thirty inches, to 19.84 grains, the limit at 100 Fahr. (bee Table 
If-) As to a loss due to change in the weight of the air, many compli- 
cations present themselves, among which a very one is the tact 
fbat dry air weighs from 2 grains at a temperature of 44° Fahr., to 8 
grains at 80° Fahr., more in the cubic foot than saturated air. ihe 
elastic force of vapor, or the absolute humidity of the atmosphere, Mr. 
flffichan says “ diminishes with the height, but the average rate at which 
diminishes is not known.”2 The records of balloon ascensions give 
s°nie information in this direction, but not sufficient to constitute any 
r»de of change. The balloonist. Croce-Spinelli, who perished in his aerial 
fiight,recorded before he died that, at an elevation of 16,370 feet, there 
no longer vapor in the air.” And the experience ot many ot us 
who have ascended great heights, agrees with that ot Gay- ussac, wlO 
recorded in his balloon ascension that, at 14,715 feet, “the air was so dry 
fflat for want of saliva he could hardly swallow bread. We understand 
fflat the air is twice rarefied at a height of 3J miles, 4 times at 7 miles, 
16 times at 14 miles, 64 times at 23 miles elevation, etc This expan- 
sion of the air with increasing elevation is accompanied with a loss ot 
part of its humid contents, through the coincident cooling which takes 
place, so plainly described by Prof. Tyndall.3 If, with our ‘minds 
1 Smithsonian Meteorological and Physical Tables, by_A. Guy ot. 
2 Handbook of Meteorology, by Alexander Buchan, ed p 162. 
3 The Forms of Water, by John Tyndall, LL.D., T.H.S., ib<4. 398 
DENISON, 
eye,” we follow a cubic foot of saturated air in its ascent through space, 
we notice the loss of most of its moisture through the chilling due to the 
expansion ; but there is another portion of the moisture, as well as of the 
air, crowded outside the cube by the same expansion. Mr. Glaisher’s 
tables, before referred to, which give the weight of vapor in a cubic foot 
of saturated air at different temperatures, are made for a barometric 
pressure of 30 inches. If these tables are as accurate for places a mile up 
in the air as for those at sea level, then there is no diminution of mois- 
ture due to elevation independent of temperature, and the saturated ait 
of such height may retain more moisture in proportion to its weight for 
a given temperature than the air at sea level. The air at the School of 
Mines, in Golden, Colorado, 5900 feet above sea level, was found by Prof* 
E. J. Mallett to contain at 60° Fahr. 331 grains of nitrogen and 99 
grains of oxygen, or 430 grains weight for the cubic foot, which is just 
about four-fifths the weight of air at sea level. 
Table II.—Showing Weight of Vapor, in grains 
Troy, contained in a 
cubic foot 
of saturated air, at temperatures between 0° and 105° 
Fahrenheit} 
Tempera- Weight of 
Tempera- 
Weight of 
Tempera- 
Weight of 
Tempera- 
Weight of 
ture of air vapor in 
.ure of air 
vapor in 
ture of air 
vapor in 
ture of air 
vapor iu 
Eahr. grains. 
Fa hr. 
grains. 
Fahr. 
grains. 
Fahr 
grains. 
0° . . 0.545 
36° . 
. 2.469 
63° . 
. 6.361 
90° . 
. 14.810 
4 . . 0.649 
39 . 
. 2.759 
66 
. 7.021 
93 . 
. 16.176 
8 . . 0.772 
42 . 
. 3.076 
69 . 
. 7.739 
96 . 
. 17.648 
12 . . 0.916 
45 , 
. 3.426 
72 . 
. 8.521 
99 . 
. 19.235 
16 . . 1.090 
48 . 
. 3.811 
75 . 
. 9.372 
101 . 
. 20.357 
20 . . 1.298 
51 . 
. 4.234 
78 . 
. 10.292 
103 . 
. 21.535 
26 . . 1.674 
54 . 
. 4.696 
81 . 
. 11.291 
105 . 
. 22.771 
29 . . 1.892 
57 . 
. 5.202 
84 . 
. 12.376 
33 . . 2.208 
60 . 
. 5.756 
87 . 
. 13.546 
Is there no diminution in the capacity of this rarefied air for moisture, 
due to this lessened pressure of three pounds to the square inch? The 
question is of importance to us as affecting the basis of our judgment of 
high altitudes. Besides, the Signal Service weather reports often come 
to us with relative humidity noted as “ not corrected for elevation,” and 
we are left to learn what such correction may be. Kow, seeking to avoid 
the headache and uncertainty which are induced by the search for suit- 
able explanations in Guyot’s and Glaisher’s complicated tables, we wiU 
simply say that the only correction given is by the former author,2 and 
adds from two to three per cent, to the relative humidity of places of the 
altitude of the Rocky Mountain base. This correction, as affecting the 
dryness of air in high altitudes, amounts to but little ; besides, as before 
inferred, the comparison of climates by the relative humidity of each, is su- 
perficial, when temperature is not taken into account. With temperature, 
however, as indicating the capacity for moisture, the question becomes 
equivalent to this: Is the comparison of climates by the absolute humidity 
of each just? Our argument in advance has been that possibly it is 
unjust to high altitudes, as far as desirable dryness is concerned. Let 
us suppose it just, however, and (adding Guyot’s corrections) make one 
or two comparisons which will suffice for all, and show the superiority 
of the highlands over the lowlands. We are enabled to compute the 
weight of vapor from Mr. Glaisher’s table already given, or from one of 
Guyot’s tables. Compare Jacksonville, Florida, with Denver, Colorado* 
1 Smithsonian Meteorological and Physical Tables, page 93. 
2 Ibid., page 72. INFLUENCE OF HIGH ALTITUDES ON PHTHISIS. 
399 
According to Dr. Baldwin,1 the mean annual temperature of Jackson- 
is 69.82° Fahr,, and the mean relative humidity .696. The Signal 
service records at Denver give a mean annual temperature of 49,2°; 
1 Native humidity .46 (corrected for elevation, .48). Then the average 
foot of air in Jacksonville contains 5.6 grains of vapor, while in 
■Denver the amount is 1.91 grains, about one-third as much. Or again, 
„° compare the humidity of Jacksonville, Davos, and Denver, for the 
u,Ve cold months ending with March, the term of the thermal cure at 
avos, we have:— 
Mean 
Mean relative 
Grains of vapor 
temperature. 
humidity. 
in a cubic foot. 
Jacksonville . 
60° 
68 
3.92 
Davos .... 
23 
842 
1.24 
Denver .... 
512 
1.13 
The small amount of absolute humidity compared with the high rela- 
UlVe humidity of Davos, shows the fallacy of judging solely by the relative 
timidity, while the whole table shows the remarkable dryness of high 
al«tudes in winter. 
, . "he sensational effect of cold with excessive absolute, as opposed to a 
Ql§h ratio of relative, humidity, and really little moisture, is conside- 
. tible. A gentleman, now a resident of Denver, who formerly resided 
111 Jacksonville, says that he “ stands the winter cold better,” and “feels 
J;Ss chilly,” in Colorado than in Florida; and the temperature of 58° 
-ptihr., in doors (which is always very comfortable in Denver), is said by 
i .r°f. Walsheto be “ disagreeably chilly” at Madeira. Excepting certain 
xilgh altitudes where mountains act as constant condensers of moist 
currents, it is now incontestably shown that, as to temperature and 
1 timidity, coolness and dryness are progressively concomitants of in- 
leasing elevations. The proof that cool, dry climates, or high altitudes, 
aie better than warm, moist ones, or tropical lowlands, needs no better 
c°tielusion than the evidence furnished by Dr. C. T. Williams’s excellent 
tinalyaig of 598 winters spent by 251 consumptive patients in foreign 
lrnates. I quote with pleasure (and with thanks for the unintentional 
tivor) the indisputable evidence which this zealous student of European 
tie! lowland resorts gives for high altitudes.3 I have already adverted 
u°, the experience of 248 consumptives who spent 386 winters in English 
home” stations, which resulted in the colder resorts carrying off the 
Ptilm.4 ETow as to the experience in foreign climates, Dr. Williams con- 
tides; «As to what class of patients profit most by dry climates, it has 
cen shown that, taking collectively all forms and degrees of phthisis, 
16 hry climates are the most likely to arrest the disease. . . • As 
0 desirability of moist climates for consumptive patients, the evi- 
is decidedly against their use in the treatment of ordinary chronic 
h misis. The addition of warmth only makes the damp tell more un- 
though a strong saline element and invigorating breezes do 
timething to counteract the humid influence. Still even "these do not 
P afe a moist climate on the same level as a dry one.” 
A'2Mherrnancy of the Air.—A striking, and to most people a novel fea- 
gp e high altitudes, is the clearness of the air, as shown by the inten- 
Jof the sunshine. I was impressed with this characteristic of Colorado 
p n,^n. address on the Climatology of Florida.” By A. S. Baldwin, M.D., President. 
2 Jjdings of the Florida Medical Association, Sessions 1874 and 1875. 
3 , orrected for barometrical heights by Guyot’s Meteorological Tables, 3d ed. page 72. 
jettsomian Lectures, Lecture 111. 4 Id. op., Lecture 11. 400 
DENISON, 
air on my first arrival three years ago, when, while riding toward the 
northeast, on a cold winter afternoon, the exposed portions of rny body 
became chilled, while the back of the carriage seat, on which the sun 
was shining, was very hot; and I have ever since been curious to under- 
stand the phenomenon. After ineffectually endeavoring to get the 
Signal Service officers to study this matter, I conceived the idea of deter- 
mining for myself the ratio of difference between the temperature in 
sunshine and shade, for each decided elevation, believing that, with the 
same conditions, excluding the influence of the wind, artificial heat, etc., 
observations at a few stations would serve to establish an approximate 
rule for almost all elevations. Accordingly, since February last, the de- 
sired temperature has been recorded at Washington, D. C.; at Royalton, 
Yt.; at Denver; and more lately by C. S. Richardson, C.M.E., at the 
Dolly Yarden mine, on Mt. Dross, Colorado. Ordinary thermometers 
in metallic frames, and of Fahrenheit scale, have been used, observations 
having been taken at 2P. M., on clear days only; and western rooms, 
not artificially heated, and with western windows, having been chosen. 
The temperature of the room has been taken in the shade and sun, with 
the window closed, and also with the window open, the direction, etc. of 
the wind being noted. The results must he taken as only approximate 
for general conclusions, because of the many conditions by which they 
may be affected, the fewness of the stations, and the short time the ob- 
servations have been continued, extending outy over parts of March, 
April, May, and June.1 I have lately found an average of the same kind 
as my own, taken at the city of Mexico,by Dr. Jourdanet,2 which I add 
to the accompanying table;— 
Stations. 
Elevation 
Difference between 
temperature in sun 
Average 
Ditto, window open 
or out-doors, the 
Average 
above sea.3 
and shade in-doors, 
difference. 
windy days ex- 
difference- 
Washington, D. 0. . 
80 feet.' 
window shut; from 
12° to 37° 
230 
eluded ; from 
17° to 370 
24° 
Royalton, Yt. . . 
. 500 “ 
16 to 42 
27 
23 to 47 
28 
Denver, Col. . . . 
40 to 48 
43 
46 to 55 
50£ 
Mexico, Mex. . . 
. 7600 “ 
... 
56 to 65 
604 
Tables 111. and IV—Showing Diathermancy of the Air. 
Elevation 
Temperature in 
Stations. 
Temperature 
closed box with 
Difference. 
above sea. 
iu shade. 
glass cover 
(suushiue). 
106° 
Mt. Bross, Col 
.... 13,400 feet. 
56° 
162° 
Alma, Col 
68 
154 
86 
Denver, Col 
88 
160 
72 
Besides the increase of diathermancy, the tables show the more uni- 
form clearness of the air at high than at low altitudes. From these 
1 Lately I have been pleased to learn, from Dr. Yacher’s brochure on “ Davos, Le Mon 
Dore,” that others also have been making observations similar to my own. But as 
these observations, one with the thermometer in vacuo, and another, that of M. Saussure, 
which consisted in “exposing to the rays of the sun a thermometer placed in a wooden boX 
lined with black cloth, and covered with glass,” were not made under conditions favorab*6 
and usual to human existence, 1 have more confidence in the utility of my own ; though tn® 
contrasts between sunshine and shade are not as great in ray observations as in t4ie 
others. 
2 Le Mexique et L’Amerique Tropicale, Cliraat, Hygifene et Maladies, par D. J°ur' 
danet. 
3 Partly from Dictionary of Elevations and Climatic Register. By J. M. Toner, M-l •» 
1874. 
4 Taken in January. INFLUENCE OF HIGH ALTITUDES ON PHTHISIS. 
401 
iiOles we can approximately arrive at the desired result, the difference 
between sunshine and shade, or the heating power of the sun’s rays, 
tj • Richardson has kindly taken many observations for me on Mt. 
H'oss, the difference between the temperature in the sun and in the 
‘made out-doors at 2 P. M. being only from 10° to 20°, and not showing 
he real diathermancy of the air. This I attribute to the rapid radiation 
0 heat and constantly moving cold air of that exposed place. As there 
)Vas no suitable building in which to try the other test, I prepared paste- 
°ar(l boxes, with glass covers, and with black velvet lining, in which we 
o<)k the temperatures at Denver, Alma, and on Mt. Bross, at 2P. M. for 
a Rvv days, at nearly the same season. The differences between these 
Records and the temperatures in the shade, noted at the same time, serve 
,? show the increasing diathermancy of the air at these greater eleva- 
J°ns, notwithstanding the peculiar influence of the cold air and wind of 
hose heights. iSTow the differences between these .diathermancy tests 
cilly as follows for the given differences in elevation : 
Table Y. 
Stations. 
Difference in Average difference 
elevation. m dlathel” 
Average difference in 
elevation for one 
degree of dia- 
and Denver .... 
■p ashington and City of Mexico . 
rM)yalton and Denver 
and City of Mexico . . 
cover and City of Mexico . . . 
-cover and Mt. Bross 
V®nver and Alma 
and Mt. Bross 
thermancy. 
. . 5120 feet. 
23° 
223 feet. 
. . 7520 “ 
36 
209 
“ 
. . 4700 “ 
20 
235 
U 
. . 7100 “ 
32 
222 
<( 
. . 1400 “ 
148 
u 
. . 8200 “ 
34' 
241 
u 
. . 3600 “ 
14 
257 
u 
. . 4700 “ 
20 
235 
ii 
Average 
221 
feet. 
_ Thus is evolved a general rule, which may be changed by more accu- 
.clte and extended observations, of one degree greater difference between the 
ffperatures in sun and shade, for each rise of about 220 feet. 
This diathermancy (the increased facility with which radiant heat is 
cinsnoitted) explains as clearly as the absolute humidity of the air, the 
|uly fluctuations in temperature so gradually augmented with increasing 
? evation. But the absolute humidity, or elastic force of vapor in the air, 
? the main key to its transparency, the elevation only giving an addi- 
,oUal increase in diathermancy to that produced by the decreasing 
Juinidity. So dry, low places, like Fort Yuma, California, will be ex- 
eptions to the rule given. However, this does not disprove, but, on the 
helps to establish the increased diathermancy of high altitudes, 
Hi ere, as we have already shown, there exists a considerably lessened 
a 3solute humidity. The effect of this diathermancy of high altitudes on 
<D’ and terrestrial radiation is wonderful. The solar radiation is rapid, 
11(1 soon after sunrise the temperature rises, because of the slight resist- 
‘)lee which the rarefied and dry air offers to the sun’s rays; while, after 
Duset, the terrestrial radiation is also rapid, because there is no moist 
* A elope shrouding the face of the earth to prevent the natural cooling 
le dry ground.1 The climax of this proof is as follows: Reasoning 
10111 the effects inimical to life in mines, cellars, and ill-lighted abodes,. 
wbil r6 cllaracter of the sunlight of high altitudes is a nearer approach, if possible, to- 
p.) 1 e hght, than at sea level, and many find it desirable to wear gray-blue or smoked, 
6 c SSOs to neutralize its effect. 
26 402 
DENISON, 
to the benefits of sunlight at low levels, where a stratum of moisture 
intercepts the sun’s rays like a thin cloud, and thence to the healthful 
influence of the unobstructed sunshine of the highlands, we can say? 
<D 7 • . -f 
without fear of successful contradiction, that the beneficial effects oi 
sunshine increase with increasing altitude. It is further to be noted 
that, the sun’s rays being less obstructed, there is a proportionately 
longer influence of sunshine in each twenty-four hours, besides the excess 
due to a usually cloudless sky over such plains as those east of the 
Rocky Mountains.1 Thus, too, is explained a certain degree of incor- 
rectness of ordinary temperature records of the Signal Service, which are 
taken in the shade and on the north side of the building, with the cold 
nine o’clock observation doubled to make up the general average. Tv 6 
are warmer during the hours in which being out of doors is desirable? 
on the elevated western plains, than is indicated by the temperature 
records. 
Atmospheric Electricity.—The importance of atmospheric electricity as 
a curative power in disease is not to be measured by the little we know 
about the element itself. The experience in high altitudes of persons oi 
susceptible nervous temperament goes to substantiate the universal evi- 
dence of science that, as a rule, electric tension in the atmosphere is nl' 
creased with each decided elevation. Leaving out of consideration the 
change in electric tension and the negative quality of atmospheric elec- 
tricity during storms, we learn from extended observations (Kew obser- 
vatory) that with a clear sky the electricity of the air is always positive? 
which quality, Alexander Buchan says, becomes manifest “on AA 
ground” at a height of five feet. It would seem that, with the increase 
of tension due to elevation, the positive electricity of the air, so abun- 
dant in dry elevated regions, would be constantly nearing the negative 
electricity of the earth. With no other evidence to prove this than the 
experiences of our nervous systems, I shall claim that this is the true 
state of electric tension of high altitudes, till evidence is produced t° 
the contrary. Row here is important teaching for the consumptive 
multitude, in fact for most of the human family. The houses we liy® 
in, and the piazzas and trees we sit under, are intercepting this vita* 
fluid, which it is very probable we were intended to utilize more than 
we do. The conception and realization of this truth make ns pine 101 
the nomadic life of the travelling Israelites and Arabians, because v’e 
are sick at heart in view of the fact of increasing deaths from consump' 
tion with increasing civilization. 
High-altitude experience goes towards strengthening the common- 
sense idea of the consumptive’s course everywhere, which is in favor ° 
an out-door life. The continued mediumship of the human body between 
the negative ground and the positive air, whether a man is on foot or ou 
horseback, is a constant renewal of his vitality. Here is a secret ot the 
great utility of camping out and “ roughing it” in dry, elevated coun- 
tries. You lie down to sleep, as only a tired camper-out can, on the 
ground, and get up in the morning from your negative electric bed to 
stretch yourself in the positive electric air. I have yet to meet with the 
experience which will dissuade me from always giving the advice to 
consumptives to live in the open air and sleep on the ground, wheneve 
conditions are favorable for so doing. • 
1 According to records in the Signal Service office at Denver, there have been on f 
thirteen days since January 1, 1873 (to August, 1876), in which the sun has been iuvisi 
the whole day. INFLUENCE OF HIGH ALTITUDES ON PHTHISIS. 
403 
. Dr. James Henry Bennet, whose personal experience with phthisical 
lvalids entitles his opinion to great consideration, thus emphasizes the 
uiportance °f defective vital or nervous power as a cause of pulmonary 
which cause even underlies “ the most minute anatomical 
researches.” “Clinical observation shows that the 
of these forms of lung disease, chronic and acute, must 
e looked upon as the evidence and result of a serious, perhaps final, 
rjunution of vital or nervous energy Unless the vitality of the 
Oividual can he roused, the morbid condition will surely progress, and 
e will be extinguished sooner or later, according to the state of the 
j°n.stitution of the patient, and to the type of the disease.” 1 Without de- 
'Uug to add much corroborative proof at hand of the soundness of this 
(more especially the influence of inheritance), we can imme- 
utely draw the inference, which is abundantly substantiated by experi- 
• Ce5 that the increased electrical influence of high-altitude atmosphere 
°ue of our most important aids in the successful battle against con- 
sumpti0n.2 
Ozone.—As to ozone, reliable deductions cannot be drawn from ex- 
U'Urnents made, because of the many liabilities to error with Schdnbein’s 
sb which was used—the starch and iodide of potassium paper—and 
Pecially one element of error which is liable to be increased in high 
titudes, namely, the decided dryness of the air. But from the tests 
mch I have had made on the western plains and in the mountains, the 
sUal increase of ozone in the mountains is shown, while on the plains 
ere is a good proportion, considering the lack of moisture and distance 
lortl the sea. A variation in the amounts observed may, I think, serve 
’,a profitable indication of the special advantage of living in the moun- 
ains du ring the heat of summer. It is this, that the excess noted dur- 
the spring months on the plains, came proportionately later in the 
•eas°u the higher up the observations were made. This utility of going 
the still higher regions in summer is in consonance with the in- 
eased benefit of the cooler temperature which we have already shown 
Ration insures. 
• Winds.—While not much can be said of the winds of high altitudes, 
dependent of local peculiarities, yet two general facts may be men- 
°ued, which will not be considered detrimental to elevated climates in 
ie\v of the generally admitted healthful influence of a moderate amount 
wind. The total movement of the air at nearly all exposed high alti- 
Kles, is of course greater than that at similar places in the lowlands, 
1 n°t nearly so much greater for many points as would generally be 
pected. As I have elsewhere explained,3 the total movement of air,4 
ll<a Die number of observations of wind direction, as to winds which 
le usually mild and bring pleasant weather,5 for some elevated stations 
Denver, Colorado, compare most favorably, for mildness of results, 
k. h the records of low altitude stations. The winds of high altitudes 
eing less diverted from their general course, their indication as to the 
2 ulwonary Consumption. By James Henry Bennet, M.D., 2d ed., p. 16. 
jn + °me urther remarks by the author on this subject may be found in The Archives of 
r„,iC and Neurology, for November, 1874. “The Influence of the Climate of Colo- 
sO,,0,!1 the Nervous System.” 
4 pDle Winds of Colorado.” Report lo the Colorado State Medical Society, 1876. 
ninti a^e X* “Total movement of air, with resultants.” Statistical Atlas of U. S. from 
« “ census, 1870. By F. A. Walker, M.A., 1874. 
fluual Reports of the Chief Signal Officer, U. S. A. 404 
DENISON, 
character of weather is more constant than at most low stations, and es- 
pecially is this the case of inland localities. For instance, according t-° 
excellent charts, in the Annual Report of the Signal Service Bureau f°r 
1876, giving wind directions which are most, and those which are least 
likely to be followed by rain,the indications are very strong for Northern 
and Eastern Colorado, and Southeastern Wyoming (Denver and Obey- 
enne), that the south, southwest, and west winds bring pleasant weather? 
while their opposites, the north, northeast, and east, bring most of the 
rainy weather.1 In Eastern New Mexico (Santa Ed), nearly the opposite 
rule holds good; the northwest, north, and northeast winds bringing 
pleasant weather, while the southeast, south, and southwest winds bring 
most of the rain. The damp atmosphere comes in both cases from be- 
low—the Missouri valley and the Gulf of Mexico—while the dry, warm 
air comes from over the mountains, which have acted as condensers* 
This is proved by the records of the Pike’s Peak station, where the ranl' 
bearing winds are the above-mentioned dry winds on the plains, and 
the pleasant weather winds are the rainy winds on the plains.2 Another 
point is that winds of high altitudes, while they have the same influence 
in purifying the air, have proportionately less force, rapidity being the 
same, according to the lessened weight of the air due to elevation. 
is to be mentioned, however, that in desirable dry regions, as the East' 
ern Rocky Mountain slope, and especially where the adobe soil of NeW 
Mexico, Southern Colorado, and Western Texas, exists, the dust storm3 
which strong winds raise are a disagreeable element, to be avoided f°r 
the time being by those having weak or diseased lungs. 
Altitude.—The physiological effects of high altitude on man are well- 
understood when we consider the lessened pressure of the air which 
obtains at a given elevation. Reckoning the superficial area of a man3 
body as sixteen square feet, and the pressure to the square inch as three 
pounds less at the base of the Rocky Mountains (6000 feet); than at sea 
level, we have this surface relieved of the enormous weight of nearly 
7000 pounds. With these figures in our minds, we are struck with the 
wonderful adaptability of the normal human organism to changes 
atmospheric pressure, when the limit of danger lies in an atmosphere 
almost twice rarefied on the one hand, and five times condensed on the 
other.3 But when we go further, and learn that Lieberkiihn4 has com- 
puted the area of respiratory surface in both lungs of man to be 
square feet, which Dalton avers is not exaggerated,5 we find a subtraction 
of pressure from those organs which is truly wonderful, even for W 
elevation of one mile. The respiratory organs, then, are those which arc 
chiefly influenced by the lessened atmospheric pressure, the effect on othd 
organs being mainly secondary to the induced activity of respiration* 
Let us analyze the modus operandi of this phenomenon. The proportion3 
of oxygen, nitrogen and carbonic acid, to each other, do not vary greatly 
for habitable elevations. There is then a fifth less oxygen in a givell 
1 See tables of winds in “ The Winds of Colorado,” just mentioned. 
2 This evidence seems to be opposed to an explanation of sudden changes in temperatur 
in New Mexico, given by Dr. Gardner as “ depending on whether the wind blows from t*l,, 
dry, parched plains of Texas, or from the snow-crowned summits of the Rocky Mountains- 
“ Diseases peculiar to Mountainous Regions.” By W. H. Gardner, M.D., U. S. A., PoS 
Surgeon, Ft. Union, N. M. (Am. Journ. of Med. Sciences, July, 1876). 
3 Parkes’s Practical Hygiene, 4th ed., p. 409. 
4 Simon’s Chemistry of Man. Phila. ed., 1846, p. 109. 
5 Human Physiology. By J. C. Dalton, M.D., 3d ed., p. 236. INFLUENCE OF HIGH ALTITUDES ON PHTHISIS. 
405 
JlaGe of air a fifth rarefied, as at 6000 feet, and the lungs must inspire a 
b more air to get the same amount of oxygen. This is favored, first, 
y .quickened respiration, which as well as the coincident increased 
ctivity of the heart is best shown in aeronauts, who make no muscular 
Gxertion as they rise.l Dr. Yacher says that M. Gaston Tessandier, the 
urviving aeronaut on the Zenith, gave him the record of his respirations 
*'• Yacher himself, when he went to investigate the wondrous effect of 
16 winter air cure (Cures d’air), at Davos, made careful estimates of his 
espirations, which were 18.2 per minute at Davos, while at Paris they 
t ere 16.6, his pulse increasing from 69 to 78 beats per minute.2 As I 
|'anie to Colorado three years ago, I noted an increase in my respirations 
20 to 30 per minute, in 24 hours, while rising 4000 feet in Western 
misas, and an increase of the pulsations from 72 to 82.3 
\ thought I noticed another of the immediate effects of elevation, 
mch I have nowhere seen mentioned, but which may yet be of account 
1 studying the therapeutics of the high-altitude cure of phthisis, an 
rv and almost constant symptom of which disease is prolonged expira- 
-011• I refer to a quicker expiration, which was as though the increased 
umber of respirations per minute tvas made up from the time given to 
Apiration.4 As to the effect of altitude on breathing, Dr. Yacher 
issue with Dr. Spangler, of Davos, and also with Dr. Jourdanet, 
l'rnerly of the city of Mexico, the two latter gentlemen claiming 
*af “ the lungs supply a deficiency of oxygen by deeper and slower,” 
bile the former emphasizes the “ more frequent” respirations. I 
\v-a 1 ave f° differ with these gentlemen on both sides—especially 
Jourdanet—saying the respirations are both deeper and more 
lequent, at first the frequence, and afterward the profundity, predomi- 
nating. According to Coindet, who made 1500 observations of the 
re(fUence of respirations in French and Mexicans, they were 19.36 
||Gl' minute for the French, and 20.30 for the Mexicans. The greater 
l^epfh and breadth of the lungs of inhabitants of high altitudes has 
e©n noted by all observers who have had favorable opportunities for 
vsting the question. Our knowledge of the mountain Indians of the 
Ystern part of the United States, tallies with the fact noted by Jour- 
miet, “that the Mexican Indians, though of medium height, have 
nUsually large and wide chests, quite out of proportion to their 
’ Even children, born in the Rocky Mountains, have been noticed 
mle yet young to have chests of unusually large capacity, and the 
*leleased circumference of the chests of consumptives after undergoing 
m high-altitude treatment, is shown in many of Prof, Weber’s cases, 
8 Well as in my own. M. Jaccound, at Saint Moritz, says there are not 
more frequent, but fuller respirations. “ This circumstance brings 
■Walloon Ascents ; by Parkes : 
Biot and Gay-Lussac, at 9,000 feet, increase of 18 to 30 beats of the pulse. 
Glaisher, at 17,000 feet, “ 10 to 24 
Glaisher, at 24,000 feet, “ 24 to 31 
3 ?P: 
to si recor(l I 8 of rise, as compared with that of Dr. Yacher, who was probably in health, 
at th°W lncreased disturbance elevation favors in those whose lungs are impaired; for 
phc ?ntime’ten monlhs after pulmonary hemorrhages, my right apex and some other peri- 
hon'u un? tissue showed signs of being clogged with inflammatory or other products, since 
1 PpUy driven away by Colorado’s light air. 
Lolorado as a winter resort for invalids. Chicago Med. Examiner, Jan. 15, 1874. 406 
DENISON, 
into use certain portions of the lung I call idle, because in ordinary con- 
ditions they take only a small part in respiration.”1 
The exercise of the will makes a great difference in the frequency 01 
respiration, and besides, I think, the respirations in high altitudes m’e 
more generally increased in frequency by muscular exertion than in lovv 
countries, as any member of an Alpine club can testify. Lungs of 
habituated capacity to high altitudes have little incentive to frequent 
respiration when perfectly quiet, as is usual when the respirations m’e 
counted. Dr. Jourdanet evidently expresses this opinion in furtherance 
of his theory de Fair),2 that the deficient oxygen inspired 
at great elevations is the cause of the immunity from phthisis. hfoW 
to both fact and theory I have to differ with this noted author, in refer- 
ence to the rationale of high-altitude therapeutics. So I may be excused 
for quoting and commenting at length on his views as given in his “ Te 
Mexique et I’Amerique Tropicale,” page 295. “We have stated that 
anaemia is the habitual condition of men who people great elevations? 
anaemia by the imperfection of the respiratory act. If it is natural t° 
admit, d priori, that this anomaly may have a necessary influence upon 
the beginning, nature, and progress of maladies in general, with holV 
much more reason must we acknowledge that the organ which presides 
over the respiratory functions would feel the first influence of it ? The 
lungs in fact find themselves in the presence of a rarefied air, dry, and 01 
diminished barometrical pressure. The three conditions of rarefaction? 
dryness and lightness of the atmosphere, evidently render the endosniosc 
of oxygen, destined to feed respiration, less easy. But if we are correct 
in saying that the most natural stimulant of any organ is the element m 
which it acts, we may affirm, without fear of contradiction, that the 
lungs are always stimulated in a less degree upon the heights than at 
the level of the sea.” After clearly showing evidences of considerable 
immunity from phthisis on the Anahuac, and at other elevated station8? 
he continues: “Moved by the consoling spectacle of this happy influence 
of great elevations upon consumptives, I have sought a reason for it with 
the view of turning this fact to a practical account. Several elements 
are grouped in my mind, in the resolution of this difficult problem* 
Upon one hand I am governed by an incontestable fact, already p1’0' 
claimed as a general fact throughout this work ; it is that the chronicit) 
of inflammatory affections is incompatible with the climate of the height* 
On the other hand, I consider the rarefaction, lightness, and dryness 01 
the air. The rest which results from these conditions excludes the 
of any permanent excitation of the lungs. I consider that, in tlmse 
circumstances, the lungs find a guarantee against pulmonary phthisis? 
while upon the coast, in a heavy and humid atmosphere, which oxidize® 
everything with which it comes in contact, a general predisposition to 
chronic inflammatory condition favors the progress of tuberculization* 
My mind is struck by the importance of these curious facts, from which 
it draws the irresistible inference that an inflammatory element is neces- 
sary to pulmonary tubercles, to follow' out the divers phases of then 
existence, etc.” 
Let us briefly dissect these anomalous theories, without objecting to 
the ultimate facts they are intended to explain. This “ respiratory diet? 
as Jourdanet calls it—the theory which makes a deficient supply &nC 
1 La Station de Saint Moritz, p. 34. 
2 Dr. Vaeher’s Davos, Le Mont Dore, page 13. INFLUENCE OF HIGH ALTITUDES ON PHTHISIS. 
407 
lessened inspiration of oxygen the cause of the immunity of high alti- 
tudes—takes no cognizance whatever of the adaptability of the respira- 
toi7 function to changes in elevation. The bare mathematics by which 
get this deficit for high altitudes, which Dr. Yacher reckons is “ a 
daily deficiency of 139 grammes” of for an ordinary person at 
throws out of consideration the existence of a pneumogastric 
fierve with its reflex function to supply any lack of air, or oxygen its 
Afal constituent. Even if the deficiency of oxygen is not compensated 
tor by more frequent and deeper respirations, it is not proved that 
ondosmose of oxygen has any constant relation to the amount of oxygen 
Aspired. On the contrary, Dr. Parkes says,1 “in experiments on animals, 
as long as the percentage of oxygen did not sink below a certain point 
0-4 per cent.), as much was absorbed into the blood as when the oxygen 
tyas in a natural proportion.” This, too, is in addition to any augmented 
Aspiration due to elevation. It is much more probable, in view of the 
111 °re perfect combustion (oxygenation) which takes place in consumptives 
Alio move to the highlands, that this deficiency is more than compensated 
lQr in high altitudes. As to the “ancemia by the imperfection of the 
Aspiratory act” which “is the habitual condition of men who people 
great elevations” (and so opposed to inflammation), I wish to ask, in all 
fan dor, how long are we to continue the manufacture, in our own minds, 
Dot by drugs, of one disease to cure another? What, we are inclined 
|° exclaim, have the much vaunted theories of allopathy (antipathy?) and 
homoeopathy to do with this question ? Is the improved and more active 
G)rculation of blood in the lungs (even more in them than in the capillary 
Glrculation in other parts of the body), a condition of “ ancemia” on the 
heights? By no means; it is simply a condition of increased normal 
aetivity. 
Let us examine this interesting point further, especially noting the 
changes in density of the respired air, while it is in the lungs. I have 
ah'eudy adverted to the wonderful extent of respiratory surface in the 
lungs. This large area and the considerable change in atmospheric pres- 
|^lre are two striking factors of the changed respiration due to elevation, 
.he mechanical effect of this lessened atmospheric pressure is what chiefly 
Aterests us. With the atmosphere say one-fifth rarefied, the respirations 
aA deeper and more frequent. Then the density of the air in the lungs 
Airing inspiration would seem to be lessened in proportion to the greater 
Quantity of air which has to be breathed. This increased approach to a 
®|ate of vacuum in the lungs is calculated to draw the blood quickly into 
!le pulmonary vessels. But expiration follows, and it is during expira- 
,|°n that the respiratory muscles have the greater power, greater because 
le muscles of expiration are in their normal condition for activity when 
he thorax is distended, and the thorax is more distended, because it has 
0 labor with more air. I have already expressed the opinion that expi- 
ration rather than inspiration is shortened by the diminished pressure of 
elevation, and this fact would still further show the increased advantage 
. the expiratory muscles. Then the density of the air within the lungs 
Is Addenly made greater than the density of that outside the body. The 
loodvessels are pressed upon, and the previously augmented flow into 
he lungs is driven quickly on to the left side of the heart. It is possible 
hat in very great changes of elevation, as in quickly climbing mountains 
ahove 12,000 feet, or rising to an immense height in a balloon, the pul- 
1 Practical Hygiene, page 407. 408 
DENISOIST, 
monary vessels may not stand this alternate rarefaction and pressure, and 
hemorrhage may result. But we are speaking now of reasonably high 
altitudes, which must be considered as varying for different invalids. The 
more rapid and perfect renewal of the capillary circulation in the lung 3 
is opposed to the stasis of blood which is an early stage of inflammation- 
Rot only that, but chronic hypertrophied tissue, accumulations of mucus, 
epithelial ddbris, and the products of inflammation, are “crowded to the 
wall” by this pressure, increased from within outward during expiration, 
and the lung thus purified and cleansed of the results of inflammation 
and morbid products in the blood, of lingering tendency, has no place for 
adventitious products or the deposit of tubercle.1 Is this exaggerated 
activity of the pulmonary vessels and tissue a condition of “anaemia, 
and is it here we find the “rest” which “excludes the idea of any perma- 
nent excitation of the lungs?” “There is no rest for the weary” lung, 
and in this lies its salvation. Rest is best for a broken bone, but if 
offers no special antagonism to progressive degeneration of lung tissue, 
even if, as is here erroneously assumed, “ the lungs are always stimulated 
in a less degree upon the heights than at the level of the sea.” 
As to the “endosmose of oxygen” being “less easy” in high alti- 
tudes, how, may I ask, if it is so, can the lungs enjoy the “ rest” claimed, 
whose function it is to promote the endosmose of oxygen ? Is it natural 
for an organ to be at rest, whose function is obstructed ? I can see no 
obstacle to the endosmose of oxygen due to lessened atmospheric press- 
ure ; on the contrary, almost every effect of rarefaction of the air is to 
complete and perfect this process. According to Bunglison, “the ra- 
pidity with which endosmose is accomplished varies according to the 
nature of the septum or tissue, and of the penetrating body, and to the 
penetrability of the tissue.” Row, in high altitudes, the improved con- 
dition of the capillary circulation, everywhere shown, but chiefly in the 
lungs, the quickened flow of blood on one side of the intercepting mem- 
brane, and the proportionately increased pressure and rapid renewal of 
the air on the other, all combine to favor the endosmose of oxygen. It 
is not then necessary for us to burden our minds with doubtful prob- 
lems to understand the healthful influence of the atmosphere of high al- 
titudes upon the organs of respiration. This more perfect oxygenation 
and capillary circulation of the blood favors,a healthy renewal of tissue, 
and is constantly washing out of the system and preventing the focus- 
ing of impurities or disease germs, of which the consumptive body lS 
full.2 
The improved respiration and circulation bring demands for increased 
digestion and alimentation. Rot only the lungs and heart, but the 
stomach, liver, and kidneys all contribute a share of this increased labor 
1 Elsewhere I have given the opinion, which I have never seen mentioned by others, that 
this outvjard pressure of the air within the lungs is chiefly what so generally cures asthma 
on the elevated inland plains and mountains of America, by the power it has in stretching 
the circular, muscular fibres of the smaller bronchial tubes beyond their easy contraction- 
Report to American Medical Association, June, 1876, on the “ Climate of Colorado, and 
its relation to Pulmonary Diseases.” 
2 An exception should be here noted, that this purifying process may be too great a task 
for the feeble remaining vital-force. Too extensive or far advanced disease in the lungs, 
the system being saturated with its accumulating effects, may naturally prove too strong an 
enemy for this or any other purifying process, and in the heated contest which is inaugu- 
rated the victim is quickly consumed. Such has been the fate of some who have suddenly 
risen to great elevations for the sake of restoration to health, when already advance 
in the last stage of consumption. INFLUENCE OF HIGH ALTITUDES ON PHTHISIS. 
409 
sustain a quicker but a more perfect life. The loss of flesh in one. 
an(l the gain in another (the latter especially for those new-comers for 
"'born to live “is gain”), are but the preponderance of waste and repair 
°ver each other, which come to all with varying results. 
Altitude of Approximate Immunity from Phthisis. 
The study of the geography of phthisis gives us an additional and re- 
markable evidence of the curative influence of high altitudes. For if 
a mode of life, or a locality of living, should give a large number irnrnu- 
from this disease, then there is the strongest inference possible that 
1 J,e afflicted who could and would adopt the same manner of life or place 
*7 abode might so far enjoy special chances of recovery. Some have 
bought that an exact line of immunity from consumption could be 
tlrawii, depending on altitude and latitude. Among these, Kiichen- 
peister made such close estimates as to give a rule for the altitude of 
bnrnnnity in any latitude. In Switzerland it was 3000 feet,1 and at the 
Pfuator 9000, the difference for different latitudes in Germany being 
10 feet less for each degree from south to north.2 
i Tut there are local conditions, variations in the climatic attributes we 
,'a.ve thus far considered, which will greatly vitiate any exact rule of 
ms kind. For instance, the Coast Range of the Sierra isevada Moun- 
"Drs, in California, which condenses much of the moisture from the con- 
burt Pacific winds, and renders the high altitudes there uncongenial to 
biost people, would give a very different climate from that of the elevated 
Fb’tions of the next range, and that in turn from the central range run- 
-11 g through the continent. It is preferable not to try to defend any 
Positive law, because, if an opponent meets with an instance of the ori- 
gbnatipn of some type of phthisis above the stated elevation, you have 
too much, and can go no further with him. It is not intended 
0 convey the impression that a given altitude always insures immunity, 
!'°1’ that an approximate immunity may not exist at some low levels, as 
8 churned for certain far northern lands, and by one M. Maydell for a 
j dgi’ant and extensive population who inhabit a steppe in Asia, said to 
one hundred feet below sea level. We know nothing further of such 
Realities, and are somewhat inclined to consider them like some new 
(1 fields, and many far-off favored localities, where “ distance lends 
Cbehantment to the view.” The argument here intended is that, if 
to thirty per cent, of all deaths occurring on the coast and bor- 
U‘l’s of rivers are from phthisis, as on the fortieth parallel in the United 
c ates, ten to twenty per cent, on higher ground under 1000 feet, five to 
teen per cent, from that height to 2000 feet, two to five per cent, from 
c> at to 4000 feet, one to two per cent, from that to 6000, and seldom a 
jpc above that point, then the proof is conclusive enough as favoring 
.T'h altitudes as a resort for consumptives, even though a signal service 
j Server on the top of Pike’s Peak should there suffer a lesion of the 
Up? should eventuate in his death from phthisis (a most impro- 
a )le supposition). We speak then of an altitude of aip'proxim.ate immu- 
L ,as is too low by one or two thousand feet, according to the valuable statistics of Dr. 
I’aFt eneva> who. Dr. C. T. Williams states, was one of the first to notice the 
2* )°f Phthisis in the high lying habitable districts of Switzerland. 
Ur , be hochgelegenen Plateaus als Sanatorien fur Schwiudsuchtige,” von Dr. Friedrich 
lB6B. 410 
DENISON, 
nity, which, like the good attributes of high altitudes already discussed, 
is found higher up as we approach the equator. And herein lies the 
strongest proof imaginable, outside of the experience of a considerable 
number of invalids, of the soundness of the combined arguments here 
presented, in regard to the climatic attributes of high altitudes, 
Drs. Weber, C. T. Williams, and Walshe have given, in valuable 
works already quoted, abundant evidence from mortality records of this 
gradual decrease of deaths from phthisis originating in high lands. The 
corroborative evidence of these authors, with others, as Kiichenmeister, 
Brehruer, Lombard, Archibald Smith, Fuchs, Nuhry, Yacher, Spangler, 
Jourdanet, Hirsch,and Guilbert, is full and explicit, but would consume 
more of our time than can now he spared. In general, the altitudes of 
approximate immunity are at or a little above the elevations given in the 
first part of this paper for favorable high altitude climates. In America, 
Dr. E. M. Wight characterizes the inhabitants of the Cumberland table- 
lands as “ a people without consumption,” their mode of life probably 
having much to do with their immunity. Dr, Archibald Smith, wb° 
practised medicine a long time in the Peruvian Andes, says that phthisis 
was unknown above 8000 feet, “ except as an exotic,” which evidence 
Dr. C. T. Williams well remarks “is important, because we know that, 
even up to 13,500 feet, large towns are found in that part of South Ame- 
rica, such as La Paz, the capital of Bolivia, and therefore there probably 
exist some of the causes specially favorable to the development of phthisis- 
In Mexico, Dr. Jourdanet places the line of immunity at 7000 feet. Hi 9 
personal observation of the rarity of phthisis in the Anahuac, referred 1° 
the cities of Puebla and Mexico, where he practised medicine respectively 
two and eight years. These two cities, comprising a population 
270,000, showed a rarity of the disease, cases occurring only among the 
poorly fed and scantily clothed class, or “among those natives of the 
heights whom the interests of business induced to visit lower levels- 
During his ten years’ practice in Mexico, he encountered but twelve 
cases of phthisis. All occurred among the indigent, a class rendered 
quite numerous in Mexico by natural indolence, acquired habits, and 
defect of social organization. In New Mexico, Arizona, and Utah, not 
a little evidence of an altitude of immunity is shown in communication3 
I have had the pleasure of receiving from army surgeons who have 
served at elevated stations.1 
1 Dr. B. J. D. Irwin reports for Fort Defiance (6500 feet), Northwestern New Mexico ey" 
“Surgeon John F. Hammond, U. S. Army, writing on the diseases of New Mexico, 
Grande valley, says, ‘ Phthisis pulmonalis I have never seen in the country, except in two 
instances, once in an officer of the U. S. army, and once in an American emigrant. It wa,s 
developed in each before he left the United States, and each very gradually improve j 
One resided in Lucoro, and the other in El Paso Del Norte.’ I can add to the forego 
[Dr. Irwin writes] that during a service of some seven years in New Mexico and Arizolia7 
ranging over a region embraced between the 31st and 36th degrees of north latitude—FOl 
Union, New Mexico, to Fort Buchanan, Arizona—l never saw or heard of a case of tuber 
culous disease (consumption) amongst the native inhabitants of those territories. When 
I went to New Mexico, in 1855, several recruits suffering with well-marked symptoms o 
pulmonary tuberculosis were sent along with the detachment destined for the troops the' 
serving in that region. I kept track of them after their arrival, and had the satisfaction 
and pleasure of learning that they all outgrew the tendency to develop phthisis pulmonalis- 
Surgeon E. P. Yollum, from Camp Douglas, Utah, reports “In an experience of three yoa' 
and a half in Utah, I have not seen a case of consumption that originated in the territory’ 
and the Mormon physicians declare that no persons born in Utah—excepting Indians' 
have had the disease, to their knowledge.” Among other army surgeons who have writ 
in corroboration of marked immunity at their stations are B. G. McPhail, Camp Apac i > INFLUENCE OF HIGH ALTITUDES ON PHTHISIS. 
411 
In Colorado, I will place the altitude of approximate immunity at 6000 
ieet. There are good grounds for this decision. I have made quite a 
thorough canvass of the subject among the physicians of the State, and 
have found but one case originating above this altitude, and that not 
very well authenticated—said to have been a case of catarrhal pneumonia 
°f the right apex which afterward improved. Drs. T. G. Horn, of Colo- 
rado Springs, and G. S. McMurtrie, of Central, with others who have 
Practised in the mountain districts for a considerable time, have reported 
Hat they could furnish no cases of the kind from their experience in 
Colorado. Between the elevations of 4000 and 6000 feet, however, I 
have found a few cases. There have been twenty-two in all up to the 
present date, occurring in the practice of physicians who have most of 
them resided in Colorado several years. Let us analyze these cases, and 
karn that it is greatly due to the looseness of the general term phthisis 
that most of them come under this nomenclature. 
Hr. H. O. Bodge, of Boulder, reports four cases from that section ; two 
°f the patients have died, and two are not losing ground rapidly ; all 
°I these cases commenced with severe colds from exposure; three of the 
patients probably had pneumonia, and one suppression of menses, which 
has since continued: time they had lived in Colorado not stated. Dr. 
Joseph Anderson, of Golden, reports a case of general tuberculosis fol- 
lowing miscarriage, rapid decline, and death in four months. Also a 
J°ubtful case of abscess following pneumonia in a young man whose 
tather died of phthisis, and which has resulted in apparent recovery. 
Hr. Jacob Reed, Jr., of Colorado Springs, reports a case in a young man 
Sjged 18, three years a resident of Colorado, and with very marked ten- 
dency to phthisis by inheritance. Had had slight cough five months 
he received a severe injury to one lung, followed by hemorrhage 
aild death in one month. Dr. H. B. Tuttle, of Puebla, has seen two 
cases “one a sequel to scarlatina, and one following extreme exposure 
during menstruation, both badly treated, both fatal.” 
Hor the city of Denver and immediate vicinity, we have the records 
df all the deaths occurring since January, 1874, two years and a quarter, 
dhese records require information as to the origin of the disease. We 
and thirteen cases recorded as originating in Colorado. They are of 
Phthisis,” “phthisis scrofulosa,” “acute phthisis supervening” as a 
SeQuel to other diseases, etc. I have interrogated most of the physicians 
Mjo reported these cases, and find two acknowledged mistakes, in that 
,e disease existed before the parties came to Colorado; two rapid cases 
°5 _ Cachexia Africana; two cases of rapid decline after child-birth; a 
dhikl one month old, whose mother died of the same disease nine days 
a case of abscess in the base of the right lung following pneumo- 
*tlla ; acute phthisis following pneumonia, and hip-joint disease ; a case of 
Whiskey consumption”; a fatal result in a very strong man, after hem- 
-ooh age from severe lifting; and a case following scarlatina. How I 
°annot see that elevation offers any special antagonism to such cases; 
and as to accidental lesions of the lung, causing hemorrhage, and also 
a°ute double pneumonia, the mechanical influence of rarefied air cannot 
0r Hie time be considered otherwise than injurious ; while phthisis fol- 
A T. (“Arizona as a Health Resort for Consumptives,” Virginia Medical Monthly, De- 
1874,); W. J. Wilson, Ft. Bayard, N. M.; Oscar A. Woodworth, Mesilla, N. M.; 
, • • Lauderdale, formerly stationed at Tucson, Arizona, and 0. B. White, Fort ludepen- 
dence, California. 412 
DENISON, 
lowing scarlet fever is not to be wondered at, in that the convalescence 
from special fevers is generally noticed to be tedious in the Rocky Moun- 
tain regions.l 
An additional evidence in favor of an approximate immunity due to 
elevation may, I think, be gained from the low rate of mortality from 
pneumonia, as well as from phthisis, as shown by our census statistics, 
especially as we are coming so generally to consider phthisis as of inflam- 
matory origin; it is that while high altitude increases the unfavorable- 
ness of the prognosis of acute pneumonia, the ratio of deaths from the 
disease in the Rocky Mountain states and territories is greatly lessened, 
showing that there must have been few cases of pneumonia there to 
have passed into chronic disease. 
Experience. 
The crowning argument in favor of high altitudes should be the care- 
fully recorded results of the extended sojourn in elevated climates of a 
good number of consumptives, representing the various types and stages 
of the disease. In presenting the following table of the records of such 
of my cases as have been kept under observation more than two or three 
months during my three years’ practice in Denver, it seems to me the 
shortness of the time is greatly compensated for by only recording 
the results during the patients’ stay in Colorado. It is to be noted 
that the results, after patients left the high altitude, were generally 
unfavorable. Those patients who had to be sent away immediately» 
and those who were not kept under observation two or more months, 
are excluded from the table, which includes all the other uncompli- 
cated cases of phthisis I have recorded. Three only of the patients 
had been in Colorado longer than three years, the time of observation 
specified, while six were in the State the shortest time, namely two 
months. The period of sickness previous to coming to Colorado, dating 
back to a persistent cough, pulmonary hemorrhage, haemoptysis, or evi- 
dent cause, varied from two months to seven years. Some had resorted to 
other climates (low altitudes) without benefit. Quite the usual amount 
of inheritance, in some cases the most decided in my experience, existed 
in these cases. 
Almost all types of phthisis are included, the classification as to the 
Nature of Disease being quite general, and only of account as indicating 
the usually more favorable prognosis for inflammatory than for chronic 
tuberculous cases. As to the Stage of Disease, I have endeavored to make 
close diagnoses, and may have put some cases in the third stage which 
other physicians would have placed in the second. However, the second 
stage, in my opinion, does not amount to much in high altitudes, and 
for practical purposes may as well be considered with the third. I* 
lung tissue has become useless, and “softening” commenced, “ excava- 
tion” is not far off, with the expansion of the lungs due to elevation. 
That such a transition is necessarily a part of the high altitude treat- 
ment in consumptives so far advanced, will not appear strange to the 
reflective mind; though its expediency in some acute cases may well be 
1 I have known a ease of catarrhal and another of chronic pneumonia, contracted in Pen" 
ver, in negroes who subsequently recovered, but who would undoubtedly have died b'°nl 
phthisis had they been sick in the East. INFLUENCE OF HIGH ALTITUDES ON PHTHISIS. 
413 
doubted. This positive character of the rarefied air prescription leads 
Cl 6to differ as to part of Dr. C. T. Williams’s classification. I refer par- 
ticularly to the “stationary” cases which include a good number of his 
Patients. With the healthful respiratory quickening; of high altitudes, 
the lungs are either not equal to the strain, or they improve under the 
exercise. I prefer to designate the apparently “stationary” cases of 
advanced phthisis by what sometimes occurs in them, namely, an exten- 
sion of excavation, while the resistance of the system to the general 
efiects of the disease is favored by the healthful surrounding influences. 
. As to whether this table represents the average severity of the phthi- 
sical patients who seek relief in Colorado, there is a 'pro and con to the 
Question, with a preponderance of evidence in favor of its representing 
rn°re than the average severity. Invalids whose disease is uncompli- 
Cated, and with whom the benefit is immediate and continuous, after 
their arrival in Colorado, do not, generally, consult physicians there, 
p proportion of such cases, including many I know to have improved, 
'Hit of which I have no record of examination, are, of course, not in- 
cluded in the accompanying table. For instance, in the Pullman car in 
Hdiich I left Denver, to come to this Congress, there were four returning 
health-seekers—three ladies and one gentleman—three of whom went to 
Colorado in the first stage of phthisis, and the other in the second or 
third; all of them apparently now enjoy a complete arrest of the disease, 
and none of them employed a physician in Colorado. On the other hand, 
a few months after my arrival in Colorado, I wrote an article dis- 
couraging the sending there of consumptives with unfavorable complica- 
C°ns, after the stage of softening, those affected with heart lesions, etc.,1 
and lam pleased to say that my professional friends in the States have 
SeMoni recommended such cases to me. However, the cases are severe 
H'ough taken as they are, and I am agreeably surprised with the pro- 
gi’ess of several having more or less excavation. 
1 Chicago Medical Examiner, January 15, 1874. 414 
DENISON, 
Both lung's affected, 38. Males, 54. Females, 12. Sent away to lower alti 
3 for heart disease, 1 irritable cavity, 3 far advanced. Became worse by going 
level, 9 
Hemorrhage or haemoptysis after leaving high altitude 
-3 
J 
X-‘ 
} i 
W 
i| J 
|| 
o 
8 
3 
O 
CD 
J* 
P 
2 
P- 
3 
o 
o' 
o 
04 
HEMORRHAGIC CASES— 
Hemorrhage or hsemoptysi 
probably without cavity 
Ditto, probably with cavit 
Hemorrhage or hiemopty 
to Colorado, without ca> 
Total 
NATURE OF DISEASE— 
Inflammatory 
(Pneumonic, etc.).. 
Catarrhal 
Chronic tuberculosis. 
Total 
AGE WHEN THEY CAME 
TO COLORADO— 
Under 20 
20 to 30 
30 to 40 
40 and over 
Total 
STAGE OF DISEASE ON 
COMING TO COLORA- 
DO— 
1st stage (deposit) 
2d stage (softening).. 
3d stage (excavation) 
Table VI.—Phthisis in Colorado. 
Analysis of 69 years, 2 months, spent by 66 consumptives in Colorado, with results. 
05 
05 
25 
11 
30 
05 
05 
3 
40 
18 
5 
05 
05 
25 
11 
30 
Number of cases. 
s before coming to Colorado, 
sis before and after coming 
118 10 
25 
12 5 
81 5 
118 10 
i—■* tO 05 
05 O CO 
05 05 CO 
O 
v. m. 
34 8 
14 4 
69 10 
Total duration of disease before 
coming to Colorado. 
on 
CO 1—1 1—J >—1 
CO <1 CD <1 
to t-1 t—M 
B 
Average for each case. 
a 
05 to CO 
- 
. 05 H 
S 
Cl 05 CO 
Number lost sight of after a 
time, and probably living 
in Colorado. 
05 
CO 
to 
23 7 
9 2 
36 5 
05 
to 
5 4 
47 3 
11 6 
5 1 
05 
CO 
to 
to CCH 
05 O tP • 
CD £ “'I U 
Total duration of disease in 
years, after coming to Colorado 
till Aug. 1, 1876, till death, or 
till departure from the State. 
CO 
o 
No. 
15 
6 
1 
5 
1 
2 
(to O M 
CnjM tO CD 
M 
£ £* 
Average for each case. 
£ 
; : h- 
• o 
to 
15 
3 
6 
to 
H- 
• -3 -d 
to 
4^ 
17 
2 
5 
Much improved or cured. 
oo 
CO 
M 1-. 
16 i 10 
CO to Cl 
S 
03 CO >—j 
05 
Cl "3 
Slight improvement. 
M M 
Ct H—1 
o 
H-* tO -q 
o 
co to • 
Slight local extension, with 
general tolerance of disease. 
to 
to 
to 
CO to to 
to 
H-* Cl to 
to 
o to 
Extension and advance. 
to I to 
I >—1 CO • 
to M >-* 
Died in Colorado. 
to 
to 
to 
15 
2 
3 
1 
1 
Ct 
o 
1 
21 
9 
20 
Ci 
o 
1 
32 
13 
4 
Ci 
o 
24 
8 
18 
Improved, or disease tolerated. 
to 
CO 
rr 
to »-J sP • 
05 
o to 
05 
>—1 Cl CD to 
05 
1 
3 
12 
Worse or died. 
to 
W 
1 05 
05 to M 
05 
03 tO • 
05 
Cl • >-* 
Died after leaving Colorado. 
o S 
; 1 - 
w 1 W 
| w w | » j w ; ( to ( to • w 
| Fatality evidently hastened by 
1 leaving high altitude. 
>1 .. 
\l 
\ - 
\ 
CO o 
\ ft 
Cl 05 w 
\ » 
1 
23 
7 
2 
\ ft 
\ 
» 05 4*- Cx 
1 Number now residents of 
\ Colorado. INFLUENCE OF HIGH ALTITUDES ON PHTHISIS. 
415 
Of these analyses, that in reference to the stage of the disease is first 
and most important. The twenty-five first stage cases were 38 per cent. 
°f the whole, and they averaged over a year and a third under observa- 
tion in Colorado. Of these, 68 per cent. (17) were much improved or 
'it the one unfavorable case, an explanation is needed. A beautiful 
young lady, age twenty, came to Denver in July, 1875, having chronic 
•uryngeal phthisis with complete aphonia, which had been coming on 
'v° and a half years; loss of weight, strength, and appetite, increased of 
ute. Dyspnoea increased, and catamenia absent three months. Grand- 
uther, father, brother, and aunt and uncle, died of consumption, and 
and sisters living, not strong. Dullness with pleuritic adhesions 
af base of right lung, and deposit, which I believed to be of true tuber- 
-oe, at left apex. Slight improvement during the fall. Afterwards she 
eat to live on a ranche, by my advice, with instructions not to mind 
.be loss of voice, but to gain in general strength. Gained seven pounds 
*n two or three months. In February, she followed the meddlesome 
advice of somebody, and submitted to “ throat treatment” from a man 
'v"o claimed to be a physician, in a neighboring town. The local appli- 
cation of a sixty grain solution of nitrate of silver was a sample of the 
•'eatment under which this delicate creature lost thirteen pounds in less 
ban a month. In two months more she died of acute phthisis. I regret 
exceedingly to have my list marred by such malpractice. Sixty per cent. 
G5) of these cases are now living in Colorado, 
The cases of the second and third stages include a variety, the second 
fbibracing several acute, and the third some extremely chronic or pro- 
nged third stage cases. Of the 17 per cent. (11 patients) who were in 
be second stage, averaging one year under observation, 18 per cent. (2) 
'xere much improved; 36 per cent. (4) slightly improved; 18 per cent. 
G) had slight local extension, with general tolerance of the disease ; in 
. per cent. (2) the disease extended and advanced; and 9 per cent. (1) 
bied in Colorado—or 73 per cent. (8) improved or tolerated the disease, and 
‘ per cent. (3) became worse or died. Of the 45 per cent. (30 patients) 
vbo came to Colorado in the third stage, averaging nine and a half 
booths under observation, 17 per cent. (5) wrere much improved, 17 per 
Cent. (5) slightly improved, 27 per cent. (8) had slight local extension 
bbth general tolerance of disease; in 33 per cent, (10) there was exten- 
mq11 and advance, and 7 per cent. (2) died in Colorado—or 60 per cent, 
improved or disease tolerated, and 40 per cent. (12) worse or died, 
i the whole sixty-six patients, 17 per cent. (11) were lost sight of after 
ley had been under observation two or more months; 37 per cent. (24) 
C n\G improved ; (24) per cent. (16) slightly improved; 15 per cent. 
GO) experienced slight local extension but tolerated the disease. In 18 
j1 Gpent. (12), there was extension and advance; and 6 per cent. (4) died 
u Colorado—or 76 per cent. (50) improved and tolerated the disease; 24 
q r cent. (16) became worse or died ; 48.5 per cent. (32) now reside in 
°lorado. Thus is shown by evidence, which is abundantly conclusive, 
b salutary influence of the elevated plains in Colorado upon phthisis— 
‘disease eminently progressive in character. Thus too is shown, what 
°se who live in Colorado have all along believed, namely, that the 
‘dtlt °| f)r^marJ Gage is pre-eminently the remedial period for high 
U to age, we find 4 per cent. (3 patients) under 20 years old when 
l(w came to Colorado, of whom one was the most remarkable example 416 
DENISON, 
of inheritance I have ever met; the little fellow weighing two and one- 
half pounds at birth, and seventeen pounds when four years old, at which 
time he came to Colorado. His father died of phthisis two months be- 
fore he was born ; his mother had been subject to a chronic cough ; and 
five of her family and six of the father’s had died of consumption, with 
evidence of its existence in the preceding generations. This ease comes 
under the head of chronic first-stage, and the duration is estimated as 
since birth. The child has been in Colorado four years with gradual 
improvement. The other two cases under 20 were advanced acute cases. 
Both became worse, and were advised to leave. Sixty-one per cent. (40 
patients) were between the ages of 20 and 80, of whom 42.5 per cent. (17) 
were much improved ; 20 per cent. (8) slightly improved ; 17.5 per cent. 
(7) experienced slight local extension with general tolerance of the dis- 
ease; in 12.5 per cent. (5) the disease was extended and advanced; and 
7.5 per cent. (8) died in Colorado—or 80 per cent. (82) were improved or 
tolerated the disease ; and 20 per cent. (8) became worse or died ; 55 p®r 
cent, (22) now live in Colorado. Between the ages of 80 and 40, 27 per 
cent, of the whole (18), resulted as follows; 40 per cent. (7) much im- 
proved ; 22 per cent. (4) slight improvement; 11 percent. (2) come under 
the head of slight local extension with general tolerance of disease ; 22 
per cent. (4) extension and advance ; and 5 per cent, (l)died in Colorado ; 
72 per cent. (18) improved or tolerated the disease ; and 28 per cent. (*>) 
became worse or died. Of the 8 per cent. (5) over 40 years old, 60 pel’ 
cent. (8) were slightly improved, none being much so ; 20 per cent. (1) 
came under the head of slight local extension, with general tolerance ot 
disease ; and 20 per cent. (1) under that of extension and advance ; or 86 
per cent. (4) improved or tolerated disease ; and 20 per cent. (1) worse or 
died. Thus is shown (as would be .more clearly indicated if the first- 
stage eases were excluded) the less favorable influence of elevation upon 
young persons with acute phthisis, and upon old persons with chronic 
phthisis, inasmuch as all but one of those over 40 years of age, were ot 
this latter character. 
When we come to analyze the nature of the cases, we find 38 pe* 
cent. (25) which may be classed as essentially inflammatory; of these 2a 
patients, 60 per cent, (15) were much improved ; 20 per cent. (5) under- 
went slight improvement; in 4 per cent. (I) there was slight extension 
and tolerance; 8 per cent. (2) advanced ; and 8 percent. (2) died in Colo- 
rado—or 84 per cent. (21) improved or tolerated the disease; and 16 pel 
cent. (4) grew worse or died, three of the four cases being examples of acute 
cheesy pneumonia. The catarrhal group, 17 per cent. (11 patients), included 
several in the second and third stages of the disease, and resulted in 2 
per cent. (3), being much improved ; 18 per cent. (2) slightly improved , 
86 per cent. (4) undergoing extension with tolerance; and 18 per cent- 
(2) advancing—or 88 per cent. (9) being improved or tolerating the Bs' 
ease ; and 18 per cent. (2) becoming worse or dying. The third division? 
chronic tuberculous, naturally embracing many of the third-stage cases, 
formed 45 per cent, of the whole (30 patients), and resulted in 20 pe' 
cent. (6) being much improved; 30 per cent. (9) slightly improved; 1 
per cent. (5) undergoing extension with tolerance ; 26.6 per cent. (8) ad - 
vancing; and 6.6 per cent. (2) dying in Colorado—or 77 per cent. (20) bein» 
improved or tolerating the disease; and 33 percent. (10) becoming wors 
or dying. Excluding the acute and far advanced cases, this analy9l 
shows in a remarkable degree the more favorable influence of the clinm INFLUENCE OF HIGH ALTITUDES ON PHTHISIS. 
417 
llP°n inflammatory than upon catarrhal, and upon the latter, than upon 
chronic tuberculous cases. 
It is useful to study the hemorrhagic cases, and to learn what influence 
Ovation has upon this class. Believing that the pulmonary hemorrhages 
' ©emingly caused by elevation, which have lately been written about,1 
uive been mainly from cavities, I have arranged the 30 cases (45 per 
cent.) which are known to have been attended by hemorrhage or hasmop- 
at any time, with reference to the existence or absence of excava- 
Seventy per cent. (21 patients) had hemorrhage or haemoptysis 
before coming to Colorado; of these, 71 per cent. (15) were probably with- 
-0l)t cavity and favorably affected, while 20 per cent. (6) were j robably 
cavity—four coming under the head of “extension and advance.” 
)PX patients had hemorrhages both before and after coming to Colorado, 
of whom had cavities when they arrived. One patient, subject to 
Repeated hemorrhages before coming, which were much mitigated by a 
Residence in Colorado, subsequently died from metastasis of the disease 
o the brain, which, by the way, is not a strange occurrence, considering 
he special influence of the climate upon the respiratory functions. Three 
lad hemorrhage after and not before coming to Colorado. In reference 
0 these three patients, it is well to explain that one with probably no cavity 
lad heart disease and complete hepatization of the right lung—at best a 
*a°st unfavorable subject for high altitudes. Another had slight hsemop- 
J;sis from a cavity while going over the divide; a third, with probable 
?avity,had hemorrhage,following a chill caused by extraordinary exposure 
I'1 a storm, and all were evidently little injured by the hemorrhages. On 
Ie other hand, four of these 30 hemorrhagic patients had hemorrhage 
going to lower levels, three of them being much injured thereby, and 
Wo probably dying in consequence. The synopsis of hemorrhagic cases 
shows a decidedly favorable effect of the elevated climate upon such 
Patients as had had previous hemorrhage without cavity, while a sorne- 
,Vllat less favorable effect can be inferred upon hemorrhagic patients with 
avity than upon the general average of those with excavation. There- 
°re, the advantages of high altitudes are pre-eminently for hemorrhagic 
?clses in the first stage, while hemorrhagic cases with excavation should 
e interdicted from going to great heights. 
It would be instructive to compare these results with those in other 
‘ miates, but we have none at hand so recorded as to furnish very definite 
inclusions. However, allowing for the absence of similar data in the 
)i°rds of others, the table may be considered as a favorable one, especi- 
.v for cases in the early stage of phthisis. It is difficult to compare it 
|VVlth Dr. C. T. Williams’s records of English and continental resorts, 
Realise, in his analyses, those patients who died during the time of obser- 
ation do not appear to have been included in the estimate. We are 
011 A fold that “ since the climatic treatment 45 of the 243 patients (who 
spont 386 winters in English stations) have died,”2 Really it would 
to be an important inquiry whether any died during the climatic 
treatment. 
th 10re *s strong evidence in favor of high altitudes to be inferred from 
e experience of Prof. Austin Flint, Sr.,3 who draws conclusions from 
M Some Eemarks on Diseases peculiar to Mountainous Regions. By W. H. Gardner, 
2 p 0.5.A., Am. Journal of the Med. Sciences, July, 1876. 
3 lecture XL, Lettsomian Lectures. 
Rhthisis,” by Austin Flint, M.D., p. 239. • 
27 F 418 
DENISON, 
his analysis of 670 cases of consumption, being all he has recorded, hut 
not all those in which he has been consulted. For though he has not 
kept records of cases for the past eight or ten years, he says, “I should not 
have omitted to make records of cases of arrested phthisis coming under 
my observation.” With this explanation, he continues, “ seventy-hve 
cases must be nearly all in which I have known an arrest of phthisis to 
take place, either with or without complete recovery, during a practice 
of thirty-eight years.” Now, though there is no analysis of these 676 
cases iu reference to altitude, several are mentioned, especially among 
these instances of arrested phthisis, which may be said to have received 
the special benefit of elevation. Among his patients were several who 
resorted to the Adirondacks with benefit; seventeen who went to Min- 
nesota, and were, with four exceptions, cured or benefited while therej 
one who went to the Peruvian Andes and was cured; and one who passed 
eleven weeks in New Mexico with decided improvement while he i’e' 
mained. Since, on the one hand, there is no evidence produced against 
high altitudes, and, on the other, so few of those patients who resorted 
to elevated stations for relief, we are compelled to present the latter fact 
as the only excuse for Dr. Flint’s giving high altitude almost no considera- 
tion, and for his arriving fit the conclusion “ that the benefit derived from 
the change of climate is due, not so much to a climatic influence per se, 
as to the circumstances incidental to the change.” I shall be the last to 
take issue with this renowned author, or any one else, as to the import- 
ance of out-door life and change of occupation ; all the most useful means 
we can combine will not be more than enough to make the consumptive 
multitude reasonably healthy. Sometimes, by unfavorable cases, the 
physician is impelled to agree with Pope, that— 
“As man, perhaps, the moment of his breath 
Receives the lurking principle of death; 
The young disease, that must subdue at length, 
Grows with his growth and strengthens with his strength.” 
Accepting Dr. Flint’s collection of cases of arrested phthisis as the 
largest, or one of the largest, that can be made from the experience 0 
any one man in America, the results of the few cases I have presenter 
must be admitted as an argument in favor of high altitude, in that the 
ratio of improvement is greater, although covering a shorter period 0 
observation. From my every day experience among the people _ 9 
Colorado, I am led to believe that as many cases of arrested phthis*® 
(75) could now be found among any average collection of 5000 people a 
the base of the Rocky Mountains. , 
One further result of my analysis should not be omitted, so importan 
is its bearing upon the time invalids should remain in high altitudes- 
The facts noted are that of six patients who have died after leaving 
elevation, fatality thereby has evidently been hastened in three; that l°ul 
of the hemorrhagic patients (a large proportion of those who left th 
heights) had hemorrhage afterward ; and that nearly half (9) of all those 
who went back to the lowlands, became worse by so doing. PrC? ' 
Weber’s cases furnish similar evidence: of thirteen cases arrested 111 
high altitudes, two were twice relieved, the disease twice returning on- 
going down to sea level. In six other cases phthisis was rekindled aite 
a descent to sea level; and two patients, who were residents of high a* 
tudes, moved to the lowlands and became consumptive, were apparent ) INFLUENCE OF HIGH ALTITUDES ON PHTHISIS. 
419 
Ul’ed on returning to the highlands, and were again taken sick when 
hey returned to sea level.1 
Jourdanet, among many striking illustrations of a failing or falling 
11 of consumptives after leaving the heights, mentions the case of a 
young lady who three times went down to a lower level with a return 
01 active phthisis, and three times, in turn, was decidedly relieved by a 
|eturn to Puebla. Dr. C. T. Williams mentions almost as remarkable an 
lristance of this loss of benefit by the return to low levels. Three of my 
ases show, in a marked degree, the injurious effect of going from Colorado 
o Southern California; one patient, in the third stage of the disease, 
leci in two months after leaving the high altitude, and one in the second 
tage, in the vicinity of San Diego, lost ten pounds, had five hemorrhages, 
financed f° the third stage, succeeded in getting back to Colorado, and 
las Unproved since. A third patient, in the first stage, was one of six young 
**, four of whom, I believe, were consumptive, who went to Southern 
rJditornia under the restless impulse which often controls such persons. 
1118 young man, with two others of his party, were made perceptibly 
orße by their sojourn in California, and returned quickly to Colorado, 
c°usiderably disgusted by their experience in the humid air of the Pacific 
,pe. All of these patients were doing well enough in Colorado, and 
Joß.t of them assumed the responsibility of going to lower levels contrary to 
c viee. As Jourdanet expresses it; “ I preserve among my notes a great 
J1'Huber of examples of the relief of the malady and of the obstinacy of 
Je invalids in returning prematurely to the climate which kills them.”2 
t '1(1 in reference to those who have returned to a lower altitude, he adds; 
°ften ask myself if actual residence would not have finally vanquished 
... malady, which a few months’ stay had relieved.” By inference, I 
Allak, an argument might be drawn from the analogous experience of 
Jose gymnasts and athletes who abandon their accustomed exercise and 
render their lungs liable to disease from lack of use; for we are all 
Ie time speaking in favor of healthful respiratory activity as opposed 
.o the rest which is so desirable in the treatment of most diseases. Such 
8 the experience which leads to the conclusion that a partial recovery 
ocessitates a permanent residence. This statement carries with it the 
ea, consonant with experience, that complete recovery does not necessi- 
•ate permanent residence, so that the time invalids should consider it 
operative to remain in high altitudes is less for incipient or first-stage 
c 8, in which complete recovery may be expected to occur, 
fathering from these arguments the conclusions which may serve as 
guide to the physician in staying the progress of phthisis, many obsta- 
p.es to successful work may be suggested. Among them, after the 
11 dranees to the patients’ following the most useful combination of 
easures prescribed, comes a difficulty in early arriving at a correct 
agnosis of the existence of the disease. It is referable to ignorance 
'1( ueglect on the part of the invalid, and, I fear, too often to inade- 
ate knowledge on the part of the physician. Often I find the invalid’s 
p-s°i'tion that his indisposition is slight, that his doctor has examined 
‘m.a»d said so, unverified by a correct and careful examination. The 
evioug existence of dyspnoea, night-sweats, loss of strength and weight, 
Coe ,10t belied in the real condition of the lungs. We must accept the 
frnc usion which is inevitable, in view of physicians so often differing 
°UI each other, as they do, in opinion, that the discovery or invention 
1 Op. cit. 
2 Op. cit., p. 304. 420 
DENISON, 
of new means of physical diagnosis, and the thorough teaching of this 
branch in medical schools, should be earnestly encouraged by the medical 
profession. 
The conclusions of prolonged, and I fear too tedious, study, I have 
embodied in the following deductions, in which I respectfully ask yolll 
concurrence:—• 
I. Cool and dry, are better than warm and moist, climates. 
11. The most favorable climatic attributes of low altitudes, especially 
the diathermancy and dryness of the air, are increasingly found with 
increasing elevation. 
111. The favorable or positive influence of high altitude upon the pro' 
gressof phthisis is best shown in the incipiency of chronic, inflammatory? 
and hemorrhagic cases; and in others in proportion as these characteris- 
tics exist, the more acute the inflammatory process, or the more activ6 
the pulmonary hemorrhage, the more gradual and tentative should be 
the rise in elevation. 
IV. Partial recovery necessitates a permanent residence, which 13 
therefore required either in an advanced stage of the disease, or when 
the recovery has been incomplete. . 
V. The unfavorable or negative influence of high altitude upon the 
progress of phthisis, is mainly seen in proportion as the disease approaches 
or is complicated with the following conditions; First, cardiac disease? 
if associated with increased labor and abnormal activity of the heaH* 
Second, the stage of softening, in acute cases, associated with extensiv® 
deposit, or with an irritable, nervous state, and lack of desirable wn 
power aided by the stimulus and hope of youth. c 
VI. The generally admitted rule that change of climate and mode 0 
life is favorable to the cure of pulmonary consumption, in proportion 
its early adoption, is rendered more stringent in that the results are m°ie 
positive in case of a resort to high altitudes. , 
VII. The stimulating effect of high altitude, associated with increase 
respiratory activity and power, is opposed to the idea of rest, and con- 
stitutes a most important agent in arresting chronic phthisis, 
VIII. High altitude is a means of arresting phthisis independent 0 ’ 
and in addition to, change of occupation and out-door life, and is worthy 
to rank with such hygienic measures. 
IX. Such is the importance of an early resort to high altitude, that 
incipient cases the patient should receive the benefit of the doubt, an 
the physician give affirmative rather than negative advice, in view 0 
possibility of error in declaring the non-existence of phthisis. 
X. High altitude being an important attribute of successful climatn 
treatment, a resort to a well-chosen elevated climate should constitn , 
part of the physician’s advice to every consumptive (who can follow 1 / 
for whom the elevation is not specially contra-indicated. 
Discussion on Dr. Denison’s Paper. 
After the reading of the preceding paper, Dr. Thomas S. Duffy, of Unt1 .g 
fordton, N. C., said:—The paper is a very interesting one. The snbjec 
one of experience and observation. The matter of moisture in the atmosp 1 
is very important. I have known coughs, contracted during dry weather, 
treatment, and yet disappear spontaneously when the weather became da INFLUENCE OF HIGH ALTITUDES ON PHTHISIS. 
421 
have taken observations of the difference in temperature between mountain 
a>'d coast springs, and have found the temperature to be 60° at an altitude of 
000 feet above the sea level, and 59° on the coast. Where I live it is very 
hhcult to find cases of consumption. As this disease is seldom cured, we 
‘Oll Id consider preventive rather than curative measures. Perhaps the habits 
the people of North Carolina are as efficient in creating an immunity from 
as the climate. North Carolinians are not in the habit of shut- 
lng doors to keep out the cold, but increase the heat of their houses, and put 
°? 111 ore clothing instead. Going from a warm to a cold atmosphere will not 
§lve cold, unless the person exposed has been previously exhausted by exer- 
It is customary for people in my State to halt while on a journey and 
Vai’tn themselves, and then proceed in the cold. They do not hesitate, when 
„ ai>'L, to plunge into cold streams. Such an act might kill a man coming 
l°in the harvest field, because he would be exhausted; but where there is no 
exhaustion, there is no danger. 
. J have been in Southern California, and have observed its climate. In the 
a,Vtime, during the dry season, there is a cloudless sky. After the sun rises, 
a ‘°S becomes so dense that objects cannot be distinguished at a distance of 
j,WePty yards. The atmosphere is heavily laden; the roofs drip as though 
ain had fallen; vegetation is sustained without rain. It is not observed that 
fog induces consumption, but, on the contrary, the people seem compara- 
lVely free from it. It is a matter of doubt whether a moist atmosphere is 
e°ndueive to disease; a moist, cold atmosphere may be, but a moist, temperate 
is not. 
A. S. Baldwin, of Jacksonville, Florida, said:—l am happy to hear the 
e,tiarks of the reader of the paper upon a subject which I have studied for 
Orty-eight years in my own State, as far as climate is concerned. It is doubt- 
l. ’whether all the beneficial effects mentioned by Dr. Denison are the result 
altitude. I have witnessed the same effects in Florida, where the atmos- 
I lerio pressure is slightly above 30°, which is assumed to be that of the sea 
JrVel, so that it appears to be the change of climate rather than the altitude 
*at is so beneficial. I have seen, in a post-mortem examination, lungs studded 
‘fh obsolete tubercle, the result of disease acquired twenty or thirty years 
P'eviously, the patient’s death being caused by exposure following a debauch; 
a!Kl I have known other cases of consumption, partly cured by the Florida 
lrnate, recur when the patients have exposed themselves carelessly. Some 
odical men administer oxygen as a remedy for phthisis, but 1 doubt whether 
ils is judicious. By visiting Florida, where the atmospheric pressure is so 
g'feat, the patient can get oxygen without the effort required for the same 
in Colorado. This would give rest; and I believe in the value of rest 
1 these diseases, and think that that is one of the reasons why Florida 
rpVes 80 beneficial. 
y the rain-fall, taking the whole State, is about 51 inches. In ray section of 
I State I have recorded 61 inches in one year, and 31 inches in another. It 
8 impossible to get the truth about the humidity of the atmosphere without 
1 Gng observations extending over a long period of years. 
II sick person requires an even temperature, and we always try to keep 
lenj f>‘om sudden changes. Experience has taught us this fact. In the ex- 
essiveiy dry climate of the western plains there is a change of 60° between 
le atmosphere of the day and that of the night; surely that is harder on a 
than a change of but 10° or 12°. Therefore, we must have, as one of 
v 0 c°Daponents of a atmosphere, enough moisture in the air to pre- 
such radiation as to produce violent changes. We have that in Florida; 
o j lave about 14° diurnal variation throughout the year, and a difference of 
.V 20" in the mean temperature between summer and winter. It seems 
(uer in Florida than in other places, even when the thermometer indicates 
j|JC fatne figures. There is no need to avoid the sun ; one can ride or walk in 
impunity, and sunstroke is unknown. 422 
DENISON, 
Dr. Henry Gibbons, of San Francisco, said :—When invalids change then" 
location and improve in health, the benefit is attributed to the influence of the 
new climate and locality, when it is more likely to be due to the mere condi- 
tion of change. Removal from a better climate to a worse one often does 
much good, for a time. This fact renders it very difficult to form a correct 
estimate as to the best resort for consumptives. Our opinions on this subject 
are constantly changing. Twenty-five years ago it was our custom, in San 
Francisco, to send consumptives to the Sandwich Islands; but we soon found 
that to be a mistake. Then we fixed on other localities from which the best 
reports were returned for a while, until it was discovered that they yielded 1)0 
permanent good. The climate of Santa Barbara, and of the southern portion 
of California, was then selected, and every body was confident of their cura- 
tive power, and hundreds of consumptives came there from all parts of the 
world. But Southern California is now wearing out. To talk of “ the cli- 
mate” of California is a. great mistake. That country has almost as great a 
variety of climates as all the rest of the civilized world combined. You may 
journey ten miles across a range of hills, and get from a noonday temperate*'® 
of 65° into an atmosphere of 105°. The Pacific Ocean, along the coast, has a 
temperature of 53° or 54°, winter and summer. Put the thermometer in the 
bay, at the foot of the wharves in San Francisco, in July or August, at big'l 
tide, and it will fall to these figures. Of course the superincumbent atmos- 
phere has the same temperature, and this cold air comes in daily during the 
summer towards noon, as soon as the sun has heated the interior. It often 
carries with it a dense mist. This is the ocean climate, which prevails only 
along the coast as far as the first highlands, or where a break in the highland3 
allows the cold wind to pour through. This cold ocean wind, as it work3 
inland, mingles with the heated air, and forms in many localities a climate 
highly agreeable and healthful. Farther in the interior, there is a glaring 
sun, whose rays are never intercepted by a cloud for five or six months of the 
year. Hero the temperature is high by dayr, and the air very dry, with night3 
always cool, but never cool enough for discomfort to the invalid. Dr. Denison 
is mistaken in speaking of the humid climate of Southern California. At San 
Diego, to which he makes reference, there is but a yearly mean of seven 01 
eight inches of rain. The fact is that consumptives are improved in many 
climates where a permanent residence may be injurious. lam consulted habit- 
ually by letter, and personally, as to the best health resort; but now, aft®1 
twenty-five years of observation and experience in California, I have ceased to 
designate any locality. Aty advice is, to all who have strength enough, uGet 
a horse or mule, and seek a climate for yourself. Ride, or lie by, as it suit3 
you. Eat good, nutritious food, and drink milk or cream; spend all the tin*® 
you can out of doors. If you find yourself improving decidedly at any g>ven 
point, stay there a while, if so inclined, but do not stay one hour after th® 
improvement ceases. Keep moving until you find the right climate and th® 
right place. The chances are that you will get nearly well in searching f°l 
it.” In confirmed and advanced cases, however, my advice is to go home an® 
die among friends. 
Dr. A. B. Stuart, of Winona, Minnesota, said:—Ten years ago I went W 
Minnesota as an invalid, accompanied by a brother-in-law suffering from pll ' 
monaiy phthisis, resulting from exposure during the civil war. In two yem3 
my brother-in-law recovered, and increased in weight from 125 pounds to 
and to-day does not have the appearance of a phthisical patient, though when 
he came he had undoubtedly a cavity in the upper lobe of the left lung. 1 
have often known patients come to Minnesota in the first stages of the disease? 
and remain until they have considered themselves well. Beneficial effects may 
be lost, however, by staying too long. If a person is unable to take out-door 
exercise, Minnesota is no place for him. 
Dr. H. A. Johnson, of Chicago, said :—I have known a number of consump 
lives go to Denver, Colorado, to Florida, to the mountains of North Carolina? INFLUENCE OF HIGH ALTITUDES ON PHTHISIS. 
423 
0 Georgia, to Tennessee, and to the south of France, and come back enthusi- 
°ftic about the beneficial effect of tfie change of climate. It seems that we are 
1 agreed as to the advantage of an open air life, exercise, not pushed so far 
as to fatigue, sunshine, and good food. Dr. Denison has attempted to estab- 
, . bie fact that in addition to these beneficial influences there is another, viz., 
btnde. Unfortunately for the solution of the problem he has had to deal with, 
‘ btude is connected with all these other influences. How can we separate 
le influence of altitude from the rest? I believe that in the earlier stages of 
j le disease, patients are benefited by going to the mountains, but, on the con- 
ary, when softening has set in, when cavities exist, I believe that it is hazard- 
for them to do so. A warm, mild climate is better then. I had about 
by patients last winter in Florida, and they came back better ; even those in 
!ose lungs cavities existed were better than they would have been had they 
i aid in Illinois. I therefore think it impossible, in our present state of 
nowledge, to prove that altitude, per se, is beneficial, and will continue to 
.slVlse patients in the first stages of phthisis to go to the mountains, and in 
plater stages to go to Florida or Georgia. 
C. J. Hare, of London, said ;—I wish, as a stranger, to thank the author 
the paper for the valuable facts therein contained on the treatment of 
| bthisis. I have often recommended long sea voyages, and have seen my 
I atients benefited thereby. I have seen patients come back marvellously irn- 
-1 i°Ved after a voyage to Australia, and an enjoyment of the wonderful climate 
Queensland. The region in which phthisis exists, gradually descends from 
,le centre towards the poles. In Iceland and Norway the disease is un- 
nown. It exists in some of the higher valleys of Switzerland, but at the 
Ulle altitude, where there is plenty of fresh air, phthisis is never found. A 
.11 ter residence in these places is good, providing the patient can take exer- 
Se* To delicate patients I usually recommend a southern, genial climate. 424 
ON THE TREATMENT OF SIMPLE ULCER OF THE STOMACH- 
M. LE BOCTEUR H. LEBERT, OF YEYEY; 
FORMERLY PROFESSOR OF CLINICAL MEDICINE AT ZURICH AND BRESLAU. 
[TRANSLATED BY CHARLES WINSLOW DULLES, M.D., 
OP PHILADE LPHIA. ] 
Though the difficulty of treating simple chronic ulcer of the stomach 
often renders our efforts futile, yet there are few diseases in which our 
art can be of so much service to our patients, both as regards hygiene 
and by medicinal treatment, properly so called. We must, at the outset, 
consider the general indications to he met. 
I. In the first place we should aid the digestive function of the diseased 
stomach by selecting for it food easy of assimilation, both from its quality 
and its liquid form or slight consistency, and by reducing its quantity to 
that strictly necessary for the maintenance of life, whenever we are 
obliged as much as possible to spare the labors of the organ. For tin3 
purpose we must not omit to call to our aid the absorbent power of the 
rectal raucous membrane to lessen by so much the work of the stomach; 
and a suitably regulated diet should always be conjoined with a propel 
hygiene, both physical and moral. 
11. While thus diminishing the work of the affected organ we must 
guard against unnecessarily fatiguing it with drugs. Since, however, 
radically curative methods have been, even of late, recommended for tin3 
disease by physicians of eminence, I shall not fail to mention them, 
as to leave to each practitioner an opportunity for free choice; but I 
must avow that to this day I incline rather to the expectant method, 
advising at the same time most careful symptomatic medicinal treat- 
ment, in which the true physician may bring to bear all his knowledge 
his sagacity, and his desire to be of use to his fellows who suffer, or who 
are threatened with actual danger. 
In the first place, I shall describe the methods proposed by Trousseau? 
Ziernssen, and Leube. 
(1) Trousseau’s plan1 is as follows: The patient takes two or three 
grammes of the subnitrate of bismuth, an hour before meals, three times 
a day for ten days, after which time the nitrate of silver is substituted, 
in pills containing each one centigramme, taken three or four times a 
day for five days. Then the course of bismuth is resumed for ten days? 
and followed for four or five days by two daily doses of calomel of 0,1(3 
centigramme each. This routine is repeated again and again for three 
or four months, when it is discontinued, to be resumed after a month s 
cessation. Evidently this mode of treatment is too systematic, and d°e3 
not allow for the very varied accidents which may arise and call tOl 
modifications during its course. _ . . 
(2) Ziemssen’s2 method consists in the employment of an artificn1 
1 Clinique Medicale, tome iii. p. 96. 
2 Ueber die Behandlung des Magengeschwurs, Yolkmann’sche Yortraege, 1871, S. 16- SIMPLE ULCER OF THE STOMACH. 
425 
parlsbad salt, composed essentially of sulphate of sodium, with a little 
and chloride of sodium. The patient takes from eight to 
sixteen grammes each morning, in water heated to 44° R., and should 
lave two or three stools in the course of the day, the quantity of the 
salt being increased or diminished according to its laxative effect. Grad- 
ually small quantities come to suffice. 
(3) The method of Leube1 adds to that of Ziemssen the solution of 
rneat indicated by the author, in which hydrochloric acid in small 
Quantity serves to extract from the meat its nutritious principles. Un- 
-ortunatelyrtunately many patients have a repugnance to this solution, which, 
bioreover, does not always bear transportation to distant places. Milk 
ls added to the diet, with Zwieback2 (or Einback); and by degrees the 
Patient can take a more substantial regimen of thick soups, roasted 
to'vls, etc. 
Eor my part, I prefer to abstain from all radical treatment, placing in 
be first rank hygiene, and in the second the treatment of symptoms. 
I- Diet and Hygiene.—Absolute diet, or rather absolute absence of 
°°d, should be enforced only exceptionally and very transiently, as after 
Perforation, or i mmediately after a violent hemorrhage. Then nutritious 
bbernata only should be used. In other cases patients do not bear food 
and we are obliged to give them milk by tablespoonfuls only,every 
bree or four hours, until a larger quantity can be borne. Under all 
bese circumstances, absolute rest in bed is indispensable. 
.Milk Diet.—lt is now half a century since Cruveilhier recommended 
use of milk as an exclusive or principal food in the treatment of 
gastric ulcer, and experience has perfectly justified his plan. For ray 
Park I have seen from it effects often so salutary, sometimes so surprising, 
bat I have, from year to year, become more its partisan. Occasionally 
a certain repugnance is met with on the part of patients who pretend 
bat they cannot take milk in any form whatever. These cases are rare, 
abd, on the contrary, patients are afterwards grateful to the physician for 
b°b having allowed himself to be checked by their prejudices and objec- 
ts which are often ill founded. The exclusive use of milk is, more- 
°Vei% rarely necessary for more than from six weeks to two or three 
rbonths, and by degrees other articles of food can be added to it. Milk 
sometimes better borne warm from the cow, sometimes heated, some- 
lrries of the temperature of the room ; and iced milk can be taken by 
?°rrie patients who can bear it in no other form. The quantity is increased 
by little until fifty, sixty, or one hundred grammes every three 
°Urs are successively reached, and total quantities of a litre and a half 
two litres are taken during the day—an amount sufficient for good 
°tU'ishment. Patients who bear onljr thirty to forty grammes at a time, 
Pllgbt to take it every two hours. At night, feeding should, if possible, 
e Interrupted. 
.°w’s milk is the most useful kind and that generally employed. Some 
Patients, however, at first bear ass’s milk better. Buttermilk and curdled 
1 preferred by some, are exceptional forms. Where cow’s milk of 
good quality cannot be had, it may be replaced with goat’s milk. Sheep’s 
1 k, niuch the richest in nutritious matters, is sometimes used with 
access by the owners of large flocks and by their families. At the start 
2 AJ’ankheiten des Chylopoetisches Apparats, V. Ziemssen’s Pathologic. Bd. vii., S. 113. 
anri ] is made by taking rolls, cutting them in half, and putting them into an oven 
an ]' ley are brown and crisp. These are much used in Germany and Switzerland, crumbled 
soaked in some liquid article of food. Einback is simple bread or biscuit.—Translator.] 426 
LEBE E T y 
pure milk is sometimes badly borne, especially if there is a marked 
tendency to acid secretions. In such cases I add one-fourth part of lime 
water, or as much bicarbonate of sodium as will cover the point of a table- 
knife. Patients who at the beginning of the milk-treatment are consti- 
pated should take one or two cold water enemata daily. When the 
milk habit is once fairly acquired, then may be added to each cup one 
or two teaspoonfuls of arrowroot or rice flour; or small quantities of 
biscuit, of Zwieback, or of white bread may be taken with the milk* 
Sometimes capricious stomachs—especially in nervous and hysterical 
women—bear fat substances very well. To these cream may sometimes 
be allowed. They are the patients who at a later period often bear ham 
and smoked or salt meat better than fowl, veal, or fillet of beef. It is 
always well to mistrust the gastric caprices of hysterical women, since 
their sense of veracity is often warped. 
When the stomach is habituated to milk, and partially reinstated m 
its digestive force, it can be accustomed by degrees to other forms of 
nourishment; to the farinaceous articles already mentioned, to beef-tea, 
to Leube’s solution of meat; and, better still, to good chicken or beet_ 
broth, to which are added farinaceous substances, or small quantities of 
meat very finely hashed or cut; or the yolk of an egg may be beaten ins 
or some granulated gluten added—which is very nutritious because of 
its azotized constituents. Milk-porridges may also be alternated with 
broths. 
Every one knows the great difficulty of getting good milk, especially 
in large cities, at the seashore, etc. It is, therefore, necessary to have a 
substitute for milk which can take its place, and be within the reach of 
all purses. Many years ago I learned to appreciate, in this respect, the 
excellent milk-powder (poudre lactee) of Nestle, of Yevey, which is recog- 
nized as much the best substitute for milk in the nutrition of young 
infants. I have likewise come to employ it much in cases of difficult 
digestion and embarrassed nutrition, in the treatment of chronic diseases 
of the adult, especially in that of chronic affections of the stomach, and 
particularly of ulcer. Since I have lived in Yevey I have thoroughly 
studied the process of manufacturing Nestle’s Farina, and have been able 
to satisfy myself that the milk used is of the best quality, and that the 
same is true of the other ingredients, and above all of the methods aim 
manner of manufacture. Fresh milk is first well examined, and then 
poured into the apparatus, heated by steam, and evaporated in vacuo at 
a temperature which does not exceed 40°-45° C. There is, thus, simpl® 
condensation without change of quality. The bread added to Nestle s 
Farina is made of the best wheat flour, by a plan which preserves T8 
gluten ; and the crust alone being reduced to a very fine flour it is s0 
much the richer in azotized constituents. The extremely fine division m 
the milk in powder, and of the flour of the crust, rich in nitrogen, greatly 
adds to its digestibility. 
A thousand parts of the milk-powder are found by analysis to contain 
49.40 parts of water, 931.10 parts of organic matter, and 19.50 parts ot 
ash. The azotized constituents form 21.40 parts in 1000. By micro- 
scopic examination I have found a division so minute that most of the 
molecules do not exceed of a millimetre in diameter, this greatly 
increasing the facility of mixing with water. 
For each meal ten grammes may be mixed or cooked with fifty grammes 
of water, and gradually the quantity is carried up to twenty gramme8 
in one hundred of water, it being well to warm this mixture to 37° O'* SIMPLE ULCER OF THE STOMACH. 
427 
Gradual! y we may rise to thirty grammes in one hundred, and in place 
two or three little meals give one of a hundred grammes every three 
lours, and even oftener, provided always that the preceding meal 
aPpears to have been completely digested. I should be glad if this mode 
°t feeding, which has already gained an established place in the nourish- 
ment of earliest infancy, could be thoroughly tested in that of diseases 
U the adult. And as experimentation in such a matter is better than 
ousting to any recommendation whatever, I have requested M. Monnerat, 
0116 of the proprietors of the article, to place at the disposal of hospital 
Physicians the material necessary for this study ; to which M. Monnerat, 
is a Syndic at Vevey, has very willingly consented. So that all my 
c°heagues, who would like to experiment with the lacteous powder in 
Pathological nutrition, may address him directly to obtain the quantity 
Squired for complete investigation. 
In continuing the progress toward a more varied regimen, the stomach 
at first often bears better well-prepared mucilaginous soups of barley, 
°atrneal, etc., than broth ; to these sago or tapioca may sometimes be 
atided with advantage, and if, besides, they have beaten up in them the 
Hdk 0f an egg5 anq contain some finely divided fragments of light meat, 
hese soups can be made as nutritious as they are savory. When, later, 
come to allow tender and well-roasted meats, such as chicken, veal, or 
,eeG in small quantity, with a little white bread, it is still needful to enjoin 
Ve patient particularly to chew solid food thoroughly, and to eat slowly. 
' e may now also permit a little wine, either pure or mixed with water, 
clf meals. A little later, fish, oysters, and game may be allowed, as well 
as potatoes, green vegetables, stewed fruit, etc. Too careful a watch 
never be kept upon the quality and especially the quantity of food 
aken. It is well to bear in mind constantly that a single indigestion 
?la3r undo the good effect of many weeks of prudent and well-ordered 
eeding. 
, Tea and coffee, in small quantities, diluted with two-thirds or one- 
Jl1} of milk are allowed comparatively later. The mineral water of 
din, or that of Vichy, will serve for some time to dilute the wine at 
V® principal meals. From my experience I prefer the natural water of 
]hu, in Bohemia, to that of Vichy. 
'' hen a patient has become profoundly anmmic in consequence of 
lo'ent gastric hemorrhage, there is a strong temptation to soon replace 
j1® severely prudent regimen by a more analeptic diet—a fault which 
have often seen committed. But the more cautiously an increased 
e °Wauce °f food is provided, the more surely is the patient strength- 
i Ihe hygiene which accompanies the diet, ought to he conformed to 
ie principles announced. There must be repose of both, body and mind, 
. specially must the patient, after each meal, avoid every rapid or 
f ,ent movement, as capable of provoking perforation, and must even 
avoM being too long in a carriage or railroad car. In regard to walking, 
'gue must be avoided, and when the patient can resume his occupa- 
i°n he should do so slowly and gradually. It is very essential that a 
any evacuation from the bowels should be secured, while any great 
Tl0l't in the expulsion of the contents of the rectum should be avoided, 
tj Jere are aiso some periods in this disease in which the examination of 
16 patient requires precautions on the part of the physician, in avoiding 
strong pressure, and all deep or prolonged palpation. 
-*4- Symptomatic Treatment.—Pain is often advantageously combated 428 
LEBERT, 
by the diet and hygiene indicated. But often, also, we cannot dispense 
with sedatives ; among which opium holds the first rank. The muriate 
of morphia may be given in doses of one centigramme internally, or 
better still, by subcutaneous injection. Sometimes suppositories of cacao 
butter, containing from one to one and a half centigrammes of morphia, 
may be used, or clysters of eighty to one hundred grammes of water, with 
ten to twenty drops of laudanum. These as well as the bimeconate of 
morphia are very soothing, but some patients bear better the extract of 
opium in doses of from one to three centigrammes several times a day* 
Other sedatives replace opium very imperfectly, because it acts in much 
smaller doses, and is equally efficient when combined with alterative 
medicines which are themselves efficacious against gastric catarrh, such 
as nitate of silver in doses of one to two centigrammes, and the subni- 
trate of bismuth in doses of half a gramme, or a gramme, or even more. 
Brinton recommends the compound kino powTder, which contains fifteen 
parts of kino, four of cinnamon, and one of opium ; of this from three 
to six decigrammes are given at a time. Locally, wet applications to 
the epigastrium often do much good, acting by cold, if frequently re- 
newed ;if left in place, as cataplasms. One or the other method is 
chosen according to the effect upon the patient. Sometimes large blis- 
ters, followed by endermic applications of morphia, give great relief, and 
in certain rebellious cases rnoxa, applied to the epigastrium, have done 
me good service. 
Hcematemesis demands, beside absolute rest, the internal use of small 
pieces of ice, and its external application to the epigastrium. Among 
haemostatics I place in the first rank the aqueous extract of ergot, given 
every hour in doses of five centigrammes, with the addition of one centi- 
gramme of extract of opium. If this fails, the solution of sesquichloride 
of iron in five-drop doses, given with a mucilaginous liquid, is indicated- 
In other cases we may succeed better with tannin, in doses of two or 
three decigrammes, or with acetate of lead, three to five centigrammes, 
1 9 ZD t L. 
with a little extract of opium added. Alum whey is a good adjuvant 
draught. If the patient, exhausted by hemorrhage, is in imminent 
danger of death, generous wines should be employed, with large doses ot 
musk, camphor, etc. When he can again take nourishment, iced milk lS 
much the best food, while nutritive enemata of milk and yelk of egg’3’ 
or those of Leube, containing meat hashed fine with sweetbread, mW 
render good service. Enemata of the Nestle’s lacteous farina, in doses ox 
twenty grammes to one hundred of water, repeated three times a day? 
may become very useful. Iced solutions of this powder may also take 
the place of milk very well, when this cannot be had of good quality* 
If the patient gets better, and his appetite returns, we must opp°se 
too prompt a recourse to restorative diet, the consequence being often a 
renewal of pain and dyspepsia. It is the same with iron, the too can) 
use of which does harm. We should begin with a mild preparation? 
such as the tincture of the malate of iron, in doses of ten to twent} 
drops, or the lactate or citrate of iron, and pass but very gradual!} 
to average doses and to the stronger preparations. I often order an 
effervescent ferruginous powder, made up of three grammes of the lactam 
of iron, nine of tartaric acid, and twelve grammes of bicarbonate °| 
sodium ; to be kept in a wide-mouthed bottle, well stoppered, to avon 
moisture. The patient takes from a half to one teaspoonful in a siua 
wineglassful of water two or three times a day. 
Dyspepsia.—The mistake of attempting to aid digestion by the help SIMPLE ULCER OF THE STOMACH. 
429 
stimulants and a tonic regimen is often committed. On the contrary, 
V lessening the quantity and regulating the quality of the food, when 
'AB pepsi a is aggravated, much better results will be obtained. And 
.ei’e is applicable all that I have said about diet and hygiene. Exces- 
s’ve acidity of the secretions, or acid fermentation, often form an obstacle 
t° digestion, and in such cases, whatever may be said, the alkalies and 
specially the bicarbonate of sodium in doses of from one to four 
grammes are indispensable. The alkaline salts of magnesium, of calcium, 
UU(I of ammonium, are less well borne in the end, whilst the bicarbonate 
sodium, if of good quality, can be taken for quite a long time. An 
effervescent powder made with bismuth has often done me good service 
111 such cases. It is for these patients, too, that I prefer the natural 
Xvater of Bilin, as a beverage at meals, to other mineral waters of the 
S:,me kind, as Vichy, St. Galmier, Vais, etc. The water of Bilin is as 
alkaline as that of Vichy, and has in it, beside, fixed carbonic acid and 
the bicarbonates neutralize the acids of the stomach too strongly, 
tincture of rhubarb, the extract of orange-peel, the tincture of nux 
v°mica, the bitter tincture,1 or that of quassia or calumba, modify the 
*ecretions advantageously, and act in a more lasting manner, so that it 
Is Well to begin their use after that of the alkalies, as soon as the stomach 
cible to bear them, which is much facilitated by giving them at first 
small doses. Among the mineral water cures used methodically, I 
know none better than that of Carlsbad. When patients are much 
I make them go through a course of two or three weeks at 
’’anzensbad, after a season of four or five weeks at Carlsbad, where they 
rriUst take the waters in small quantities, one to three hundred grammes 
'*HUy, avoiding also the wells that are too warm, and looking upon a 
temperature of 50° C. as the highest admissible. Some patients even 
derive more benefit from the use of Carlsbad water when cooled than 
'vhen at its natural heat. Anti-ferrnentatives, such as creosote, hypo- 
sulphite of sodium, etc., have been highly praised, but have never done 
llle much service in this disease. 
Vomiting.—Diet is the best anti-emetic, and here iced milk, aided from 
Sine to time by swallowing small pieces of pure ice, may be very useful. 
Effervescent powders with the subnitrate of bismuth, a mixture of 
of sodium with lemon-juice, iced soda-water, and saturated 
a‘kaline solutions prepared with lemon-juice, with the addition of small 
,ses of laudanum, are the best medicinal remedies in such cases. Bills 
opium, each containing one centigramme of the extract, sometimes 
koswer best, three or four being used in the twenty-four hours. Often 
Be iodide of potassium has seemed to me to stop the vomiting better 
lan any other means. I cause four grammes of it to be dissolved in thirty- 
H’° grammes of bitter tincture, of which ten to twenty drops are to be 
taken th ree times a day. 
Constipation ought not to be permitted. Cold enemata and artificial 
ai’lsbad water are good preventives. I often direct two or three pills, 
?,lc‘h containing five centigrammes of aloes, to be taken belore going to 
The powder or extract of rhubarb suits better for some patients. 
Ie essential point is to regulate the stools, without provoking either 
p [I he author doubtless alludes to the tinctura amara of the G. P. which consists of 
'wtus Aurantii Immaturi, Herbie Centaurii, Radicis Gentianae, aa partes ii, Rhizomatis 
pars i, Spiritus diluti, partes xxxy.—Translator.] 430 
LEBEHT, 
numerous or liquid evacuations. One stool of moderate consistence daily 
is enough. 
The occurrence of 'perforation demands the most absolute rest and the 
use of opium in full doses—three to six centigrammes of the extract at 
first every hour, and afterwards every two hours. The treatment may 
further he aided by the use of subcutaneous injections of morphia. Abso- 
lute diet should be enjoined, and ice may be applied to the epigastrium- 
This mode of treatment has already proved successful in some cases cd 
this accident, which is one of the most dangerous to which man lS 
subject. 
Constriction of the pylorus is usually beyond the resources of art, even 
the best chosen diet furnishing only unsatisfactory results. In such 
desperate cases resort may be had to the expedient of washing out the 
stomach, after the method of Kussmaul. 
In conclusion, the patient’s general condition merits all our attention 
during the long course of the disease. Primary chlorotic anaemia, as 
well as that which follows upon a severe gastric hemorrhage, demands 
the circumspect and prudent use of the ferruginous and hitter prepara- 
tions already mentioned. The effervescent ferruginous powder is a 
remedy which lam fond of employing under such circumstances. 111 
summer, the air of the country, of the mountains, or of the sea-shore, may 
aid the action of an analeptic regimen and of tonics. It is essential also 
that, even when a cure has been obtained,the patient’s diet and hygiene 
should still be watched over with the greatest care for years. 
Discussion on Dk. Lebert’s Paper. 
After the reading of the preceding paper, Dr. W. Scott, of Cleveland, Ohm? 
said :—I have listened with great pleasure to this paper, which treats of the 
method of managing a very troublesome disease. I have always treated gastric 
ulcer in the manner described by Dr. Lebert. The primary condition to be 
observed is to keep the organ completely at rest, and to control pain by the 
use of opium or morphia. I have treated a case of this kind for thirty-on® 
days without having anything nutritions in the stomach during that time. 
Dr. H. P. Yeomans, of Canada, said:—l have found, when treating cases m 
the first stage, when there is much vomiting, that nitrate of silver in pilubu’ 
form is of service. It may be given in small doses, combined with the coin' 
pound extract of gentian. I have always found it successful. 
Dr. C. J. Hare, of London, said :—Great difficulty is experienced in getting 
the stomach to retain anything during the course of treatment. I have found 
that milk, boiled for ten or fifteen minutes, and then skimmed, can be borne by 
the stomach very often when nothing else can. I think that the language 
employed in this and many other papers is adapted to create the impression 
that the disease is more frequently met with than is actually the case. Physi' 
cians ought always to be sure that the disease is really present before they begin 
any particular mode of treatment. 
The President, Dr. Alfred Stille, of Philadelphia, said:—l think the <ffs' 
ease does occur frequently. While spending the summer at Lake George, N. 
at a place where there is scarcely a village population, I have met with no lesS 
than four cases among the resident population. lam surprised that the con- 
densed milk used in this country has not been, as far as Prof. Lebert’s papel 
indicates, introduced on the continent of Europe. Condensed milk forms one 
of the best substitutes for fresh cow’s milk that can be found. A gentleman 
skilled in infantile diseases has told me that he has been able to use it when 
fresh cow’s milk was not tolerated, prepare it as he might. I think it rathei SIMPLE ULCER OF THE STOMACH. 
431 
pbjectionable on account of the quantity of sugar usually employed to preserve 
\ but it has seemed to answer better than any other form of milk—even than 
°ded milk. In regard to food, I think that a good deal depends upon its tem- 
fici'ature. I have known cases in which no other food than that rendered cold 
ice could be retained and digested. A German gentleman, long resident 
111 this country, had been examined by several eminent physicians who were 
Enable to determine exactly what was the nature of his disease, but were inclined 
0 believe it to be cancer of the stomach. After a careful investigation of the 
case, X concluded that it was one of simple gastric ulcer, and placed the patient 
bnder a strict dietetic treatment, when his vomiting ceased, and he gained flesh 
jPidly, and was able to take long walks and attend to his business as a mer- 
. la°t. He, however, relapsed, and I began to doubt whether I had been right 
111 my diagnosis. The patient then inquired if a voyage would injure him, and 
pSbed whether I would object to his consulting several medical gentlemen in 
I advised him to consult certain eminent physicians, and wrote out 
°1’ them a history of his case. He accordingly visited one or more of these 
Physicians, who also regarded the case as one of simple ulcer, but whose treat- 
ment was not followed by marked advantage. Another, however, advised food 
made cold by ice, and no other remedies. The patient immediately began to 
mprove, and returned home, after an absence of four months, having gained 
been pounds of flesh. This confirmed me in my original opinion as to the 
mature of the disease. Soon afterwards the gentleman was attacked with 
lemorrhage of the lungs, and ultimately died of chronic phthisis. After death 
m lung was found to be universally tuberculous. In the stomach there was 
1)0 active lesion, but in the greater curvature, and on the posterior wall of the 
mgan, was a cicatrix, consisting of a white spot entirely denuded of the super- 
mml layers of the lining membrane, from which radiated white bands of a 
P’ous aspect. 
bb-. Michael O’Hara, of Philadelphia, said:—ln a case of gastric ulcer 
Pended with hemorrhage, I at first used the ordinary treatment with opium 
a."4 bismuth. The latter drug was not of much service, but I found oxide of 
1 ver beneficial. The patient recovered, and some time afterward was again 
with hemorrhage and recovered a second time under the use of opium 
ail(l nitrate of silver. Not long since the same patient has passed successfully 
1 rough an attack of typhoid fever. 
bb‘- Henry Gibbons, of San Francisco, said;—ln the case of a child under 
y care, fresh and skimmed milk were tried unsuccessfully, and nothing but 
milk was retained by the stomach. In another case nothing but 
bb Warm from the cow could be tolerated. 
J, Smith, of Charles City, lowa, said:—l recall a case in which 
°thing could be retained but shavings of ice cut with a plane. The patient 
covered, and was able to attend to his business in six weeks, 
bb** Darius Mason, of Prairie du Chien, Wisconsin, said:—A good form of 
cudensed milk is that made simply by the evaporation of its watery portions. 
le use of the granulated article can be avoided by the employment of this 
e°»icleused milk. 432 
CASES OF PERNICIOUS PROGRESSIVE ANEMIA, 
WITH 
SOME OBSERVATIONS UPON THE ANTE- AND POST-MORTEM 
CONDITIONS OBSERVED IN THAT AFFECTION. 
BY 
R. P. HOWARD, M.D., L.R.C.K, 
PROFESSOR OF MEDICINE IN THE m’gILL UNIVERSITY, CANADA, 
Before such an audience as the present, and especially in this city, 
is not necessary to make many introductory remarks upon the meaning 
of the terms “ idiopathic anaemia” and “progressive pernicious anaemia* 
Englishmen are aware that, in 1855, Addison, of Guy’s Hospital, apphoCl 
the term “ idiopathic anaemia” to a form of “general anaemia occurring 
without any discernible cause whatever,” and “ with scarcely a singlo 
exception proving fatal.” Germans need not be informed that BiernpV’ 
of Zurich,in introduced the name “progressive pernicious anaemia 
for the same class of cases, of which he had seen fifteen. And American3 
are well aware that, in 1875, Dr. Pepper, of the city to which belongs the 
honor of entertaining the first International Medical Congress held n1 
America, gave an able resume of what was known on the subject down 
to the month of October last, together with the history of three case9 
which he had himself observed. 
As the subject is of much importance and interest at the present time? 
I beg to invite the attention of the Section to four cases of the disease 
that have crossed my own path, and to some observations upon th® 
ante-mortem conditions which have been observed in sixty-two cases, anc 
the post-mortem changes found in fifty-one examples of pernicious pro' 
gressive anaemia. 
Case I.—J. H., aged 41, a shipping merchant, known to me for twenty 
years as of light complexion, average nutrition, and strictly temperate habit® ? 
has never had bad health till within tAvo years, during which he has had 
times uneasiness after eating, sore mouth, and a gradual loss of strength 
color. Residence at the seaside for the last two months has not benefit® 
him; has lost a sister by consumption, but his parents and the rest ol h1 
family are healthy. ~ 
On September 4, 1814, first consults me; walks in as if tired, and devoid 
energy and spirit; complexion sallow, white, different from the hue of j 
dice; conjunctivas and nails colorless; raucous membrane of mouth an 
tongue very pale, with slight abrasions here and there. Careful examinatm 
reveals no disease in thorax or abdomen; liver seems to extend a fingej 
breadth below margin of ribs; appetite poor; sense of oppression felt # 
eating; bowels act every day or two; urine not jaundiced, free from alburn^11 ’ 
has not lost blood from stomach, nose, or rectum. Malignant disease wa 
suspected; a careful diet, and pepsin with chlorohydric acid, ordered. 
Seen a fortnight later in consultation with Dr. Sutherland, but nothing ne 
was elicited. Patient had been restless at night, and had rather rapidly l°s PERNICIOUS PROGRESSIVE ANAEMIA. 
433 
strength; could no longer walk out, and the ankles had become oedematous 
1,1 tlie evenings. 
October 16, Dr. Campbell added to the consultation; no additional facts 
as°ertained; agreed that internal carcinoma probably existed; claret and raw 
’f6/ to be tried. Under date Nov. 1, it is recorded that patient only gets out 
bed to have it made; is with difficulty induced to take beef-tea and oysters, 
Ueh are his only food; sleeplessness persists; slight oedema of scrotum; 
iJ, systolic basic murmur; external jugulars pulsate visibly, and fill up from 
a dull, lemon-colored hue of skin; no patches of discoloration in axil- 
inguinal, or genital regions; many moles on right side of neck; urine 
not albuminous ; blood pale ; no excess of white corpuscles ; has not 
feu able to take iron in any form, but has persevered with the pepsin and 
I DJ. On November 16, signs of effusion into both pleurae were detected ; these 
‘fefeased, and he died chiefly by apnoea on November 22. 
-Autopsy—Drs. Campbell, Sutherland, Ross, and Chipman, present with me. 
jr Pint and a half of clear, citron-colored serum in either pleura, and about six 
Uldounces in the pericardium ; both lungs healthy, but extremely bloodless, 
t yfept at posterior aspect; their bases collapsed ; no coagula in venae cavae or 
lcUspid orifice; the latter large, admits three fingers; all the valves healthy, 
few fluidounces of serum in the peritoneum; the liver, kidneys, supra- 
I ,llal capsules, and pancreas, normal ; spleen also, and of usual size; gall- 
’ adder moderately distended with bile; mucous membrane of stomach ex- 
feits no trace of disease; pylorus and entire intestinal tract in normal state. 
Die organs, however, very pale and bloodless. Many of mesenteric glands 
aD»er enlarged, several of them to the size of a wild strawberry. I regret that 
's the viscera were not examined microscopically, the existence of fatty de- 
'■fe’ieration cannot be affirmed. The diagnosis of “ cancer” or “latent ulcer of 
■/e stomach,” was at fault; profound anaemia alone was found to account for 
eath ; and the case recalled Addison’s description of “ idiopathic anaemia.” 
Case II.—T. W., aged 37, a wholesale dealer in fruit, first consulted me on 
PHI 22, 1872,0n account of breathlessness and palpitation when walking, 
‘ a gradual loss of strength. Sixteen years ago he had a single attack of 
for a few weeks; the only one he ever had. He had resided in Toronto 
°r years, and in Montreal for the last eight years ; and since then his 
,„rn Pi exion has gradually become pale, and a former tendency to short attacks 
l diarrhoea from slight causes has increased. Has not been dyspeptic ; has 
®ver lost blood beyond a few drops from the nose a couple of times a year 
, len suffering from a cold. For the last twelve months his complexion has 
’feu very pale. 
(|. Do is an only son, and has had but one sister, a healthy woman. His father 
o’f* suddenly of heart disease, at twenty-seven years of age, and his mother 
j s°uie bowel affection ; she had been subject to rheumatism. Patient is a 
■ge-fratned, well-nourished man, but the subject of extreme pallor of the 
*=eUeral surface, lips, and lining of the mouth, without oedema of ankles or 
at° •S* r^^ie Pll*B6 fe small, soft, and regular ; a soft systolic murmur, audible 
c feid-sternum, is propagated up the pulmonary artery and aorta; a contin- 
st°>US bum *s *ieal'd in the jugular vein, and along the right border of the upper 
°inal region. The limits of the liver are normal; those of the spleen per- 
fj1?8 slightly increased. The urine is free from albumen ; the appetite indif- 
l} rent*> A generous diet, claret, and a combination of iron and quinine were 
veeSCri.bed 5 anfl in June he was sent to the seaside, with instructions to perse- 
v-fe with the above measures. He was very much benefited, and did not re- 
Slt fee till the February following (1873), when he presented the original 
fj, fepfems of profound anaemia more intensely than before. A drop of blood 
. ?ln Die finger-point was watery-looking and of a very pale red color, but con- 
‘ feed no excess of white corpuscles. 
an -• Carefel examination in conjunction with Dr. Campbell failed to discover 
disease in lungs, heart, liver, spleen, or kidneys; nor had the patient 
28 HOWARD, 
been suffering of late from diarrhoea or dyspepsia, although his appetite had 
been failing for some time. We agreed that the case was probably one 
“ idiopathic anaemia,” like the previous one which we had seen together. Ah 
the various remedies, including iron, quinine, pepsin, etc., except phosphorus, 
that could be rationally prescribed, failed to meet the increasing pallor and 
failing strength. Food was given by mouth and rectum. The pulse gi‘e'Y 
smaller and weaker ; faintness followed sitting up in bed; the appetite com- 
pletely failed—indeed, food was loathed; the bowels became very torpid; 
epistaxis, sometimes severe, became a frequent symptom; a moderate eleva- 
tion of temperature was noticed many times; his spirits sank, and towards the 
last a feeble delirium and childishness were observed now and then ; oedema 
appeared in the legs, and death by exhaustion took place on April 22, exactly 
a year from his first interview with me. No autopsy could be obtained, s0 
that the diagnosis of “ idiopathic anaemia” wants that confirmation. ATO 
other view of the case, however, I submit, appears more rational, neitbm 
“ Hodgkin’s disease” nor latent carcinoma. This defect does not exist in my 
third case. 
Case III,—Mr. T., aged 53, lost his wife very suddenly in her first confine- 
ment, about five years ago. Has been known to me for over twenty years as 
a temperate and healthy but not robust-looking man, which his occupation a 8 
a book-keeper may perhaps account for. He consulted me first in August, 1812, 
for a slight diarrhoea. He next came under observation in April, 1814, suffm-' 
ing from dyspepsia, which was benefited bjr pepsine and muriatic acid. On 
August 31, he still complained of epigastric uneasiness after eating, and looked 
more delicate, paler, and more spare than usual. No local disease in the abdo- 
men could be discovered however, and mix vomica and cod-liver oil were ad- 
vised in addition to the pepsine mixture. He did not return till Jan. 30, 181&1 
when he looked much paler and very sallow, and complained chiefly of weakness, 
so that he had of late driven to his office. A few days before he had passes 
blood at stool, but the hemorrhage did not recur. The anaemic looking surfa°® 
was of natural temperature; the pulse 12; no enlargement of spleen, liver, 01 
external lymphatic glands could be detected. The urine, free from albumen, 
deposited uric-acid crystals freely, and had a sp. gr. of 1030; no 
patches on any part of body. 
In the latter part of February diarrhoea occurred for a few days; patients 
weakness and pallor were rapidly increasing; a soft systolic basic murmur was 
noted, and a drop of blood from the finger was pale and watery. The mid’0' 
scope showed no excess of white corpuscles ; nine or ten only could be countec 
in the field, and they looked smaller than usual. The surface was very pa^lC 
and of a somewhat light straw color. In addition to pepsine at his meals, 
pill containing reduced iron and mix vomica was prescribed, with beef-tea, 
claret, etc. 
March 4. Urine still the color of pale sherry, and sp. gr. 1020. Deposit8 
uric acid; is free from albumen ; feet and legs oederaatous. To have in acux' 
tion to the ferrum redaction, A,, gr. phosphorus (Warner’s pills) after evei} 
meal. . 
He had been seen by Dr. Campbell in consultation with me on March 2, aBC 
no organic disease could be detected to account for the serious anaemia am 
prostration. Of course the case reminded us of our two previous 
of “ Idiopathic anaemia,” and as such I told the friends I regarded it. Alter 
this the downward course was rapid. Soon vomiting and a tendency to dial 
rhoea appeared. The appetite failed ; the pulse grew gradually more freqnen , 
18,84, 90, 102, and became weak and jerking, though regular; a constau 
u beating” in the head was complained of; faintness was experienced on sittnm 
up in bed ; and a mild delirium at night was followed by childishness and 
of purpose in the day. The eyelids became somewhat puffy; the urine * 
tained its high density and color, although the temperature of the body c 1 
not exceed the normal till a few clays before death; fewer white corpuso e 
were found in the blood on March 18, three in one field and one in another , PERNICIOUS PROGRESSIVE ANEMIA. 
435 
le fed corpuscles were of course deficient, but no attempt was made to esti- 
ute their number. The stain made by a drop of blood upon a white hand- 
kerchief was very' pale. The voice grew feeble ; the body wasted somewhat; 
he bloodless appearance of skin, mucous membrane, and nails, increased ; and, 
during the last three days of life, a progressive stupor, dilatation of the pupils, 
]ackening of the pulse-rate, retention of urine, and labored respiration, indi- 
eated a suspension of the cerebral functions. At this time the temperature of 
he body became somewhat raised. He died on March 28, 1875. 
Autopsy,x twenty-seven hours after death ; moderate cadaveric rigidity ; some 
shbcutaneous fat; no blood escaped while opening cavities. 
■Thorax.—About two fluidounces of clear citron-colored serum in left picn- 
ic cavity. Some bridles of adhesion over apex of left lung, in which are found 
;v° or three dry, black and white caseo-calcareous masses, almost the size of a 
fhhall bean, and surrounded by a capsule of pigmented and indurated tissue. 
he right pleural cavity obliterated by very firm adhesions; in the extreme 
ahex of right lung a patch of black indurated tissue about an inch in diameter, 
a separate small nodule of mortar-like material. The rest of both lungs 
ealthy, but oedematous, and very anaemic looking. Bronchial glands not en- 
ai’ged. Pericardium contains about four fluidounces of serum ; a good deal of 
clt on right side of heart; scarcely any blood in cavities of heart; very small 
°l°rless coagula in both ventricles; valves normal. 
Abdomen.—Liver normal; half a fluidounce of green bile in gall-bladder; 
Ween very small, firm, and its capsule shrivelled; cut surface pale and smooth; 
„ esenteric and lumbar glands unusually small; stomach and intestines per- 
tly healthy, but their coats very pale; supra-renal capsules and kidney's 
h°Gnal; all these organs contain very little blood. 
.. J'he spleen, a portion of the heart, and blood from the splenic vein and from 
’e inferior vena cava were taken away for microscopic examination by Dr. 
v s'er, to whom lam indebted for the following report, as well as for other 
a‘Uable assistance in the preparation of this paper:— 
, Blood from the inferior cava and the splenic vein: The colorless corpus- 
es did not appear in any excess, averaging in a number of observations from 
jlx to eight in the field of No. 7, ocular 3. They presented slight variations 
o|. sjze, and the protoplasm was rather more granular than normal. Clusters 
from six to ten adhering together were not uncommon. Nuclei variable;. 
.?llle had only one, others two or three. In the blood from the splenic vein 
*e colorless corpuscles presented the same characters; a few retained their 
" lrcboid movements when placed upon the warm stage. Max Schultze’s 
a <v"ular masses were abundant, and some of large size; the individual ele- 
e'its composing these masses were very distinct. The red corpuscles looked 
a Ural, a few only were crenated ; a somewhat unusual variation in size was 
0 'ced among them. Many measured scarcely the goVo °f an inch in diameter 
with the No. 9 (immersion), 
j.. spleen. Weight one ounce and five drachms. Portions teased in saline solu- 
,li°a and examined with the No. 9 (immersion) showed the ordinary structures 
ret with in the organ (pulp cells, blood corpuscles, and connective tissue). 
e^erneuts of the latter, as might be expected from the diminished bulk of 
ae. organ, were in excess, and consisted of the fibrous tissue of the trabeculae 
Sa( Numerous nucleated fibre cells. Examination of their sections yielded the 
results; the elements of the organ appeared normal, there being simply a 
Proportion between the connective tissue and the pulp, 
sin- *eart' A small portion of muscle from the left ventricle showed marked 
ot fatty degeneration.” 
T 
jy, i egret that the bones were not examined in either of these cases, but 
1‘ ■*-epper’s paper had not been published when the last of them termi- 
4>r- Osier kindly assisted me at the autopsy; Drs. Campbell and Chipmati 
e also present. 436 
HOWARD, 
nated. In the second autopsy a condition was found that, as far as lam 
aware, has not been hitherto observed in this disease, viz., marked atro- 
phy of the spleen and great reduction in size of the mesenteric and pre- 
vertebral lymphatic glands. At first, I thought that this condition 
might account for the oligaemia in that case, but the subject of hema- 
topoiesis in the adult is so unsettled that I do not venture to express an 
opinion as to the relationship existing between the anemia and the state 
of the organs in question, although they are generally supposed to be 
concerned in the elaboration of the blood. A symptom observed in this 
last case that interested me much during life was the high color and den- 
sity of the urine. It did not resemble the urine of ordinary anaemia, but 
rather that of rheumatic fever ; and I am disposed to refer it to an exces- 
sive destruction of the red globules, as neither fever nor rapid wasting 
were present. 
A fourth example of this disease came recently under my notice, in con- 
sultation with Dr. Greene, of Granby, to whom I am indebted for a 
report of the case. 
Case IY.—Mrs. W., astat. 46, a highly respectable married woman, the 
mother of four children, of whom two survive, and are robust and plethoric- 
In early married life she had had a few slight attacks of epistaxis, but had 
enjoyed tolerably good health till within about two years of the menopause, 
during which period menorrhagia existed. Then her health began to fail, and she 
became somewhat anaemic. No cause could be found in the condition of the organs 
for the hemorrhagic tendency. When first visited by Dr. Greene, nearly two 
years after (in March, 1875), she presented all the symptoms of intense anaemia, 
including the blood-murmurs in the great vessels. The only evidence of local 
disease discoverable was some fulness and tenderness of the liver, irritability 
of the stomach, and a yellow tinge of the conjunctiva. Although the digestive 
disturbance disappeared and she was able to enjoy carriage exercise during the 
summer, and had a very good appetite, the anaemia increased, and she had two 
or three slight attacks of epistaxis. In October the gastric symptoms returned 
with increased severity, and an aphthous condition of the mouth and fauces, 
which she had had more than once before, recurred, and was attended with slight 
diarrhoea, with a daily augmentation of the temperature, which could not he 
controlled by quinine or salicine. When seen by me last winter, in consultation 
with Dr. G., she was unable to leave her bed, and exhibited all the symptoms 
of advanced anaemia. A careful examination of all the organs, including the 
uterus, rectum, external glands, spleen, liver, etc., failed to detect local disease, 
and I expressed the opinion that it was a case of u progressive pernicious an#' 
mia.” A drop of blood taken from the finger-point was thin and pale in color 5 
but was so spoiled by drying when I got back to Montreal that Dr. Osier could 
not satisfactorily make out its characters. The patient died on January 
from exhaustion, preserving her mental faculties to the last. She had had two 
or three very moderate losses of blood from the nose since she had been seen 
by me. 
Although satisfied in my own mind that the case just related was one 
of pernicious anaemia, yet as the diagnosis lacks the verification of an 
examination of the blood during life, and of the body after death, I would 
not have related it but that the family history appears to me important 
as proving that a predisposition to anaemia may exhibit itself in famih®9 
and that it may perhaps be inherited. 
This last patient’s youngest sister has been anaemic since childhood? 
a married cousin has been anaemic since having an attack of typhoid 
fever about two years ago; and a grand-uncle died at sixty-two, with 
symptoms like those manifested by the niece, and was anaemic. Judgmg PERNICIOUS PROGRESSIVE ANJEMIA. 
from the papers which have been of late written upon this subject, it is 
ft°t generally known that Dr. Wilks,1 of Guy’s Hospital, in 1857, pub- 
lished a series of cases of the disease we are considering under the cap- 
tlon, “Cases of Idiopathic Fatty Degeneration.” “ This designation,” he 
marks, “ is given to a class of cases in which an excessive anosmia and 
"wility are the peculiar phenomena observed during life, and a fatty 
of all parts of the body, but especially of the heart, the most 
appearance found after death.” And further on he says, 
-•-be following seven cases will afford examples of this remarkably fatal 
a,]oemia and fatty degeneration.” Two years2 later, when describing 
auothe r case of “ Idiopathic Anaemia,” he applies the latter title to his 
rmer series of cases. What a notable anticipation of Gusserow’s 
observations in 1871, and of Ponfick’s in 1873. It is due also to Prof. 
Robert to say that he was one of the first to call attention to our sub- 
Dct. In 1853 and 1854 he had met with six cases of what he called 
I Uerperal Chlorosis,” only one of which, however, had terminated 
F'tally; and in 1858, under the title “Essential Anaemia,” he published 
details of that fatal case and of another subsequently observed, 
logether with the appearances found after death. His third fatal ease, 
autopsy, occurred in 1859.3 
. These series of cases of Dr. Wilks and Prof. Lebert are not mentioned 
111 Dr. Pepper’s able paper on the subject, nor are the single cases of fatal 
?baemia published by Dr. Combe4 about 1823, by Sir Dominick Corrigan 
lb 1844, by Dr. Dickinson in 1863, and by Dr. King in 1871 ; nor Dr. 
ai'clay’s two examples published in 1851. 
. I have met with ten alleged examples of pernicious anaemia recorded 
the appearance of Dr. Pepper’s article: the first by Dr. F. Fede5 in 
Gober, 1875, however, appears to me to have been an example of so 
Gled “ Myelogenous Pseudo-leukaemia,” as the spleen was found after 
Gth of threefold the normal size, and its firm pulp “consisted of some- 
. at larger cells than in the natural condition, and they appeared very 
lrmlar to the elements of the bone-marrow.” The bones of the skeleton 
G’e thickened, the compact substance much reduced and replaced by a 
Gde meshed spongiosa, in which the microscope found similar structures 
the normal red marrow of bones ; there were, however, numerous mul- 
nuclear (growing) cells and blood-corpuscle-containing elements. The 
lvG, also, was a little enlarged ; the blood contained no excess of white 
c°rpuscles. 
j Di December, 1875, Dr. Pye-Smith6 published two cases of “ Pernicious 
I lGpathic Anaemia,” with autopsies. Both occurred in men; no cause 
°uld be assigned for the disease in one; in the other, possibly, one or 
v° attacks of intermittent fever experienced seven years previously may 
Gve stood in that relationship. The ordy morbid appearances discovered 
• examination of the cadavera were fatty degeneration of the heart 
t? both, of the liver in one, and thickening of the mucous membrane of 
in one. The bones were not examined. 
Dfrs year Dr. Scheby-Buch7 has recorded two cases of “ Essential Anas- 
1 Guy’s Hospital Reports, 3d series, vol iii. pp. 203-213. 
2 lb., vol. v. p. 108. 
3 Archives Gen era! es de MSdecine, Avril, 1876. 
4 Quoted by Dr. Dickinson, Trans. Path. Soc., xiv. p. 141. 
5 Quoted in Centralblatt f. d. Medic. Wissenschaften, Oct. 16, 1875. 
® Virchow’s Archiv, Ixv., Dec. 27, 1875. 
7 Deutsches Archiv fur Klin. Med., xvii. Band. p. 467, 1876. 438 
HOWARD, 
mia.” It is open to question whether either deserves the title of “ Essen- 
tial,” as the man, aged 48, had had “ ulcers on his legs which discharged 
from Easter to Christmas,” and the woman, aged 60, had been “ sickly 
for several years.” The spleen was found enlarged in both. In the 
female there existed, in addition, dilated bronchi, fatty degeneration of 
the viscera, and “numerous cells resembling white corpuscles, in groups, 
in the marrow of one radius. The marrow was pale-red, and contained 
but “ few fat cells,” and only a few red globules. (Perhaps these cases 
ought to be regarded as examples of pseudo-leukaemia. I have retained 
them however.) 
In the number of the Centralblatt for June 24, 1876, there is a notice 
of three cases of this disease recorded by Krieg,1 and an autopsy. Only 
a very meagre report is given, and I have not been able to procure the 
original paper. Two of the three patients were men, aged respectively 
52 and 45 years, and in good circumstances. Ho other details of these 
cases are given. The third case was that of a married peasant woman? 
aged 48. How many children she may have had is not stated. It 18 
simply observed that she had been ordinarily stout till within a year. 
During that time petechise appeared upon the lower limbs, bleeding took 
place from the gums, and pleurisy set in. The autopsy revealed visceral 
hemorrhages, fatty degeneration of the heart’s fibre, and a fibro-sarcoma 
at the base of the brain. Nothing is said about the condition of the 
bones. 
An instance of this disease is related by Dr. E. 11. Bradford, in one of 
the July numbers of the Boston Medical Journal for this year. The case 
is interesting, as affecting a girl only eleven years old, the earliest age at 
which the disease has been observed. Ho cause could be discovered- 
The blood globules were reckoned during life, and both red and white 
found to be numerically deficient. The red were paler than normal, and 
had lost their biconcave contour. “There was not much variation m 
size between the individual globules. All were smaller than usual- 
There was not much detritus. The white globules seemed abnormally 
granular, and were irregular in shape.” 
Amongst the peculiar symptoms mentioned, are severe pains in the ear 
and abdomen, and severe attacks of pain in different parts of the body ? 
a daily expectoration of blood to the extent of about three ounces, and 
upon one occasion equal to a pint. The temperature during the three 
weeks before death, ranged from 101|° F. to 99|° F. Death was p1’0' 
ceded for a day or two by loss of consciousness, a firmly contracted and 
flexed condition of the right arm, and a motionless state of the 
leg. Ho disease of the spleen, lymphatic glands, lungs, or other organ 
could be detected during life. Ho autopsy was made. 
The latest reported case that has come under my notice, was brought 
before the Societe des Hopitaux, on July 14, 1876,2 by M. Lepine. DlO 
anaemia began with the third pregnancy of a delicate woman, who? 
however, had never been the subject of any serious disease, although she 
had many times suffered from gastric troubles. A careful post-mortem 
examination discovered only a circumscribed fatty degeneration of tbo 
heart, and an insignificant unilateral broncho-pneumonia. Ho disease 
of the spleen, glands, or bone-marrow, existed. _ , 
I have not tabulated Ponfick’s, Grofner’s, Quincke’s, or Grenville s 
1 In WUrtemb. Corr. 81., 1875, No. 39. 
2 Yide Bulletin Generate de Therapeutique, 30 Juillet, 1876, pp. 85-87. PERNICIOUS PROGRESSIVE ANAEMIA. 
439 
not having been able to procure their details. Zenker’s case of 
amemia due to uterine hemorrhage, and Chadwick’s ease arising appa- 
letitly from post-partum hemorrhage, I have also not tabulated, as they 
4l’e at least not typical cases. For a like reason, I have excluded a case 
extreme anaemia which occurred under my own care in a puerperal 
Patient without undue hemorrhage or other evident cause to account for 
16 profound anaemia; from which, however, she recovered after a long 
Perhaps all cases of recovery from apparently pernicious anse- 
*llla, should, in the present state of our knowledge, be excluded, while 
:.iey should be very carefully studied in the hope that they may shed 
]ISPt on this obscure department of pathology. 
An analysis of these cases of pernicious anaemia suggests the propriety 
dividing them into distinct classes or groups, and even it may be of 
to some of these the title of “ idiopathic”:— 
Group I.—Thus all the cases which occurred during 'pregnancy ought 
0 stand by themselves, for while no sufficient reason can be assigned 
XvPy in such females the usual moderate impoverishment of the blood, 
vPich obtains during gestation, should have attained such a development 
48 to have proved fatal, yet the existence of so well characterized a con- 
ventional state as that of gestation, as a condition common to so many 
G the examples of so-called pernicious anaemia, cannot well be regarded 
48 accidental. To this class belong by far the largest proportion of 
sported cases. All of Gusserow’s five cases were in pregnant females ; 
8everal of Biermer’s were ; one of Lebert’s fatal cases, and one of Wilks’s 
Pere ; Corazza’s only case was that of a woman who had had four children 
Pll hve years, and died soon after delivery, and the latest reported case, 
rapine’s, began with the third pregnancy of a middle-aged woman who 
la<l only suffered from attacks of gastric disturbance. 
Group ll.—Some examples of the disease followed so closely upon 
Parturition, quite independently of undue losses of blood, that they should 
p haps be called puerperal cases. One of Marshall Hall’s cases, one of 
a•'clay’s, and some of Biermer’s, appear to have been in some way cou- 
nted with the puerperal condition. Indeed Lebert met with several 
Samples of severe anaemia under conditions which induced him to draw 
special attention to an u acute puerperal chlorosis,” and many authors 
4Ve written upon the chlorosis of pregnancy (notably Beau, Andral 
aP(i Gavarret, Eegnault, Cazeaux, and See). 
.As by far the largest proportion of the recorded examples of fatal per- 
vious anaemia have occurred during pregnancy and soon after delivery, 
Would be important to be able to arrive at an explanation of the rela- 
•°nship between child-bearing and pernicious anaemia. This is perhaps 
vt possible. Even if it be urged that frequent child-bearing and more 
r ess prolonged lactation may be regarded as spoliative processes of no 
Van power, and that amongst the poor, in whom these influences are 
specially prevalent, there is very frequently an insufficient supply of 
generous food and pure air to meet the spoliation, and hence the im- 
poverished blood, it is difficult to comprehend why it is that pernicious 
•Hernia is after all so seldom met with, while the influences just 
Vntioned are so prevailing. Moreover, fatal anaemia occurred in one of 
_ usserow’g cases during the first pregnancy, a circumstance which, in 
e light of the preceding observations, renders it probable that the preg- 
state per se predisposes to progressive blood deterioration, an idea 
ome what borne out by the rapid course of the disease in all Gusserow’s HOWARD, 
cases, one of them lasting only five weeks, from first to last; two occupy* 
ing but four to five months ; a fourth even less time ; and the last ending’ 
in the eighth month of gestation. 
Group 111.-—Closely allied to the pernicious anaemia of pregnancy 
appears, on first thought, that common affection still styled chlorosis- 
The latter, like the former, is most frequent in females; it is very generally 
accompanied by disturbance of the uterine functions, and its causation 
is unknown. On second thought, however, there is the striking differ- 
ence that chlorosis very seldom proves fatal, while the anaemia of preg' 
nancy appears to do so frequently; the former is amenable to treatment’ 
the latter rarely if ever is cured. 
The only examples of fatal anaemia in young females independent °| 
pregnancy that I have tabulated are three cases recorded by Marshal* 
Hall; one by Wells in a married woman 31 years old; one by Immermanu, 
in a patient also married and of the same age ; one by King in a woman, 
aged 27, who had had since puberty more or less menorrhagia and fen- 
corrhoea; one by Pepper, in a woman aged 36, who had been exposed to 
malaria and had had bronchitis for five months before the anaemia appear- 
ed, and Bradford’s case of a girl only 11 years old. Of these eight cases, 
only two, one of Marshall Hall’s, in a girl of 18, and Bradford’s case, can 
be fairly cited as typical examples of chlorosis proving fatal, and s0 
far resembling pernicious anaemia. Inasmuch, then, as the ordinary 
chlorosis of young women is notoriously very seldom fatal, while that 
less frequent form incident to pregnancy frequently is, we may not con- 
clude without further light that both forms of anaemia acknowledge the 
same causation, although we may grant that both may be called “idio- 
pathic” or “ essential,” until some satisfactory explanation of their origlll 
is forthcoming. 
Group IY.—Another group comprises those cases which have been 
preceded by chronic diarrhoea. Bierrner states that pernicious anseinu1 
frequently follows that affection; hut, with the imperfect history given 
in very many of the published cases, his observation remains unproven- 
It is true that diarrhoea is frequently mentioned among the symptoms ox 
the affection, but many authors fail to say whether the diarrhoea Pre' 
ceded the other evidences of the disease, or merely accompanied them- 
Indeed, beside tbe cases given by Bierrner, the only others in which 
chronic diarrhoea is recorded amongst the antecedent conditions of the 
anaemia are: Corrigan’s case, in which diarrhoea had existed “off R11( 
on for years;” one of mine, in which a tendency to that affection hah 
been observed over eight years; and one of Pepper’s, in which “chronic 
follicular catarrh of the intestines had existed for many years;” this 
patient had also “chronic suppuration of the gall-bladder,” and a forme1 
history of psoriasis of twelve to fifteen years’ duration. These facts, 
then, scarcely bear out Bierrner’s statement. 
Diarrhoea formed a leading symptom in the following cases: two ox 
Hebert’s; three of Wilks’s, in one of which there were cicatrices am 
ulcers in the colon ; one of Barclay’s; one of Pye-Smith’s, and Lepiue& 
case—in all eight. But it appears from the notes of all these cases 
that an impoverished condition of the blood coexisted; and also sonic 
one or more of the other conditions known to have pireceded or accom- 
panied pernicious anaemia in other cases, such as pregnancy, parturition, 
hemorrhage, etc. 
Group Y.—Six more of the tabulated cases may be grouped together 
inasmuch as the antecedent conditions were such as to involve blood- PERNICIOUS PROGRESSIVE ANAEMIA. 
441 
Waste ; they might have been included with the last group, which also 
lruplies blood-waste, had not previous writers attached so much import- 
ance to chronic diarrhoea per se in relation to pernicious anaemia. Such 
are Wilks’s case of an errand boy, aged sixteen, who had not been well 
*°r three years, and had often suffered from epistaxis, and whose colon 
c°ntained cicatrices and ulcers; King’s case, which had been preceded 
during thirteen years by menorrhagia and leucorrhoea; my fourth case, 
ln which for two years before the cessation of menstruation, there had been 
dienorrhagia; one of Pepper’s cases, preceded by chronic bronchitis for 
dve months; and Buch’s two cases—one sickly for years, and the subject 
ot chronic bronchitis and an abnormal condition of the marrow of the 
I>a(lius; the other, a case of pernicious anaemia, closely following upon 
dicers of the legs, which had discharged freely from Easter to Christmas. 
Cases of fatal anaemia occurring in persons who have long suffered 
b'orn repeated attacks of loss of blood, or from protracted leucorrhoea, or 
d°in chronic bronchitis, or from chronic ulcers, while they may be in 
°de sense included in the title “progressive pernicious anaemia,” cannot 
be regarded as examples of “idiopathic anaemia” as delineated 
)y Addison in his masterly description of the disease. He confined the 
to “cases in which there had been no previous loss of blood, no 
exliausting diarrhoea, no chlorosis, no purpura, no renal, splenic, raias- 
jdatic, glandular, strumous, or malignant disease.”1 This is a point which 
lils been so much overlooked of late that the terras “ idiopathic anaemia” 
aild “pernicious progressive anaemia” are not now synonymous. 
Croup YL—There is a group of six cases (one by each of the following 
'Vriters: Broadbent, Pye-Smith, and Lebert, two by the author, and 
°ne quoted by Buch) occurring in patients from forty-one to fifty-seven 
foars of age, in which no antecedent condition is mentioned sufficient to 
°ailse the anaemia except dyspepsia. In only three of these did the indi- 
gestion last a considerable time, and in one of them (a case of ray own) 
Was not severe. In the other three cases the dyspepsia occurred 
lather among the early symptoms than among the antecedent conditions. 
. must be admitted that even severe and protracted dyspepsia very rarely 
fficluces a fatal anaemia; and I incline to regard the relationship in these 
c‘ases as that of coincidence only. 
Croup Yll.—Extreme poverty or poor diet were the conditions under 
pernicious anaemia was observed in four men (Lebert, Wilks, 
lckinson, and Cazenave, each a case), and if these were the real causes 
0l the blood disease, such cases require little discussion; the anaemia is 
R'erely a consequence of inanition. But why this fatal form of anaemia 
ls c°mparatively so rare, while poverty and poor diet are so frequent, we 
°annot say. 
Croup YIII.—A remarkable case is related by Pepper, in which a 
llla,b after having had jaundice “ about a month,” then exhibited well- 
marked anaemia which proved fatal. In Corazza’s case severe icterus 
a^so an antecedent condition, but the patient was also pregnant, and 
Jad had four children in five years. 
Croup IX.—Finally, there remain nine cases in which no antecedent 
“edition is mentioned that can fairly be regarded as causative unless it 
A a case of Pye-Smith’s, in which there may have been two slight attacks 
, mterrnittent fever, years before, “ although on this point [the patient’s] 
decount was somewhat uncertain,” and two of W ilks’s, one, in which 
1 Addison’s Works. Syd. Soc. Ed., p. 212. 442 
HOWARD, 
“domestic trouble and recent marriage” coincided with the appearing 
of the anaemia ; the other, that of a woman aged fifty who had been 
“ thirteen years in a lunatic ward.” Failing health and progressive 
anremia are a summary of the conditions mentioned in the whole nine 
cases (Wilks three, Barclay, Combe, Pye-Smith, Lebert, Immermann, and 
Howard, each one1). 
It results from this analysis that the conditions—as far as they nre 
known—under which these cases of pernicious anremia originated, may 
be thus grouped ;—(1) pregnancy especially where oft repeated ; (2) par* 
turition (and these two conditions appear to be especially frequent); iy) 
chlorosis, which is rare; (4j chronic diarrhoea or intestinal catarrh, 
which is by no means as often antecedent as some authors state ; (5) blood- 
waste, direct and indirect, from protracted menorrhagia and leucorrhcea, 
from chronic ulcers, from chronic bronchitis, and from repeated epistaxis 
combined with ulceration of the bowels, conditions present in six cases; 
(6) dyspepsia, observed in three cases; (7) extreme poverty or poor diet, 
mentioned in four cases only ; (8) jaundice, the only known antecedent 
in one case, and associated with frequent child-bearing in another ; and 
last (9) no antecedent condition mentioned other than “failing health, 
which must exist when anaemia is developing. 
Reflecting upon the frequency with which these several conditions 
obtain, they cannot fairly be held to be frequently productive of, °r 
antecedent to, a progressive pernicious anaemia, and some of them seem 
to be quite incapable of producing so grave a disease. The conclusion 
is almost inevitable that either an inherited or an acquired predisposi- 
tion to defective development or regeneration of the blood must exist m 
these cases of pernicious anaemia, otherwise such conditions could not he 
followed by such profound and unmanageable alterations of the blood. 
Passing from the ante-mortem to the 'post-mortem conditions, it cannot be 
said that Morbid Anatomy has thus far explained the occurrence or the 
nature of the disease. 
1. The fatty degeneration of the heart and other viscera first specially 
insisted upon by Wilks in these cases of fatal anaemia, is a consequence, 
not a cause, of the blood impoverishment, and is observed also att 
severe hemorrhages, and in protracted fevers, in starvation, and othei 
analogous conditions, 
2. The small size “ hypoplasia” of the heart and of the large arterif 
pointed out by Yirchow as existing in some severe cases of “chlorosis, 
and which may be regarded perhaps as congenital, even if it wd’® 
proved to he constant in chlorosis, could not be anticipated in the othd 
forms of anaemia included under the term pernicious. It is true that "T0 
have not many observations on this point, because the subject has net 
been generally investigated. However, Pye-Smith found “ the aorta 0 
proper size and its coats healthy” in his second case ; its condition is no 
given in his first; in both the heart was over the average weight. Buck, 
after comparative measurements, did not find the aorta smaller in b,s 
two cases than in other anaemic and cachectic bodies, if not so wide as 111 
healthy persons. , 
3. In fifty-one autopsies of progressive anaemia that I have collected, 
either the spleen is described as normal, or the “ viscera” (and thereto10 
the spleen) are said to have been normal, thirty-six (36) times; as molo 
1 Not having’ been able to get Krieg’s original paper, I cannot say anything of his oases- PERNICIOUS PROGRESSIVE ANAEMIA. 
443 
ol' less enlarged, usually but slightly, thirteen (13) times; once (1) as 
Srviall and shrivelled ; and once (1) its condition is not stated (Krieg’s 
Spleen normal 
. 36 
“ enlarged ..... 
. 13 
“ small and shrivelled 
. 1 
Condition not stated ..... 
. 1 
51 
appears to have found this organ free from lesions in his fifteen 
cases ; and Griisserow, although he mentions slight enlargement of the 
jWeen in his cases, says it presented no characteristic changes of its pulp. 
11 °>ie of Pepper’s cases, the spleen was enlarged by one-half; “-its pulp 
dark and much softened,” without leuksemic lesions. In the other, 
i ivas “slightly enlarged ;” its pulp “ softened and purplish, without any 
eiitaemic patches or enlarged Malpighian corpuscles.” “ Under the micro- 
c°pe, the field was crowded with small round cells (smaller than the 
Ujority of the cells in the marrow), spindle-shaped cells, and very pale 
blood globules.” Much importance cannot be attached to the soft- 
•e?s of the spleen in this case, as it had undergone sufficient decompo- 
vtl0U to crepitate when handled. In one of Buch’s cases, the spleen 
moderately enlarged and of a pale red-brown color; in the other, it 
Us also somewhat enlarged (12J centimetres long, 6 broad, and 4 thick), 
. a brown-red color and firm, and its glomeruli evident; in Immermann’s 
llgle autopsy, this organ was also slightly enlarged and hard. In the 
Ul.v instance in which the spleen was found atrophied, it weighed but 
drachms, felt tough and cut with resistance. Its cut surface 
as pale, and the microscope proved an absence of pulp cells and blood 
ii ii vv vjlj v illivi vu w M. V' » vu. (V i i UJ v-v i j.' iaih v.i. Ny i vv/ va 
°fpuseles and a preponderance of trabeculae and of nucleated fibre cells. 
U cannot then be affirmed that this important blood gland, the spleen, 
1 Ual]y presents any abnormality, much less any special lesion in per- 
sons anaemia.1 
|,j A similar remark may be made respecting the lymphatic glands. In 
e fifty-one autopsies, their condition is not mentioned sixteen (16) times ; 
presented no lesions thirty-three (33) times (including Bierraer’s and 
I 2O cases), the mesenteric glands were “ pretty generally en- 
flJged” in one case ; and in the remaining one the same glands and the 
«}bap were unusually small, as if atrophied. The last was the case in 
P lleh the spleen also was atrophied. In it also one gland only in the 
an axillary gland, was found slightly enlarged. 
Condition of lymphatic glands not stated in 
. 16 
No lesions in 
. 33 
Mesenteric glands generally enlarged in . 
. 1 
Mesenteric and lumbar glands unusually small in 
. 1 
51 
p other lesion of great importance remains to be noticed. Prof, 
epper, in 1875, on examining one radius of his last case of progressive 
(•eper?^a frmad the marrow “ to be made up almost entirely of granular 
''vie’ f‘e considered as due to the hyperplasia of the marrow 
1 production of lymphoid cells—a change described by Ranvier in 
I Jy 
hloo<i1S(|>ilßei ie spieen- no doubt, may be a cause of anaemia, just as disease of the other 
-glands and lungs may be. 444 
HOWARD, 
1867,1 and by Neumann and others subsequently, as existing in sorn0 
cases of leucocythsemia. Dr. F. Fede, about the same time as Peppel’’ 
described similar alterations of the marrow of the bone, in a case whw" 
he published as one of progressive pernicious anaemia, but which, p 
already stated, owing to the accompanying alterations in the spleen, 19 
rather an example of pseudo leukaemia. This year Dr, Scheby-Dlic‘l 
examined the radius in a case of pernicious anaemia, and found the nia1’' 
row of a pale-red color, and containing a few flit cells, single drops ol 
here and there, and numerous cells in groups resembling white corpus- 
cles, and only a few red corpuscles. On the other hand, in the latest- 
recorded case, M. Lepine found no affection of the bone-marrow. rl^lo 
bones were not examined in the other forty-eight cases, so that the b’e' 
quency with which this little-known lesion may have existed in then1 
cannot be even surmised. 
The import and nature of the change itself are scarcely settled. It ha9 
been observed in several cases of leucocythsemia, and in a few of pseudo- 
leukaemia. Dr. Horatio C. Wood, Jr. (of Philadelphia),2 examined the 
long bones taken from patients dead of various chronic diseases, and old) 
in one instance found any abundance of leucocytes in the marrow, 
in that one there coexisted marked general enlargement of the lymphatic- 
and of the spleen. Circumstances prevented a complete examination oI 
the case, so that it may also have been one of leukaemia or 
sernia. He thinks it not improbable that the lesion occurs in scrofulosi* 
and in chronic or even acute pyaemia; and I am indebted to my friend* 
Dr. Osier, Professor of the Institutes of Medicine in McGill University 
for the details of an autopsy which he recently made upon a man wh() 
died of tuberculous peritonitis, in which the marrow of the femur, the 
only bone examined, was found to have suffered these changes. Passing 
over the notice of the case and of the condition of the periosteum fouU 
after death, I will relate only his description of the bone-marrow. 
u Medulla. Upper half of left thigh removed for examination. On sect'011 
of the bone, the medulla presented a uniform grayish-red color, nowhere haviu» 
the yellowish fat-like aspect of normal marrow. In the cells of the cancellated 
portion the marrow was of a lighter red color. 
“ Red blood-corpuscles. A very evident difference in size existed in the06 
elements, very many of which measured 45V5 of an inch in diameter; a levV 
were even smaller. Curious irregular forms were numerous, due to the proti’U 
sion of portions of the stroma of the corpuscle. Nothing special was notice4 
about their color or general characters. , 
u Colorless corpuscles. These elements outnumbered considerably the re( 
corpuscles in all the specimens examined. Three or four varieties were 110 
ticed: (1) Corpuscles agreeing in general characters with those of the blooe > 
protoplasm firmly granular, nucleus vesicular, variable in number, rang'fG 
from one to three of four. Many of these were larger than ordinary wlutL 
blood-corpuscles, and the nuclei were evident without the addition of any 16 
agents. (2) Somewhat smaller corpuscles with coarsely granular protopla*1*1 
and one or two vesicular nuclei. They were not very abundant, and cqr>c 
sponded closely with the coarsely granular corpuscles which are somethin* 
met with in the blood. (3) Corpuscles with clear vesicular bodies and so > 
nuclei, usually only one. These were not very numerous, three or four 00 > 
occurring in the field of the No. 9 (immersion). (4) Small bodies like f‘eL 
nuclei, protoplasm finely granular. These correspond closely with the nuc c 
1 Vide Jaccoud, Nouveau Diet, de M6d. et de Chir., t. xx. p. 430. 
2 Am. Jouru. Med. Sci., Oct. 1871, p. 376. PERNICIOUS PROGRESSIVE ANEMIA. 
445 
tlie former variety, and are probably identical with them, having been freed 
'S' the rupture of the cell. Of these varieties No. 1 was by far the most 
abnndant. 
Transitional forms. Nucleated, colored corpuscles were noticed in each 
'J|eeimen examined, as many as three or four occurring in the field of the No. 9. 
ey ranged in size from 3^o- to 2sW °f an inch ; the majority of them being 
v'glitly larger than the ordinary red corpuscle. The nucleus in every instance 
single, and the protoplasm finely granular. Three corpuscles were seen 
ldi the nuclei dividing. The coloration of the cell substance was in each 
ase very distinct, and only exceptionally was it less distinct than in the sur- 
°Tiding colored elements. * 
j Cells containing red blood-corpuscles. Two or three only were observed; 
case an ordinary white corpuscle contained a single red corpuscle and 
0 nuclei; in another a somewhat irregular protoplasmic mass contained 
0/e® rec* corpuscles and one distinct nucleus. None of the ordinary myeloid 
giant cells were found.” 
• this case of tuberculous peritonitis, then, there existed the changes 
j1 the bone-marrow, which have been observed in so called myelogenous 
ehkfernia, and in Pepper’s case of pernicious anaemia. 
■tt is not logical, in the present state of knowledge, to conclude that a 
hit ion of the marrow which has been found in so many different 
t k tions, as leukaemia, Hodgkin’s disease, pernicious anaemia, and 
j,. ”erculous peritonitis, is a pathological state essential to those affec- 
r °»s. Moreover, quite recently, Dr. Moxon,1 of Guy’s Hospital, and 
°l'e recently still, Dr. Schtschastny, of St, Petersburg,2 have maintained 
the bodies resembling white corpuscles found in the bone-medulla 
'cucocythaemia “ were in reality leucocytes which had escaped from 
blood.” Even if it were true that the condition of the bone-marrow 
J Tjestion was constantly present in pernicious anaemia, the bearings of 
*act upon the nature and origin of the disease would remain to be 
yb'ked out, as physiologists have not altogether accepted the views of 
ebrnann and Bizzozero, that in the adult the medulla of bones is con- 
Y?ned in the development of the white corpuscles of the blood (Flint, 
. l!'chow, and others). It is worthy of notice that the two cases of perni- 
. ,°Us anaemia in which the medulla was found in a morbid state were com- 
..'cated, and such as could scarcely be called by the original name of the 
s©ase, “ idiopathic anaemia.” Pepper’s patient, aged fifty, had suffered 
an obstinate form of psoriasis for twelve to fifteen years; from 
w bcular catarrh of the intestines for twenty-five years; and from the 
of nearly all his upper teeth for twelve years before his death, and 
tl°iUld not wear false ones. The autopsy revealed not only changes in 
e f Medulla of the bones, but chronic suppuration of the gall-bladder, 
argoment of the solitary glands of the intestines, and enlargement of 
Uirl Sf,leen* Scheby-Buch’s patient had been sickly for several years, 
ififl aut(W discovered, in addition to disease of the marrow, chronic 
laairnation and dilatation of the bronchi, and a somewhat enlarged 
ari(i Am spleen. 
Qu’fVl ma-ke °nly one observation upon the diagnosis of the disease. 
Cer} ? lately, Dr. H. Eichorst3 has affirmed that the disease may be 
nin U diagnosed in the early stages from the microscopic characters of 
1 Lancet, May 4, 1876. 
2 Petersburger Medicin. Wochenschrift, No. 20, 17 Juli., 1876. 
3 Centralblalt, Berlin, Juni 24, 1876. 446 
HOWARD, 
the blood. He says some of the red globules are of normal size, but very 
pale, and have lost their tendency to form rouleaux; others scarcely 
attain one-fourth the diameter of a normal perfect corpuscle, so that they 
look like drops of fat tinged red, and have lost their biconcave appeal’' 
ance. As the disease advances, these “red drops” or foreign elements 
increase in number ; so that before death he has found them as numerous 
as the intact red corpuscles. The white corpuscles are always in small 
number. 
The diagnostic character here insisted on, viz., the presence in the 
blood of red globules of much smaller size and paler color than natural 
has not always been found according to the few accurate reports made i'l 
recent cases. The red globules were observed to be small and pale ill 
one of Buch’s cases. In Bradford’s case, in which the blood was spe- 
cially examined, while “there was not much variation in size between 
the individual globules, all were rather smaller than usual; there was 
not much detritus.” The “ white corpuscles seemed to be abnormally 
granular, and were irregular in shape.” In one of my cases (Mr. T 
Prof. Osier noticed “a somewhat unusual variation in size amongst the 
red globules. Many of them scarcely measured uoVoth of an inch 1,1 
diameter; the white also presented slight variations in size, and were 
more granular than normal, and Max Schultze’s granular masses were 
abundant. 
On the other hand, Prof. Pepper carefully examined the blood in e>ne 
case, and makes no mention of this variation in size of the red globules? 
which he describes as “pale, and less biconcave than normal,” and adds? 
“no abnormal elements were seen.” And Pye-Smith reports in one case? 
three weeks before death, that “ the colored elements of the blood are 
not evidently changed either in number or characteristics, but they torn1 
no rouleaux.” 
It should be borne in mind, too, that M, Laptschinsky, of St. Peters- 
burg,1 has described precisely similar alterations of the blood in varion9 
diseases in wTiich marked febrile symptoms obtain, with the addition? 
however, of an increase in the number of white corpuscles. 
It may be that the characters of the blood described by Eichorst are? 
when present, highly suggestive of pernicious anaemia, but they do n° 
appear to be always present in that affection, and further investigation 
of the subject is needed before accepting that author’s confident state' 
ment. 
I must conclude this paper, already too long, without an examinatio11 
of the relations existing between pernicious anaemia and Addison’s <b9' 
ease, leukaemia, pseudo-leukaemia, and purpura haemorrhagica, or of t*l 
part taken by the sympathetic system in the production of the bloo( ' 
changes. Time will not permit of such an undertaking. 
The conclusions that I venture to draw on this subject are:— 
I. That all the various forms of anaemia, i. e., forms as determined by 
the conditions under which they occur, may occasionally take on Pr°' 
gressive and pernicious characters. 
11. That such is not unfrequently the case with the anaemia of pre£ 
nancy and parturition, while the converse is true of chlorosis. _ c 
111. That it has not been proved that there is a distinct variety 0 
1 Lancet, Oct. 31, 1874, p. 157. PERNICIOUS PROGRESSIVE ANAEMIA. 
447 
having an etiology and pathogeny peculiar to itself, and de- 
manding the name “ progressive pernicious.” 
IV. That neither the spleen nor the lymphatic glands usually present 
ariy, much less any special, lesion in pernicious anaemia. 
V. That it remains to be proved that hyperplasia or other change of 
ae bone-marrow, is a cause of anaemia. 
Vi. That if it be a cause, it has yet to be shown whether it is the 
CaUse of a variety that should be especially styled pernicious and pro- 
gressive, and that at present the weight of evidence appears to be op- 
P°sed to that view. 
VII. That it is premature to regard pernicious anaemia as a myelo- 
&e''ous pseudo-leukaemia. 
• VIII. That while pernicious anaemia is perhaps rather more frequent 
1 females than in males, the difference in the liability of the sexes is 
a°t very great. Omitting Bierrner’s 15 cases, the majority of which 
Oonged to the female sex, there remain in my table 47, of which 20 
Gl'e males, and 27 females. 
IX. That with the view of obtaining information as to the nature 
1 1(f causation of the defective haematosis in all cases of anaemia, and 
Tecially fatal cases, it is necessary to obtain a careful history of the 
Patient’s previous health and that of his family, to investigate the pro- 
gressive changes that take place in the blood and urine as the disease 
g Jrsues its course, and to examine post-mortem the condition of the bones 
1(f their marrow, as well as of all the other organs of the body. 448 
HOWARD, 
Table showing some Details of Sixty-two Cases of Pernicious Progressive Anemia, 
Sox. 
>-» 
JO 
Marrow 
Author. 
% 
O 
be 
< 
o 
Viscera. 
Spleen. 
Glands. 
Liver. 
Heart. 
Kid- 
Blood. 
of 
Previous condition of health. Remarks. 
Duration. 
ft 
cS 
Q 
M 
F 
< 
neys. 
bones. 
I)r. Conihe, Trans. 
ab’t 
1 
47 
Healthy. 
N ormal 
Normal 
Dale— 
Normal 
Not 
Anaemic symptoms the first indication ; hydrothorax. 
9 months. 
Med.-Chir. Soc. 
1823 
like 
exam’d 
Edinh. 
1830 
4 
18 
flesh. 
Not 
The fatal case with autopsy occurred after confinement. 
Females, p. 84. 
Sir 1). Corrigan, 
exam’d 
The other three patients never were pregnant. 
1844 
1 
21 
1 
Healthy. 
Soft- 
Diarrhoea off and on for a year. 
exam’d 
Dub. Med. Jour. p. 
ened. 
506. 
r 
i 
1 
34 
Chalky mass 
Normal 
Normal 
Normal 
Pale, 
Cyst in 
Not 
Ill twelve months ; pain across loins and scanty urine ; 
13 months. 
in apex of 
healthy 
one. 
exam’d 
coma. 
Dr. Barclay, Med. 
1851 
2. 
40 
lung. 
Healthy. 
Normal 
Normal 
Normal 
Normal 
Fatty. 
Not 
Several children; last, four months before death; sore 
4 months 
after 
480. 
exam'd 
mouth soon alter confinement; no other previous his- 
tory. Two months before death diarrhoea, which re- 
i 
confinement. 
curred ; continued to nurse for three months. 
About 1 year. 
1857 
r 
1 
31 
1 
Fatty. 
Normal 
Normal 
Fatty. 
Fatty. 
Fatty. 
No in- 
Not 
No pregnancy; domestic trouble, and recent marriage. 
crease 
white 
exam’d 
One year ot failing health ; no hemorrhage nor diar- 
rhoea ; a servant. 
1857 
1 
52 
1 
Fatty. 
Normal 
Normal 
Fatty. 
Fatty. 
Fatty. 
corpus. 
Not 
Not 
6 months poor diet; lupus in youth; rheumatic pains 
Not given. 
stated. 
exam’d 
and sometimes headache ; tanner. 
1857 
1 
50 
1 
Fatty. 
“Semilunar 
ganglion 
Fatty. 
Fatty. 
Fattv. 
Not 
Not 
13 months in lunatic ward; no pregnancy; tolerable 
Not given. 
stated. 
exam’d 
health till last few months of life ; no hemorrhage or 
diarrhoea. 
Dr. Wilks, Guy’s 
Hospital Keports, 
1857 
T 
1 
16 
1 
healthy.” 
Normal 
Normal 
Fatty. 
Fatty. 
Fatty 
No in- 
Not 
No ague; ill three years; frequent epistaxis; of late 
diarrhoea and epistaxis both obstinate ; an errand boy. 
Ill 3 years. 
colon and 
c’ease 
exam d 
3d series, vols. iii. 
ulcers. 
and v. 
1857 
1 
31 
1 
Lungs, 
Normal 
Fatty. 
Fatty. 
Fatty. 
Not 
Not 
No history, but that was very ill of bloody diarrbcca and 
occasional hsematemesis during last few weeks of 
Not stated 
stated. 
exam’d 
accurately. 
intestines 
all healthy. 
Fatly. 
pregnancy, and violent epistaxis ; never had ague; 
occupation not stated ; died 7 weeks after delivery. 
1857 
1 
30 
1 
Large but 
healthy. 
Fatty. 
Fatty. 
Fatty. 
Not 
Not 
Good health previously; no cause assignable; gradual 
weakness before admission for four months, and two 
stated. 
exam’d 
CD 
weeks before, blood per anum. 
3 years and 7 
weeks ill. 
1839 
1 
46 
I 
Healthy. 
Normal 
Fatty 
S - 
j".. W-.U1, failinp-• k 3-' since catamenia 
I 
> x—. -n. wiicea. 
* w PERNICIOUS PROGRESSIVE ANAEMIA. 
449 
t 
' . -"S' 
• 
Anchor. 
hO 
CO 
"c3 
A 
<D 
c3 
Sc 
M 
X. 
F 
6 
tD 
< 
Viscera. 
Spleen. 
Glands. 
I 
Liver. 
E'H W i 
J.O.J- ! 
1 
oones. 
.ok 8TJ ’ 
i«l • ♦!!! • Pr 
VT"f<j,f 
Previous conditiou ' „alth. Remarks. 
Duration. 
r 
i 
24 
i 
Healthy. 
Normal 
En- 
Pale- 
Normal 
Not 
Not 
Good health before ; latter half of second pregnancv be- 
About 
larged. 
yellow. 
stated. 
exam'd 
came weak and pale ; died 15 weeks after delivery. 
9 months. 
1 
45 
i 
Healthy. 
Normal 
Enl’gd, 
Normal 
Not 
Not 
Poor and badly fed ; good health till within a year ; six 
14 months. 
healthy 
stated. 
exam’d 
months after, having become thin, and pale, and weak 
1858 
3^ 
not 
diarrhoea set in. 
412. 
fatty. 
i 
55 
i 
Healthy. 
Normal 
Fatty. 
Fatty. 
Normal 
Not 
Not 
Passable health; hysterical; Oct. 1858, extreme weak- 
3| months. 
stated. 
exam’d 
ness and other symptoms of ansmia; tendency to 
attacks of diarrhoea. 
Dr. Dickinson, 
1863 
i 
1 
44 
i 
Healthy. 
Normal 
Not 
Normal 
Fatty. 
N ormal 
No in- 
Not 
Two years ill and very poor : at first only symptoms of 
Not stated. 
Trans. Path. Soc. 
Great 
men- 
crease 
ox am d 
garrulity and oddness of manner; later, ansemia ; a 
xiv. 141. 
sympathetic 
tioned. 
white 
butler out of employment. 
also natural. 
corpus. 
Cited hy Schehy- 
1858 
i 
1 
57 
No 
Two years headache and indigestion; healthy in youth ; 
Not stated. 
Buch, Wiener 
laborer ; no autopsy ; died comatose. 
Krankenhaus- 
bericliten, 1878, 
I860 
1 
1 
21 
1 
Lived under had conditions ; stone breaker. 
do Med. de Bor- 
exam’d 
d oa u x, F 6 vri cr, i860 
Dr. L. Corazza, quo- 
1869 
i 
i 
24 
1 
Not stated 
Slightly 
Fatty. 
Fatty. 
Fatty. 
Not 
Never regained health after fever at 15 ; had 4 children 
ted by Pepper, 
generally. 
swollen. 
exam’d 
in five years ; in middle of last pregnancy had jaun- 
Meissner, Buch, 
dice; confined in November, but remained feeble,suf- 
and others. 
fering frequently with diarrhoea, dyspnoea, and som- 
nolence before death. Died January 27. 
Dr. A. Gusserow, 
1871 
5 
5 
24 
5 
Normal, but 
Slightly 
Normal 
Fatty, 
Fattv, 
Fatty, 
No in- 
Not 
Good health; all pregnant; 4 had several children ; 1 
vide Biennial lie- 
to 
tatty, some of 
enlarged. 
several. 
several. 
several. 
crease 
exam’d 
had only 1 child. Without apparent cause and slowly 
trospect, 1871-72, 
3b 
them. 
white 
during pregnancy severe anaemia appeared, and to- 
6 weeks. 
p. 397, and Arch. f. 
corpus. 
wards eighth month foetus was expelled, and each 
Gyiuik. Heit 2, 
1871. 
patient died soon. 
Dr. King, Brit. Med. 
1871 
1 
i 
27 
1 
Normal. 
Normal. 
Normal 
Normal 
Normal 
Normal 
No in- 
Not 
Childless; subject to menorrhagia and leucorrhoea 13 
About 13 
Jour. 1871, p. 613. 
crease 
exam’d 
years ; always rather delicate. A vear before admis- 
months. 
white 
sion began to have diarrhoea and vomiting, and to lose 
corpus. 
flesh for two or three months, then got better ; but 
three months later symptoms returned for two months 
and again remitted. Died exhausted. 
Biermer, of Zurich, 
1872 
15 
18 
15 
Healthy, but 
Normal. 
Normal 
Fatty. 
Fatty. 
Fatty. 
No in- 
Not 
“ Frequently followed chronic diarrhoea, and childhear- 
Correspondenzbl. 
to 
tatty. 
crease 
exam’d 
ing seemed especially to predispose to it.” Majority 
tiir Schweizerische 
52 
white. 
women. 
Aerzte, Jahrgang2, 
corpus. 
1872, No. 1, quoted 
in Med. Times and 
Gaz. Nov. 21, 1874 
p. 581. 450 
HOWARD, 
Table showing some Details of Sixty-two Cases of Pernicious Progressive Anaemia— Continued. 
Sex. 
g 
Ph 
Spleen. 
Marrow 
Author. 
g 
M 
F 
Viscera. 
Glands. 
Liver. 
Heart. 
Kid- 
Blood 
of 
Previous condition of health. Remarks. 
Duration. 
P 
d> 
<1 
neys. 
bones. 
r 
1 
18 
No 
Healthy; shoemaker; no autopsy. 
Healthy; married; number of children not mentioned. 
1 
31 
1 
Slight en- 
Not 
Fatty. 
Fatty. 
Fatty. 
Deutsches Arch. f. 
1874 
1 
largement 
stated. 
crease 
Klin. Med. 1874, 
and 
white 
xiii. 209. 
hardness. 
corpus. 
Dr. Broadlent, 
1875 
1 
1 
43 
1 
Healthy all 
Normal. 
Normal 
Normal 
Not 
Not 
White 
Not 
Good health till 4 months before admission. Indigestion 
Practitioner, Jan. 
except pan- 
exam’d 
exam’d 
corpus. 
exam’d 
and severe vomiting for two months ; no hemorrhage ; 
1S75. 
creas. 
defici- 
ent. 
jaundice. Pancreas larger, firmer, and more vascular 
than usual; blood globules rather larger and thinner. 
1 
26 
No 
A dressmaker; single; bronchitis 5 months; lived in 
malarious region, and had doubtful symptoms of ague. 
Six or seven months after recovery from bronchitis 
great weakness and irregular fever in afternoon and 
crease 
white 
corpus. 
from origin of 
bronchitis. 
Dr. Pepper, Am. 
decided ansemia all present. Died comatose. No 
Jour. Med. Sci., 
Ixx. pp. 313-347. 
1875 
3- 
1 
57 
1 
Fatty. 
Enlarged 
Normal 
Fatty. 
Fatty. 
Fatty. 
No incr. 
Not 
<iu topsy. 
Good health; slight sunstroke in 1871; jaundice in 
one-half. 
white 
exam’d 
March, 1872, and when it disappeared a month later 
50 
corpus. 
ansemia found present. 
1 
1 
Slightly 
Normal 
Fatty. 
Fatty. 
Fatty. 
No incr. 
Dis- 
Psoriasis 12 years ; no upper teeth 12 years ; chronic 
follicular intestinal catarrh and chronic suppuration 
enlarged. 
white 
eased 
52 
corpus. 
marrow 
of gall-bladder. 
f 
1 
1 
Healthy: 
Normal. 
Normal 
Normal 
Fatty. 
Not 
No in- 
Not 
Porter; parents died at 78 and 98. Cough; anorexia; 
transitory diarrhoea for four months, and then when 
7 months. 
muc. memb. 
fatty. 
crease 
exam’d 
Dr. Pye-Smith, 
of stomach 
white 
first seen was intensely anaemic. 
Virchow’s Archiv, 
1875 
2<i 
47 
thickened. 
corpus. 
Ixv. 
1 
1 
Solar plexus 
Normal. 
Normal 
Fatty. 
Fatty. 
Not 
No incr. 
Not 
Doubtful attacks of ague; in last seven years has suf- 
fered several times from dyspnoea, and his face paled 
Could not be 
| 
normal. 
fatty. 
white 
exam’d 
determined. 
1 
48 
corpus. 
and strength failed gradually. 
' 
1 
1 
Healthy. 
Mode- 
Normal 
Normal 
Not 
Not 
No in- 
Not 
Carpenter ; no previous disease ; no unfavorable condi- 
tions of life ; ulcers on legs discharged freely from 
About 17 
rately 
exam’d 
exam’d 
crease 
exam’d 
months from 
Dr. Schehy-Buch, 
Deutsches Archiv, 
Bd. xvii. pp. 466- 
490. 
1876 
2- 
1 
60 
1 
Dilated 
enlarged. 
Mode- 
'Not 
Fatty. 
Fatty. 
Fatty. 
white 
corpus. 
No in- 
Dis- 
Easter to Christmas, 1871, and since then pale ; died 
in collapse. 
Nurse; sickly for several years ; well-fed : from Easter 
failure of 
health. 
Not to be 
bronchi. 
rately 
stated. 
crease 
eased 
1873 grew worse and more ansemic ; died gradually 
determined, 
enlarged. 
white 
marrow 
collapsed and comatose. 
only 2 weeks 
11 
corpus. 
in hospital. 
Dr. E. H. Bradford, 
Boston Med. and 
1876 
L 
No 
Not 
Health good; well-fed ; other members of family healthy 
looking ; during March began to lose appetite, and 
1 white 
exam’d 
days only. 
Surg. Jour. July 
to 245 
gradually lost strength and color. No disease found 
1876. 
48 
red. 
during life. 
Krieg, quoted in 
Centralblatt, Ber- 
r 
1 
1 
F?Hr. 
Not 
Married peasant; not stated how many children ; was 
- u" * hit • before death; during 
brain. 
» 
lin, 24 June, from 
1876 
31 
\ “is and pleurisy. 
1 
1 
52 
No 
— 
Bl. 1875, No. 39. 
I 
1 
45; No PERNICIOUS PROGRESSIVE ANAEMIA. 
451 
Author. 
I> 
k 
1 Spleeu. 
....... 
lHeart. 
l Kid- 
j neys. 
/ Blood. 
Marro \ 
/ of 
/ bones. 
/ 
/ Previous condition of health. Remarks. 
/“ 
Dr. E. P. Howard, 
Sept. 
“ April. 
1S71 
1872 
r 
i.. 
41 
37 
1 1 
Healthy. 
Normal. 
Mesen- 
teric en- 
larged. 
N ormal 
Normal 
Normal 
No in- 
crease 
white 
corpus. 
Not 
exam’d 
Forwarding merchant; healthy till two years before ; 
sister died of consumption ; rest of family healthy. 
For last two years at times uneasiness after meals, 
sore mouth, and gradual loss of strength and color. 
Merchant; ague sixteen years ago ; a tendency to diar- 
rhoea. Came to Montreal eight years ago, and since 
then complexion had gradually grown paler and ten- 
dency to diarrhoea increased. Father died at 27 of 
cardiac disease, and mother of bowel disease. No 
autopsy, but no disease could be detected during life. 
Bookkeeper; healthy, not robust; slight diarrhoea in 
1872. April, 1874, indigestion, which continued in a 
mild form all the year after, and pallor showed itself 
in August. 
About 2 years 
and 2 months. 
1874 
1 
.. 
.. 
53 
1 
Calcareous 
masses in 
lungs. 
Atrophied 
A tro- 
phied 
mesen- 
teric 
and 
lumbar 
Normal 
Fatty. 
Normal 
No in- 
crease 
white 
corpus. 
Not 
exam’d 
determined. 
About a year 
from time he 
consulted me. 
Notes given me by 
Dr. Greene, of 
Granby. 
Dr. F. Fede, quoted 
in Centralblatt f.d. 
Medic. Wissen- 
schaften, Oct. 16. 
1875 
i 
46 
No 
Kespectable married woman, four children ; years ago 
had few slight epistaxes ; menorrhagia for two years, 
and then began to be anemic; seen by Dr. Q. two 
years later ; intense an a; mi a existed ; died exhausted. 
Jan, 17, 1876. Family history indicated predisposition 
to anaemia. No disease of organs detected during life. 
1875 
1 
30 
Fatty. 
normal 
size and 
cont’ning 
larger 
cells than 
natural, 
and like 
those 
found in 
marrow. 
enl’ged 
crease 
■white 
corpus. 
on ribs; 
dis- 
eased 
marrow 
been always sickly, and was exhausted by repeated 
hemorrhages; for a year had suffered rheumatic pains 
in joints ; case of myelogenous pseudo-leuksemia(?). 452 
ALCOHOL IN ITS THERAPEUTIC RELATIONS AS A FOOD 
AND AS A MEDICINE. 
BY 
EZRA M. HURT, M.D., 
OP METUCHEN, N. J. 
We propose to consider the subject of this paper1 by inquiring into—■ 
I. The value of alcohol as a food ; 
11. Its value as a medicine; ( 
111. How far its value is modified by variability in the composition of 
spirituous liquors. 
I.—Any article, to rank as a food, must be convertible into tissue ot 
force, in such a way as to contribute to healthy vitality and aid the body 
in the performance of its normal functions. This includes that energ) 
which the body needs in the execution of its own processes of nutritiop 
and repair, and that which must be generated to fit it for the expendl' 
ture of proper force in its contact with the world about it. So definß® 
is the relation between the human system and the usual foods by whicl 
it is sustained and propelled, that in respect to most of them we are n° 
left in doubt. If we take any one of the ordinary aliments, and subjeC 
it to chemical analysis, and then apply the same process of examination 
to human material, we are not slow to trace the correspondence of to 
two. Since chemistry has come to be more perfect in its methods 0 
analysis, and physiological investigators have been careful to study rein' 
tions, and test them by science and art combined, these adaptations ai 
seen to be systematic and definite. 
[The ascertainable qualities which constitute a food are, in the original paper, illustrate 
by a comparison of the various aliments with the organic constituents of the body. 
description is given of the ascertained processes of their conversion into tissue and tol 
The testimony of Wanklyn, Fowne, Attfield, Bridges, Liebig, and Bernard is adduced 
to the accuracy of our knowledge of foods, with allusions to the experiments and testin'0' 
of Yoit, Bischotf, Wilson, Playfair, Lankester, Franklaud, Haughton, Mapother, and othc 
It is shown that alcohol, as subjected to such tests, fails to establish itself as a food.J 
There has been such unanimity of consent among those of divergent 
views in other regards, as to alcohol, that it is not a tissue-builddk 
food, that it is by quite common consent excluded from this class. 
have never seen but a single suggestion that it could so act, and t*ll 
mere guess. One writer (Hammond) thinks it possible that alcohol 
somehow enter into combination with the products of tissue decay?* 
“ under certain circumstances might yield their nitrogen to the cons 1 
tion of new tissue.” There is no parallel to this in Organic Chem18 .J 
nor can any evidence be found in Animal Chemistry to surround 
guess with the aureola of a possible hypothesis. . 0t 
It has been conclusively proved, says Lionel Beale,2 that alcohol is 
1 [The entire paper being too voluminous for insertion, the author has furnished aA iTOr.] 
for the Transactions, reserving the right to publish the whole in a separate form.- 
2 Med. Times, 1872. ALCOHOL AS A FOOD AND AS A MEDICINE. 
453 
a tood, and does not directly nourish the tissues. “There is nothing in 
tl cohol with which any part of the body can be nourished.”1 “It is not 
ynionstrable at present that alcohol undergoes conversion into tissue.”2 
TpCohol contains no nitrogen ; it has none of the qualities of the struc- 
re-building foods; it is incapable of being transformed into any of 
r leni; it is therefore not a food in the sense of its being a constructive 
agent in the building up of the body.3 The food tables of Letheby, 
iankland, E. Smith, etc., give no place to alcohol as a tissue-forming 
?0(L and only allude to ale and porter as containing some nutritious 
cnients from the presence of other substances. The period of youth is 
Jat in which it should be used to give muscular development and struc- 
Ul'e-building power, if possessing these properties, but authors and 
eXperinienters with one accord exclude it from the diet of children. 
• U Comparative Histology we find the structure of animals, and the 
cWs of growth, repair, and tissue-secretion, quite similar to those in 
’|an : yet none of the careful experiments as to foods, or the development 
the animal kingdom, have ever given alcohol a place for the construc- 
r. 011 of tissue. This undoubted exclusion of alcohol from nitrogenous 
c°ds is all the more significant because recent investigations have shown 
lat this class of foods not only makes cells, but that it has very impor- 
arit correlation in heat producing processes. 
is alcohol cannot be placed amid carbonaceous, or heat or force producing foods. It 
0 n°w shown how uniform is the production of heat or force as the result of the union of 
rjCgen with the carbons ; how accurately it can be tested, and how alcohol fails in this test, 
to16 accuracyof experiments illustrated by those of Pettenkofer, Fowne, etc., with confirma- 
quotations from Liebermeister, Edward Smith, Parkes, and H. C. Wood, Jr., showing 
y alcohol fails as a producer of heat and force.] 
I? idea that alcohol is a heat-producing food, and so, like calorific 
°°ds, is consumed in the system according to the usual law of disinte- 
Station, pas peen s0 far accepted that Anstie, speaking of its anti-pyretic 
ect, as now admitted, says, “Until within the last few years it was 
,ever even suspected.”4 In his advocacy, while claiming that somehow 
e°hol must be oxidized and converted into force, he then says “ this 
j^lce cannot be heat.” In other words, the most remarkable exception 
'aH the laws of energy must be assumed to exist in order to make ten- 
r } e the view that alcohol undergoes oxidation, so as somehow to elabo- 
e life force. Yet as H. C. Wood, Jr., in his recent work on Materia 
o^edica, expresses it: “No one has been able to detect in the blood any 
the ordinary products of its oxidation.’’5 
b(!K^amil,ation as t° whether alcohol increases the excretion of carbonic acid (carbon- 
]jQ 3ae)i which is a leading proof of the food value of the hydrocarbons, of oils, and of such 
di!)U-] as in their change impart vital force. It is shown that “ the quantity of carbon- 
aUal'1- • wa^er produced” in vital processes is as accurately determined as in inorganic 
of* bslS- Testimony of the leading experimenters examined and compared. The “ weight 
is that it diminishes the elimination of carbonic acid” (H. C. Wood, Jr.). So 
j, r?nl combining in any way so as to form water, alcohol is the great parcher of tissue. 
Uiic] •ls.inclu*rod next “ Is not the formation of fat a result which proves a nutritive process, 
Uia]AA secured by the use of alcohol ?” Whatever may have been the results from 
Ueitl , Uors’ or from sugary or other mixtures containing alcohol, it is shown that alcohol 
Soiti cotl^ains any fat material, nor is any conversion of it into fat, such as takes place with 
e eods, ascertainable. Explanation of cases of increase of fat while liquors arc used. 
aS 'low imPei’fect a test of healthy nutrition, is mere increase of fat. Examina- 
-0 *acts as to the reappearance of alcohol in the secretions, and how far its quantitative 
s anieron, Manual of Hygiene, p. 282. 2 Hammond, Tribune Lecture, May, 1874. 
s on Alcohol, p. 21. 4 Practitioner, vol. ii., 1873, p. 422. 
°P- cit., p. 107. 454 
HUNT, 
absence is a test of its appropriation as a food. The imperfection of the evidence as shou 
by a survey of the experiments and views of Anstie, Ford, Parkes, Thudichum and HuPr ’ 
Richardson, Duroy and Massing, Ringer, etc.] 
Parkes says, in reply to Anstie,1 “ Even if complete destruction withlll 
certain limits were quite clear, this fact alone would not guide us to tlie 
dietetic use of alcohol. We have first to trace the effect of the destruc- 
tion, and learn whether it is for good or for evil. You seem to thin 
that the destruction must give rise to useful force, but I cannot thin 
that this is necessarily so.” When an article appears to a considerab 
extent in the excretions, it seems to indicate at least that it is not reacti y 
assimilated. If under experiments absolutely complete, instead of veij 
defective, alcohol could not all be found, we would look for such resu 
of disintegration as the laws of animal chemistry would indicate, and 8 
bow the changed products had been made available as food. Finding 
none of those products which are derived from alcohol as consumed o 
of the system, nor such as occur when foods are appropriated in the ty 
tern, we would be quite excusable for asking some evidence of food-va u 
beyond the fact that the exact quantity imbibed could not be recovere 
from the excretions. „ g 
We can find no chemical law or practical excretory result which deling 
alcohol as a food. “ The mode of destruction is in fact unknown. 
search in vain for products of oxidation, except a slight change perml!, 
of a portion into acetic acid, in the stomach, and, in the case of the 1111 
bition of large quantities, the acidity of the urine which is found s^l^j,lg, 
increased. “Yet in animals poisoned with alcohol, Buckheim and i- ‘ . 
sing could find no acetic acid in the blood.”3 Yo one has as yet 
able to show a method of consumption such as ought to be manifest® 
this article acts as a food. If decomposed at all, it is, says Richan-s 1 
probably “ at the expense of the oxygen which ought to be apphec 
the natural heating of the body,” , -c* 
But if those who would defend alcohol as a food are unable to men 
it as such by any of those tests which indicate nutritive or 
foods, may we not assign it a place in what are called accessory 01 
iliary foods ? 
[Accessory and auxiliary foods defined, and the terms shown not to be an indefinite es <^.jg 
ment for failures of evidence. How as a so-called accessory or auxiliary food alco 1 
to find for itself such a place as is assigned to water, chloride of sodium, condiments, ory 
etc. It is shown howr modern chemistry has made even those which we once called at 
foods to have a definable place.] , 
Alcohol not only does not merit a place as an accessory food, accoi ■ 
to any known laws of such foods, but it is very wTell known to }*\oo.e, 
deterioration of tissue, and to disturb the relation between the 111 
nous foods and water. In appropriating the water so as to dry the 
as already noted, it thickens membranes intended for that vital A u, 
mission of fluids known as endosmose. Thus local “ sclerosis or aha 
in<r of nerve tissues is one of its frequent manifestations.”4 . ,r 
& 1 bv s»yink 
[Special examination of the attempt to define alcohol as an accessory fo°(i (qrogres- 
that it delays metamorphosis of tissue. The whole subject of progressive and r gj]o\vn 
sive metamorphosis of tissue examined. Their importance as physiological process 
to he such that delay of metamorphosis is in itself, as a rule, a disturbing and 1 cage o* 
process. It is so exceptionally beneficial that it must be directly shown, in g froin 
any special medicament, that it is conservative of health, and how it is. Quota 
2 Parkes, p. 272. 
4 Hammond. 
1 Practitioner, p. 85. 
3 Ibid. ALCOHOL AS A FOOD AND AS A MEDICINE. 
455 
he-m’ Cameron, Beale, Hammond, and others, showing the inconclusiveness of this 
him' 0t ?v^ence- Bull examination of this argument as attempted to be substantiated by 
thamr^1011 0r change iQ excretions, and by its impeding of corpuscle and other blood- 
E 
met Xarninati°n claim that alcohol belongs to the catalytic substances, and modifies 
atnorphosis by the “ action of presence.” 
Es, c\oes alcohol show a food value by the tests of dietetic and sanitary experience? 
that ni,na^on °f the cases of Anstie and Inman, and rebutting evidence. It is concluded 
an‘ 1 a\c°hol is not shown to have a definite food value by any of the methods of chemical 
Isis or physiological investigation.] 
\r We next propose to discuss the place of alcohol in the Materia 
in -a’ and its therapeutic action. “ There is,” says Lionel Beale, “no 
of rf important question in medicine to be determined than the action 
ag a c°hol in disease.” As we come to inquire into the value of alcohol 
b a medicine, after having found its reputation as a food unsustained, 
j 18 Well to remember that the terms food and medicine are often more 
. arly allied than the mention of the words is apt to indicate. A medi- 
o.! e 18 that which helps to heal or repair, for that is both the etymolo- 
Waning of the word and the practical design of the article used. 
e process of restoration or repair is often but an application of the 
tiggcess of natural nutrition. Amid the progressive changes of food into 
A lle? and the retrogressive disintegration which all life implies, we 
ag IK)t deceive ourselves by terms. Much of the discussion, therefore, 
b 0 the value of alcohol as a medicine, is in reality to be determined 
cp 'Wat it can do toward repairing the waste of tissue which occurs in 
What it can do in this regard depends largely upon the deter- 
te,Ua^10n °f its food value. This we have seen to be so small and inde- 
in Hlnate> iat *f will not d° to push it forward as a valuable medicine 
v. lOse. respects in which medicine chiefly concerns nutrition and the 
*mti°n of animal heat. 
t],r f . n we find that alcohol has no nitrogen with which to nourish ; 
. *f does not respond to the laws by which animal heat is usually 
th* f ’ fbat at f)esf undergoes such imperfect change in the system 
sueB 111 Ucb of it is found unchanged in the secretions, excretions, and tis- 
ide8’*that fim products of its primary or secondary change cannot be 
or Wificd ; that it is not settled whether it diminishes the carbonic acid, 
tiVerea> or other excreta, or whether such diminution would be repara- 
of ’ e .may well hesitate to assign this drug a place in the category 
p6l.Je .inal agents. When it has eluded the ingenuities of science, the 
it 'x aasi°us of art, and the astute diligence of interest, to extemporize 
to v- V must be remembered that it has made a signal failure 
rea> Ul,fieate its position as a medicine in any one of the particulars in 
f° which it is most frequently urged as of value. 
far f° the consideration of the place of alcohol as a medicine, we come to inquire how 
theip +uVariability in the composition of spirituous liquors and their unreliability modify 
lherapeutic value.] 
ab]e We are f° consider any article therapeutically, we ought to be 
Wbo ? . n°w that it is the article which it professes to be. The clinician 
a o«ivC ainis. uniformity of result, and a declared therapeutic effect, from 
fhe c;611 ai^cle, has reason to question whether the effect was a result of 
inopep!]?- cause, when he finds that the alleged cause was necessarily 
U°t te.RinJ0 
by reason of absence or admixture. If the article used was 
8 e(f either as to quality or quantity, if the general rule in respect 456 
HUNT, 
to it is unreliability, we surely cannot trust general opinions as to its 
dietetic or medicinal value. 
We have been used to hear criticism as to the composition of liquor 
without much professional impression derived therefrom, supposing tna 
these criticisms were chiefly based upon general accusation, or the tna 
of bar-room specimens, and that the bonded warehouse and the druggist s 
label were an assurance of purity. But in the medicinal examination o 
liquors we find some facts which address themselves to us most direct!} 
in their clinical bearings. In our inquiry in this line we shall pursue 
the same course as when examining into food value, seeking our informa' 
tion from chemists, from medical experts, and from the best accepte 
authorities on the composition of alcoholic medicines. _ ~ 
There is much difference in different spirituous liquors, and in/*1 
ferent specimens of the same kinds of liquor, as to the amount and km s 
of alcohol and other ingredients, independent of any question of adult ' 
ration. A reference to the Proportion Tables of Brande, Fontenelle, Benc 
Jones, Thudichum and Duprd, etc., will show at a glance such variation 
as these: Wines, in general, contain from 8 to 26 per cent, of ? 
Madeira from 19 to 26 per cent.; Port from 17 to 25 per cent; SheU} 
from 19 to 25 per cent.; and various other wines from 16 to 18 per 
Thudichum and Dupre state that a natural wine may contain from 9 
16 per cent, of alcohol. Fowne says of them, “ The quantity of alcou 
varies very much.” Sherry often has from 6 to 8 gallons, port wi 
3 gallons, and the best port 13 to 15 gallons of brandy, added per c/lW 
This is not considered admixture, but original “fortification,” us R 
called. Native European wines, by the English law, must not have o' 
26 per cent, of alcohol. Champagne, Burgundy, and the Rhenish win * 
contain an amount varying from 8 to 14 per cent., by measure, 
alcohol. . t £ 
Such statements are made still more significant from the authority 
Parkes, who says : “So various is the amount of alcohol in wines t* 
the same district, that a very general notion only can be obtained q 
tables, and samples of the wine actually used must be 
Brandy, whiskey, and gin contain from 50 to 60 per cent, of alcohol, < 
rum from 60 to 80 per cent.; apple brandy should have from 40 to 
per cent. As we shall see hereafter, these are so varied in other regam 
in the various processes and methods of manufacture, that their jll 
restricted alcoholic variation is an inadequate measure of their 11 
peutical import. _ . 
If, as claimed by most, alcohol is the chief available medicinal 1 
dient of alcoholic stimulants, it is clinically requisite to know just njore 
much we are administering in each dose prescribed. This all the 11 )0 
when leading representatives of alcoholic treatment now claim tna 
limit in health is within two ounces in twenty-four hours; and tve 
limit in disease is far narrower than once believed. In face of the » 
facts which come to us from pathology and from practice as n 
effects of over-doses on the nervous and circulatory systems, am je 
secretion and excretion, it is not good practice to deal with an 
without some definite knowledge of the dose administered. jjeCj 
effects are a proper measure of degree of use, when they are so lUSfc 
and classified, and so numerous, as to justify inferences, yet tha 
1 Op. cit. p. 265. ALCOHOL AS A FOOD AND AS A MEDICINE. 
457 
e^er be an imperfect clinical study of any medicine which is unable to 
the amount administered in any given case. 
'L>ut t^le time is already at hand when, in speaking of alcoholic liquors, 
e.niUst define what form of alcohol we mean, as well as how much of 
ls present, since they are often mingled, and their physiological and 
effects are totally different. Let us gather up briefly from 
and experimenters, such as Fowne, Attfield, Richardson, and 
r r^Sc°tt, a few significant facts, which are, we believe, not gainsaid, 
• lc present the question of the medicinal use of alcohol, so called, 
nfimte a new light, 
towne skives a list of twelve alcohols, as belonging to what is known 
u*e monatomic series. Of these, five chiefly concern us in medicinal 
dietetic relations; these are the methylic, CII40 ; the ethylic, C2II60; 
g^le propylic, C 3H80; the butylic, C4III0O; and the amylic, C 5H120. Fowne 
qOs: “The term alcohol,originally limited to one substance, viz., spirit 
0 'Vlne, is now applied to a large number of organic compounds, many 
which, in their external characters, exhibit but little resemblance to 
ainary alcohol.” Yet, as we shall see, no usual liquor is clear of some 
, e °t them besides the ethylic, which is the one known as common 
c°h°l; and, secondly, their effects are medicinally quite different.. 
a first of the series, methyl alcohol, naphtha, or wood spirit, is not 
1 yf'ginal impurity in manufactures of an ethyl (or common) alcohol; 
the form of methylated spirit has been added in the falsification 
j 'floors.”1 Pure methyl alcohol is a colorless, thin liquid, very similar 
j. sfnel 1 and taste to ethyl alcohol, and, like it, is a mobile, watery 
TMIP “It has an aromatic odor, free from empyreuma, and a sharp but 
tin faste*”3 The methylated spirit has been used fraudulently in 
s e Manufacture of the sweet spirit of nitre.4 Richardson5 has made 
important inquiries in respect to this substance, tie names the 
e Se °f a well-known physician who himself used it in preference to 
alcohol, regarding it as less injurious. Richardson has long 
“it* Prac^ce as a substitute for the common alcohol. He says 
tin ls.Much more rapid in action, and much less prolonged in its effects, 
wp1 eommon alcohol, so that it produces its effects promptly, and, 
hemp *S importance, it demands the least possible ultimate ex- 
Pet-Mre an™ force for its elimination from the body. This latter 
pr °f great moment, for, in the end, all these alcoholic fluids are de- 
PatSßantS’ alfbough at first, by their calling vigorously into play the 
HipUl' 01'ces, they seem to excite, and are therefore called stimulants— 
dii c t^eMselves supply no force.” He notices its special power of re- 
riQ ln* temperature (p. 32), and calls it the lightest and least inju- 
jY)ajS the alcohols (p. 23). If we are giving an alcoholic medicine 
Vei-v6 substance, we are using the spirit most allied to, and yet 
nil costinct from, ethylic alcohol, or the purported kind.6 
actic)ie f>loPyTc alcohol is not yet much understood in its medicinal 
dispp' . Chancel7 obtained it from fusel or amylic alcohol by fractional 
h]a 1 afion. One of its isomeric modifications has a very close resem- 
atl(] Ce f° efbyl alcohol. It is not unfrequently found with it in liquors, 
’°* c°urse, modifies its characteristics. Its medicinal action is not 
' p 
2 Pmf fkninsular Journal of Medicine, Detroit, April, 1876. 
4 AtSV- 51°- 3 Prescott’ loc- cit- 262- 
6 See • i '’ J3, 5 Cantor Lectures on Alcohol, p. 30. 
ABO Monroe, “Is Alcohol Necessary ?” 7 Fowne, p. 31. 458 
HUNT, 
yet well enough understood to draw the contrast between it and the 
genuine ethyl drink or medicine. It is, if possible, even more greedy of 
water than the latter, and so still more robs the tissues. 
Butylic alcohol is often contained in amylic alcohol, and so is present 
in the usual fermentations. When valerianic acid is artificially prepared 
from butylic alcohol, as is commonly done, the various valerianates at’6 
often contaminated by butyrates.1 There is reason, therefore, to believe 
that it is often present with the other alcohols. Richardson seems to 
have shown that this heavier alcohol is much more apt than the ordi- 
nary alcohol to cause tremors of the kind occurring in delirium tremens- 
Its effect is certainly very different from that of the alcohol designed for 
common medicinal use, and it must be studied by the physician in its 
own distinct effects. 
The next in the series is known variously as amylic alcohol, potato 
oil, grain oil or grain spirit, and fusel oil. In its relation to the ethyfio 
or assumed common alcohol of alcoholic liquors, it is of most interest t° 
the physician. “It constitutes,” says H. B. Prescott,2 “the chief.part 
of fusel oil, which also contains the fourth alcohol (butylic), and traces 
of the third (propylic), and these together appear quite invariably 
the alcoholic fermentation of sugar, their preparation being varied by 
conditions.” “It is the great and naturally occurring impurity °f 
liquors,” says Fowne (p. 585). In the manufacture of brandy from corn* 
potatoes, or the must of grapes, the ethyl (common) alcohol is found to 
be accompanied by an acrid oily liquid called fusel oil, which is vei’}7 
difficult to separate completely from the ethyl alcohol.” Attfield3 say9’ 
“ Amylic alcohol is a constant accompaniment of ethylic or common 
alcohol, when the latter is prepared from sugar which has been derived 
from starch.” This, of course, applies to all alcoholics prepared from 
grains or vegetables, either by brewing or distillation.4 Hot only doe9 
it thus occur naturally, but some of that found in wines and spirits is 
probably added. Much of it is imported to England, it is believed, Rr 
that purpose.5 Ho doubt much of it is thus returned to us as a direct 
re-importation, marked pure from the bonded warehouse. As common 
alcohol dissolves it readily,6 as it has a pungent but not acrid taste by 
dilution, and has a fruity taste and smell, it is much relished. It is the 
heaviest and most injurious of the five alcohols thus far noticed. It ha9 
a burning, acrid taste, its vapor producing oppression of the chest- 
When produced as so often in manufacture, or when added for profit 
and improvement of flavor, it is “ an extremely dangerous addition t° 
ordinary alcohol.” Its action is the same as that of butylic alcohol* 
“ except more prolonged by reason of its greater weight and insolu- 
bility.”8 
In this country, where whiskey and other fermented products are 90 
largely used, the art of their concealment and modification so as to g1 Ye 
a relished flavor, is well understood. There is little doubt that certaR1 
effects of alcoholic liquors of late years are due to the more profita- 
ble utilization of the “ contemporaneous” alcohols with the ethylic. B 
is also true that the addition of such alcoholics as the methylic, or 04 
various substitutes for all the alcohols, has left what is called the exp6' 
rience of prescribers somewhat mythical. 
1 Attfield, Med. and Pharrn. Chemistry, p. 322. 
3 Op. cit. p. 389. 
5 Richardson, op. cit. p. 36. 
7 Ibid. p. 536. 
2 Loc. cit. 
4 Fowne, p. 520. 
6 Fowne, p. 535. 
8 Richardson, p. 37. ALCOHOL AS A FOOD AND AS A MEDICINE. 
459 
on . eXt d shown how, in the various modes of preparation and manufacture, variations 
n lJr n°f only from different vintages, distilleries, and breweries, but from difference in 
' 10t* a»d the financial interests of makers—all within the limit of legitimate prepara- 
*s diown, by the testimony of chemists, how different alcoholics are modified by 
so/ r/a^*°n or Citation. Testimony of Thudichurn and Dupr6, Mulder, Parkes, Richard- 
b Rattershall, Prescott, Cameron, etc.] 
There is still another most important therapeutical view to be taken 
the various alcoholics. 
-the time has already come when prepared liquors which have never 
?een a vintage or a distillery, dispute their right to he accounted genu- 
and not to be branded with the epithet “ adulteration.” The ablest 
|. niost candid French work and authority on the manufacture of 
Aiuors (Duplais), discusses the question from the stand-point of business 
ntegrity, and leaves it without adverse decision. Prof. A. B. Prescott, 
Ae able chemist of Michigan University, in bis work on the Chemical 
lamination of Alcoholic Liquors, says: “The term brandy, as used 
.1 commerce, without qualification, must be held by common consent to 
lcmde artificial brandy.” He makes three divisions, viz.: veritable 
Randy, artificial brandy (or that made of the same ingredients according 
0 chemistry), and fictitious brandy ;i.e. a fraudulent imitation. There 
ar.e biany preparations known as brandy essences, which are so combined 
Ttb spirit as to make artificial brandies difficult of distinction from the 
Writable.1 
Grriften, who is an authority, and who has examined many specimens, 
3’8 that he found what he called Public House Brandy not to be a dis- 
/ *cd spirit, and yet that it had the taste of a good cognac. He gives a 
ei'p:ian recipe which he says, after long keeping, gives a brandy very 
bffnlar to real cognac in taste and odor. He adds that this sort of so- 
- Rstication is evidently becoming an ordinary commercial practice. 
Je recipe, as given by him, contains much purified spirit, but only eight 
Hearts of wine to 150 quarts of mixture. 
i Thiplais’s most able and scientific work, of 700 pages octavo, translated 
. y McKennie, and published by Baird, Philadelphia, 1871, would be 
Complete without its pages on u Imitations.” Speaking of cognac, as 
u / difficult of all brandies to prepare artificially, it says (p. 298); 
is a fact worthy of note that the brandy obtained in consequence of 
, e addition of a spirit foreign to the wine, in limited proportions, cannot 
e distinguished from the natural wine by itself, that is to say, without 
le addition. Finally, brandy resulting from the new method, defies all 
pthods of investigation. We may suspect the mixture, and even know 
£ existence, but we cannot furnish the proof; neither the most skil- 
and practiced taste, nor the persevering researches of the most skilful 
*ll learned chemists, have been able to detect it. M. Payen himself 
some time since that, in the actual state of the science, 
discovery of the mixture presented insurmountable obstacles.” Such 
a Pierre Lacour, on “ The Manufacture of Liquors, Wines, 
Cordials, without the aid of Distillation,” and others well-known to 
_ alters, and but little to physicians and pharmacists, show to what 
f ection the experts have attained. The chapter of Duplais on the 
the/ai'a-tion vai’i°as liquors, of which alcohol, sugar, and water, are 
qJe dasis, also shows how artificial and successful are such compounds. 
10 author, after admitting that “the immoderate use of spirits, and 
1 Prescott, p. 23. 460 
HUNT, 
even liquors, is pernicious,” and after designating the drunkard as “a- 
wretch who is unworthy to live” (pp. 437-8), claims that the “ aromatics 
and sugar are good for digestion,” and the small quantity of alcohol not 
injurious to persons in health. 
We have had occasion to examine recent popular books of recipes for 
the imitation of liquors, and it is wonderful to what perfection the art 
has been elaborated. When we look into our recent chemistries and see 
how many natural products are duplicated in art, and that fruit essences 
and flavors are so well imitated that connoisseurs cannot distinguish 
the artificial from the real, it is to be expected that the great profits 
accruing would induce the production of liquors without the trouble of 
vintage, wine press, or distillery. More Madeira wine is in the market 
than could be made on the island of Madeira if each grape made a gallon* 
Critical examinations have gone far enough to show that in all alcoholic 
drinks, as consumed for thirst or medicine, the veritable article is largely 
reduced or superseded by admixtures and imitations. The editor of the 
London Lancet well says: “We suggest it were well worth our while 
in the future for us to transfer our allegiance, when we would prescribe 
alcohol, from the wine and spirit merchant to the chemist.”1 When 
imitations are repudiating the reflection of being “spurious,” and 
claiming legitimate place beside the “ veritable” products, and when the 
“ fictitious” are difficult of distinguishment, is it not high time for the 
therapeutist to take reckoning as to his professional position in reference 
to alcoholics as at present prescribed? 
In face of facts, such as we have adduced, it is a burlesque on the pre- 
cision of modern therapeutics to deliver ex cathedra opinions as to the 
medicinal value of alcohol, when we are using all sorts of remedies under 
the name, are attributing to them results which are shown to be impos- 
sible, and prescribing them with an unscientific laxity which would he 
scouted in the confines or even in the purlieus of any exact science or 
any expert art. 
In the light of accumulating facts as to the whole alcohol series, as to 
the manifold and variable combinations prescribed under the cognomen 
of alcoholics, and with candid regard to the wide and contradictory 
range of their composition, we must needs review the record of our materia 
raedica. We must recognize the unscientific and empirical data on which 
we have rested, as insufficient to overcome the facts of histological and 
pathological research, and feel that demand is made upon us to show the 
conservative modus operandi of a medicine which so significantly asserts 
itself as a toxic and depressant. 
Such questions as these are presented for exact consideration, to a de- 
gree that neither science nor practice would ignore. 
(1) What is the effect of ethyl alcohol as a medicine ? 
(2) What trustworthy experiments have we as to its physiological 
effects, and as to its therapeutic indications? 
(3) What guide as to the quantity to be given ? 
(4) What testimonies of experience as to its clinical use? 
(5) With present light as to the manifold variations of alcohol ill 
legitimate manufacture, and its change by admixture, are the usual tes- 
timonies as to the advantage of ethyl alcohol as a medicine of any pro- 
fessional value, unless composition has been determined ? 
1 Lancet, Nov. 1, 1873, p. 639. ALCOHOL AS A FOOD AND AS A MEDICINE. 
461 
(■-*) How far can methyl alcohol take the place of ethyl alcohol as a 
Medicine?l 
. (7) How much does any alcohol or fusel oil occur in various alcoholics, 
'ther by virtue of manufacture or admixture? 
(°) How far are the effects of wines dependent upon their numerous 
X lllarating ethers, their albuminous matters, their sugars, acids, and 
..ta, and how far are the effects of each kind due to the varying propor- 
f °VS °f these? The same inquiry may be made as to all alcoholics from 
(9) How far is the effect of whiskey due to its ethers, essential oils, 
sugars, malt, etc., and so as to all distilled liquors from grains? 
HO) How far do the effects of malted ales, beers, etc., depend on sugar, 
Btarch, etc. ? 
Hf) How muck are clinical experiments worth which speak of the 
d*Ue of alcohol as a medicine, with utter disregard of such items ? 
~ (H) Is it possible so to deprive wines, etc., of all alcohol, as to secure 
leir action independent of the spirit ? 
He rest of the paper reviews the changes in the use of alcohol in various diseases, and 
}j|j<nvs how assumptions as to its value have been modified. It shows, also, how other ex- 
arauts can easily be substituted in a large majority of cases.] 
The following are the conclusions submitted to the Section of-Practical 
Hedicine:— 
I- Alcohol is not shown to have a definite food value by any of the 
of chemical analysis or physiological investigation. 
H- Its use as a medicine is chiefly that of a cardiac stimulant, and 
admits of substitution. 
HI. As a medicine, it is not well-fitted for self-prescription by the laity, 
j>nd the medical profession is not accountable for such administration, or 
n the enormous evils arising therefrom. 
IVb The pmdty of alcoholic liquors is, in general, not as well assured 
\v) at of articles used for medicine should be. The various mixtures* 
T Jen used as medicines, should have a definite and known composition, 
id should not be interchanged promiscuously. 
Qa motion of Dr. J. M. Ridge, of Camden, N. J., seconded by Dr. IST. S, 
e AVis5 of Chicago, 111., the conclusions of Dr. Hunt’s paper were adopted as 
ttm vSS* ie ophhou of the Section, and were ordered to be transmitted to 
National Temperance Society, the Women’s National Christian Temperance 
HC.10-1’ the Pdend’s Temperance Union of New York, in reply to commu- 
tations addressed by those bodies to the International Medical Congress, 
ncl by the Congress referred to the Section on Medicine. 
says that it is practicable to substitute it. A. B. Prescott expresses the 
m V°u Hat the views of Richardson are correct. The introduction of methylated 
See r>Ce ti)e excise proof-spirit, has been a most important measure in Great Britain. 
Soci ,Port of Professors Graham, Hoffman, and Redwood, Quarterly Journal of Chemical 
' e y, vol. viii.; and Fowue’s Chemistry, p. 518. 462 
REPORT OF INVESTIGATIONS MADE UNDER THE DIRECTION 
OF PROFESSOR RUDNBW AT THE INSTITUTE OF PATHO- 
LOGICAL ANATOMY OF ST PETERSBURG. 
COMMUNICATED BY 
PEOFESSOR REDREW. 
I. Sclerosis of the Vessels of the Lungs. 
Dr. Bekesnewitsch. 
Many eminent writers maintain that the vessels of the lungs are sub- 
ject to a disease known as “ Sclerosis,” or the “Atheromatous process/ 
Dittrich, in his work entitled “ Tiber den Laenneckschen Lungeninfarct/ 
especially describes this disease, and states that it affects the arterial 
branches of the lungs, and causes the formation of a substance within 
the inner and middle coatings of the vessels, which he further asserts 
becomes, in time, either a fibrous tissue, or fatty or calcareous matter. 
Dittrich further says that this affection occurs more frequently with 
cardiac disease, especially of the right ventricle, or when the lungs are 
themselves affected with atrophy and emphysema. 
Far from agreeing with this authority, we are led to believe from 
more recent observations, that instead of sclerosis resulting from emphy- 
sema, emphysema is more probably due to sclerosis. Other writers and 
anatomists seem to have given but little attention to this form of lung 
disease, some being disposed to accept Dittrich’s theory, while others 
maintain the opinion that sclerosis of the lung vessels is extremely rare. 
In consequence of the small number of careful observations made m 
respect to this disease, and the diversity of opinion which appears to 
exist, I have instructed Dr. Beresnewitsch, one of my pupils, to deter- 
mine by the minutest microscopical observation, (1) what arteries are 
directly affected (whether bronchial or pulmonary), and (2) under what 
conditions this disease occurs, the latter question to be investigated before 
the former. 
Dr. Isaacson, one of ray pupils, some years ago investigated, under 
my direction, many cases of emphysematous degeneration of the lung9> 
and found that this disease was always due to an affection of the lung 
vessels. The development of emphysema begins when the bloodvessels 
become closed by coagula, around which the tissues disappear by reason 
of want of nourishment. The occurrence of this coagulation is due to 
the destruction of the inner coating of the artery, and now Dr. Beresne- 
witsch has shown that this destruction is due to the presence of syphl' 
litic infection, which in course of time manifests itself not only in the 
capillaries but also in the larger vessels, sclerosis consisting in the de- 
velopment of connective tissue between the layers which form the inner 
coating of the artery. CONTRIBUTION'S TO PATHOLOGICAL ANATOMY. 
II- On the Development of Cancer in the Lymphatic G-lands. 
Dr. Afanasieff. 
Cornil, Thiersch, Waldeyer, Rudnew, and others, by their investiga- 
. i°nss bave already proved that the primary development of cancer 
‘JVays originates from the morbid condition of true epithelium. The 
s. cater part of the writers of the present day agree with this opinion, 
il*e the number inclined to differ therefrom becomes gradually less 
HI less. The minute and careful investigations of later days tend to 
ufirm this view, as we hear of no cases at the present time, in which 
c *s reported as arising otherwise than in the epithelium, 
th 118 has been based upon the fact, only lately discovered, that 
ere are many new formations which have hitherto been considered as 
c ucerous, but which, although very similar, are not cancers at all, but 
Hors which are called endothelioraatous, a term which perfectly sepa- 
c T8 them from cancers which are epithelioraatous. 
pon the secondary knots of cancer, the opinions of different writers 
. n°t accord—some affirming that the secondary formations actually 
'S(T from the passing of cellular particles from the primary growth, 
others maintain that the cellular particles transferred, impregnate 
8 °Be already existing, and thus together' lead to the formation of the 
v.Condary knots. Waldeyer, Liicke, and a few others, accept the former 
but refuse to accept the latter. These authorities appear to base 
ieir opinion upon the doctrine of Rernak, who asserts that the cells of 
uPpor and lower layers of the embryo never mix with the elements 
fhe middle layer. 
fu conjunction with my colleagues, I have lately undertaken a careful 
of the lymphatic glands affected with secondary cancer, 
we find that, whether the glands are sound or affected by previous 
tj H’bid processes, the condition of development of cancer knots remains 
,e same, and in either case is due solely to the cellular particles trans- 
fted from the primary cancer, and does not in any way result from 
-n e already existing elements of the glands, which elements, far from 
11 Uicipating in the formation of the cancer knots, undergo a retrogres- 
lVe change." 
111. Pathology op Sclerosis of the Arteries. 
Dr. Engelhard. 
a i le rnprbid changes to which the arteries are subject have been known 
de,°n£ flme- Crell, Haller, Morgagni, and other writers of past times, 
**bed fhlckness and ossification of the arterial walls, but they did 
to 113088688 flie means now brought to bear in investigation, and seem 
an]laVe cons’(lcred the different stages of the disease, not as we now 
****««! them to be, various phases of the same affection, but as 
'a v distinct morbid conditions. The opinion of the authors referred 
an’ uP°*y the causes of disease of the arteries, seems to have been vague 
to t|Contrary to fact, inasmuch as they attributed this form of disease 
Pel 16 a^B°rpti°n of foreign matter previously infused into the blood, 
ari ei^.ail(l Stokes are, however, of opinion that sclerosis of the arteries 
Ses from local changes produced by the nutrition, while Rokitansky, 
0 formerly adhered to his own theory that the disease was due to the 464 
RUDNEW, 
deposit of a certain substance from the blood, now agrees with Dittrich 
and Yirchow in attributing its origin to abnormal extension of the 
arteries. 
With these three distinct forms of opinion, at variance with each 
other, which is to be considered as the correct one? The recent investi- 
gations made by myself and colleagues tend to convince us that not on® 
of the already stated views is according to fact. 
We find that the first morbid appearance is due to a rupture of the 
media which permits a passage from the adventitia to the intima. This 
rupture causes irritation of the adventitia, and provokes inflammation, 
the products of which pass through the seat of rupture and propagate 
within the intima. This rupture, crevice, or cleft, as it may be termed, 
although probably of minute dimensions at first, is greatly influenced 
by the amount of the product of inflammation, so that, as that product 
increases, so also does the crevice become increasingly large, until in due 
course the media in certain parts are totally destroyed, and the regular 
circulation of the blood is markedly obstructed, thus giving rise, after a 
time, to the various forms of aneurism. This will explain the manner 
in which sclerosis and aneurism of the arteries originate in certain cases. 
Another form of the disease may be regarded as arising, not in conse- 
quence of an affection of the media, but of the intima itself. The internal 
surface of the intima ceases to retain its natural smoothness and rotundity, 
becoming undulating in appearance from an irregular thickening of its 
tissues, which thickening gives rise to scores, the ulceration of which, 
being permitted to increase, involves in destruction first the media and 
afterwards the adventitia. When the destruction of the media is com- 
plete, aneurism soon follows. 
Having thus classed the forms of this disease under two distinct heads, 
permit me to specify the several causes by which they are produced- 
The first and most frequent cause of the changes of the vessels may be 
considered to be syphilitic infection of the body ; the tissues of the media, 
under a syphilitic influence, being extremely fragile and liable to be 
ruptured from distension. Another very frequent cause is found in the 
morbid effect produced by alcoholic drinks. I may mention in reference 
to these two causes, that the first or syphilitic affection generally attacks 
the media, while the influence of alcohol is found to affect chiefly the 
intima. Among the many other causes of the production of sclerosis of 
the arteries, is the absorption of certain poisonous substances, such a 9 
mercury, phosphorus, etc,, as well as of those poisonous matters the 
chemical nature of which is but little known, as those of typhus and 
intermittent fever, etc. 
How permit me to describe the anatomical changes, microscopical as 
well as macroscopical, to which the coats of the bloodvessels are liable- 
The macroscopical changes consist in a local thickening of the intima, 
having the appearance of yellowish spots dispersed over the inner surface 
of the arteries. The next stage or change is confined to the enlargement 
of the artery until it reaches the condition of aneurism. In describing the 
microscopical changes, I would distinguish very clearly the two different 
changes in the coats of the vessels. In the first or syphilitic affection 
the disease begins with a rupture in the media, which permits the 
inflammatory product of the adventitia to pass to the intima. Tin9 
inflammation has generally the character of granulated inflammation- 
The second form commences, on the contrary, in the intima, the fimt CONTRIBUTIONS TO PATHOLOGICAL ANATOMY. 
465 
? lange consisting in the appearance of minute cellular particles collected 
|.nt° nests of a size more or less large. These cellular particles arise 
'om two sources ; sometimes they are formed by division of the tissue- 
s> but more generally their existence is due to the extravasation of 
16 white blood-corpuscles. These nests do not long retain their form, 
in consequence of the degeneration of the cells are transferred into 
c°res, giving rise to the Endarteritis ulcerosa. 467 
SECTION ON BIOLOGY. 
PRESIDENT OF THE SECTION. 
JOHN C. DALTON, M.D., 
OF NEW TOKK. 
AUSTIN FLINT, Jr., M.D., FRANCIS W. CAMPBELL, M.D., 
VICE-PRESIDENTS. 
OF NEW YORK. f OF MONTREAL. 
JAMES TYSON, M.D., 
SECRETARY. 
OF PHILADELPHIA. 
THE MICROSCOPY OF THE BLOOD. 
BY 
CHRISTOPHER JOHHSTOH, M.D., 
A distinguished writer, Dr. Thomas 'Williams,1 states that “in the cate- 
j D °t the nutritive fluids unmixed fluidity is not known; solids are 
or r,O(^Uce(L Fluids are not self-productive ; they require either the direct 
• the catalytic agency of solids. The fluids even of the vegetable organ- 
gA1 bear floating corpuscles,” And again farther on he insists that “no 
gle real example occurs in the whole animal kingdom of a nutrient 
1(1 totally destitute of morphological elements. This rule (of the cor- 
* rpe,uAtion of the animal fluids) is ultimate and absolute.” 
eo + rom anJ other, both in vertebrates and invertebrates, in that it is 
j 'tinned Li a closed system of vessels, and moves in a determinate circu- 
*tory orbit. It was “ this circulation, the discovery of which does 
a.’ an(l could hardly,” says Flourens, “ belong to one man, or even to 
single epoch, Galen opposed Erasistratus ; he opened the way which, 
e‘'wards followed by Yesalius, by Servetus, by Colombo, by Csesal- 
n nu.8> by Fabricius of Acquapendente, led us to Harvey.” Whilst 
a the great Servetus, however, we ought possibly to have cited 
other Spanish claimant, Francisco de la Reyna, of whom Don Fran- 
Benito Jeronimo Feyjoo (a very eminent and learned man, who 
ni°i’e for the intellectual life of his country,” observes Ticknor,2 
u!n bad been done for a century”), in the third edition of his “ Cartas 
lu'ti aß’” Published in Madrid in 1774, makes the following mention. 
y0 be twenty-eighth Carta he says: “The literary phenomenon which 
bring to my notice is rare, and curious as rare. Is it possible that 
OF BALTIMORE, MD. 
etc a>id Foreign Medico-Chirurgical Review, Oct. 1853, p. 361; Art. 1., The Blood, 
ticknor’s History of Spanish Literature. 468 
JOHNSTON, 
a Spanish farrier can have been the first discoverer of the circulation of 
the blood? Yon write me that a friend of yours has a Book of Farriery? 
by the Farrier Francisco de la Beyna, printed in Burgos in the house of 
Felipe de la Junta in the year 1564, and that he saw the fellow to it b1 
the Royal Library, probably the only copies in Spain. You send me tbe 
transcript of a passage in Chapter 94 of the said volume, so clear, so 
decisive, as to the circulation of the blood, that it establishes the fact 
that the aforesaid Reyna was acquainted with it. This little sentence 
banishes all doubt; “So that the blood goes round and circulates throughout 
all the members (Be manera que la sangre anda en torno, y en rueda p°r 
todos los miembros).” Or, as Feyjoo, on page 318, quotes, “ our Farrier? 
who first, before Harvey, used the word circulation,* and who left it dis- 
tinctly written that the blood goes round and circulates through all tbe 
members (la sangre anda en torno y rueda por todos los miembros).” 
However this may be, the circulation of the blood, the passage of tbe 
blood from the arteries into the veins, was graven as a fact by Harvey, but 
the direct demonstration was wanting. It came at last, the microscope 
afforded it; yet it was denied to the grand old age of Harvey, who died 
without witnessing it. But in 1661 Malpighi saw the blood pass from 
the arteries into the veins of the mesentery, the lung, and the urinary 
bladder of frogs, and by that act crowned the work 
“By the side of the Wolffian bodies, on the axial side, the general 
epithelial lining of the great lymph sac, the pleuro-peritoneal cavity? 
thickens, its cells assume a columnar shape, they proliferate freely, and 
then form a raised mass of “ germ epithelium.” “From this layer the 
ova are subsequently developed, whilst the vascular stroma of the ovary 
is formed by an outgrowth from the side of the Wolffian body.” In the?6 
lew words a modern writer, while noticing the advanced genesial labors 
of Dr. Foulis,2 expresses upon certain points the common belief of embry- 
ologists, and points out, in terms which they may or must accept, tb® 
manner of a new departure of nucleated protoplasm in the production 
of “primordial ova” from the germ-epithelial corpuscles. And agaim 
according to Schenck,3 we assert that “ originally the entire pleuro-pern 
toneal fissure is lined on its inner surface with cylindrical cells, whim1 
originate from the subdivided lateral portions of what was at first tbe 
middle germinal plate.” And this layer of cells serves exclusively t° 
form the subsequent peritoneal epithelium. But the cylinders soon d>s' 
appear, leaving as their descendants entirely flat, pale elements; tbe 
median angle corresponding to Rernak’s middle plate, and later tb® 
Wolffian bodies, which grow out from this spot, alone retain their covet- 
ing of cylindrical epithelium. Since then this peculiar cylindrical epl' 
thelium, this germ-epithelium, gives rise out of its own elements to tbe 
primordial ovum, it follows that all tissues whatsoever reckon these 
extraordinary elements as their ancestors; and that, whatever be tb® 
intermediate forms, the transition is neither sudden nor remote ft’o.111 
cylinders of germ epithelium to the corpuscles of the blood, that fluu 
organ of which it is now our province to speak. 
The microscopical study of tbe Blood, however fascinating, is beset 
with difficulties even if we confine ourselves to the human subject, affi1 
1 ErrorHuic sanguinis circulation}, ex dextro cordis ventriculo per pulmones, etc- 
Andreas Csesalpini Qusestionum peripateticorum, lib. v. p. 125. Edition of the Giuutas> 
Venice, 1593. 
2 Lancet, March 14, 1876. 3 Strieker, p. 540, Beitrag, etc. MICROSCOPY OF THE BROOD. 
469 
these are greatly increased if our observations extend to other animals 
'yhich are spoken of as standing lower in the scale. Its state or condi- 
tlon as deprived of life, its constituent parts motionless and tending to 
decomposition, must be regarded, or else it must be studied in the energy 
°f life as it hurries on in the performance of its errand, making its ci» 
Ulk and coming again and again to the primum moventem; as the swf 
of Avon spoke of “ those ruddy drops which visit this sad hea 
y'er is the blood simply alive, it is also the seat of life; it is life itse 
1 Vita est in sanguine, vita est sanguis ipsa.’' Again the blood may be 
microscopically or otherwise, as an organ self-sustaining, replen- 
lshing its substance, providing for its own nutrition and loss by wear; 
as an organ, “ m&re de tousles tissus,”1 offering to every structure the 
pabulum for its needs; as an organ, through or by its anatomical con- 
stituents, brought into intimate association with the great acts of nutri- 
tlQu; and as an organ gathering up the molecules of somatic attrition 
Everywhere and conveying them to an emunctory. The blood also offers 
*°r consideration various accidental, incidental, and temporarily abiding 
Matters, such as therapeutical remedies, introduced by the mouth or by 
Hie hypodermic needle; poisons of every kind; bacteria, on the high 
authority of Billroth and others ; and Filaria sanguinis, as seen by many 
n the blood of dogs, but studied in India, in the human blood, by T. R. 
•Pewis, M.8., and by him associated with that singular condition of 
'vMch chylous urine is a marked feature. 
The elements of which this exceedingly composite fluid is made up, in 
the vertebrata, may be arranged in several categories, one of which 
Vvould include all of the many components, whether tending centripe- 
tally or centrifugally, whether these be a solvent, or be themselves held 
|u suspension or solution, and all regarded and scrutinized in the state 
lu which they absolutely exist in the blood; another would segregate 
the same elements, and present them isolated, each in its own distinct 
and independent physical condition ; and Anally a third would establish 
a distinction between the elements having form and those having no 
definite figure, or being; formless in their actual mode of being in the 
1 • , O / O 
oving, moving, sanguineous stream. 
It is true that the microscope must be the handmaiden of science in 
Each of these fields, limitrophic but yet autonomic, whether the objects 
be originally, primarily, or secondarily encountered in them ; but it is 
;vUh the elements of the third category that the microscope chiefly ex- 
hibits and exerts its magical power, presenting to the eye, “ and to the 
Intelligence by the eye,”2 life-histories of the forms which swarm in its 
dluminated circle, whether the tendencies be intrinsic or extrinsic, nor- 
mal or pathological. The elements which have a form, characteristic 
and determined, and an approximative size, are the red corpuscles and 
the leucocytes, white corpuscles, or white globules; and with these we 
Propose to deal exclusively, regarding them from two points of view, 
(1) that of anatomy and physiology, and (2) that of medical juris- 
prudence. 
It is with the origin and reproduction of the blood-disks, as with the 
of a new being; the most intense interest as well as curiosity is 
Excited, and all possible means of research are called into requisition to 
Push, plus ultra, the limits of knowledge, and to mark with tangible 
UEfiniteness the boundaries of legitimate speculation. And it so happens 
1 Dugks, Physiologie. Art. Sang. 
2 Flourens,-Lemons Orales. [C. J.] 470 
JOHNSTON, 
that an integer of the “ germ-epithelium” becomes or is a primordial 
ovum, and that from certain of its derivatives, even in the vascular sys- 
tem itself, the ruddy corpuscles arise, oscillate, and hesitate with uncer- 
tain aim, until the primum movens gives direction as it acquires power, 
vhereupon they speed away in ceaseless commotion. But the microscope 
ows the forms of the “primordial blood-colored blood corpuscles*”1 and 
agnizes these bodies in all their after career; and yet so differing are 
,vgments that they are asserted by Afanasieff to originate in the fowl 
contemporaneously with the first vessels of the vascular area, or in the 
vascular layer and area opaca, detaching themselves from the walls of 
the vascular spaces, or originating,-according to the views of His, in the 
form of groups, from large masses of protoplasm in the walls of the ves- 
sels, and at a later period bursting into their lumen.2 
'•,# O # - . 
In mammals it is impossible to adduce other expression than Kolb' 
ker’s,3 that at a very early period nucleated colored corpuscles in process 
of fission are visible in the blood of the embryo.4 In proportion, how- 
ever, as the embryo and spleen especially undergo development, these 
forms are less abundant; and, after a certain time, leucocytes first make 
their appearance in the blood of the liver. Or that of Schmidt,5 in a 
papier “on the origin and development of the colored blood corpuscles in 
man,” which is that “ the facts already observed [by him], and being in 
accord with each other, strongly indicate that the primary birth-place of 
the colored blood corpuscles in the human embryo is to be sought in the 
gland-like follicles of the umbilical vesicle.” We can, therefore, say 9 
the same author, “look upon the blood corpuscle as a gland cell” and 
consider that in early embryonic and in later life the organs in which 
the processes of generation and formation of the blood corpuscles in man 
take place, represent nothing else but glands, and that the leucocytes, or 
rather the nuclei of the leucocytes, are metamorphosed into colored cor- 
puscles. 
In January, 1875, the younger Flint,6 in the first volume of his Physi- 
ology, gives a summary of our knowledge, in the present state of which 
the following seem to be the most rational views with regard to the de- 
velopment and nutrition of the blood corpuscles;— 
(1) “At their first appearance in the ovum they are formed by no 
special organs, for no special organs exist at that time, but appear by 
genesis in the sanguineous blastema. 
(2) “When fully formed they are regularly organized anatomical ele- 
ments, subject to the same laws of gradual waste and repair as any of 
the anatomical elements of the tissues. 
(3) “They are generated de novo in the adult, when diminished in 
quantity by hemorrhage or otherwise, and, under these circumstances, 
they are formed in the liquor sanguinis by the same process by which 
they take their, origin in the ovum.” 
From what has been advanced it appears that in all of the foetal life of 
man, regarded as a representative of mammals, four conditions of the 
blood manifest themselves, to wTit: (1) the primordial, colored, flattened 
corpuscles existing alone at a very early period; (2) the appearance of 
leucocytes associated with the preceding; (3) the occurrence of circular, 
1 Remak; Rollett, in Strieker, p, 291. 2 Rollett, p. 291. 
3 Zeitschrift fur Rat. Med., 1867. 4 Rollett. 
5 H. I). Schmidt, M.D., Monthly Microscopical Journal, February 1, 1874. 
6 Flint, Physiology, vol. i., Blood, etc. MICROSCOPY OF THE BLOOD. 
471 
disks mingled with the two other forms; and (4) the with- 
iawal from the blood-mass of the first formed, the temporary embryonal 
mred corpuscles, upon which the blood corpuscles, red and white, adopt 
1 elation which is only to be altered by disease or physical violence, 
, n<* here we are immediately struck with the difference between the 
ansient form as nucleated, and the permanent form as non-nucleated, 
Y?(| We ask ourselves if it can be, as Flint has declared, that the red 
I§ks are probably generated by the same process in the embryo and in 
le adult. If, for a while, we wander from the domain of fact to the 
of fancy, we may find in the works of Leeuwenhoek, that great 
|au largely in advance of his time, a wide generalization deduced from 
serrations made with indifferent lenses, or ill prepared objects. That 
as about the end of the seventeenth century. In the fourth decade of 
le eighteenth century (before 1745, the year of his “calling to a new 
• llc* holy office”), we find that learned visionary, Emanuel Swedenborg, 
a tract “written in Latin before his illumination”1 on the lied Flood, 
that “ the blood contains all organic forms from the primary 
laritual, to the ultimate angular, and in this respect is the compendium 
dllc complex of all the forms of nature.” That “ each blood globule 
,olltains within it, and carries in its bosom, details more numerous than 
,le eye can ever discover, or the mind conceive.” And further he lays 
mvn this postulate, that “ the red globule admits of division into six 
esser and pellucid globules. For six lesser globules have been actually 
®eeu in one ]ai.ge biooci globule, and, indeed, the mode in which they are 
j'uted, and the relative position they occupy to each other, have been 
escribed and drawn, and wax models representing the whole have been 
e°nstructed. Moreover, the several lesser globules have been seen in the 
act of separating from the compound body; and furthermore, experience 
Us shewn that these prior or simpler globules are themselves divisible 
ho still lesser ones, and even into least, when [illogically enough he says] 
Y*ht can follow them no longer.” “All these particulars must be received 
Y true, because the observer, Leeuwenhoek, and the witnesses to his ob- 
• vations, are worthy of credit.” And finally, as far as we care to quote 
author, Chapter Y. opens with the declaration that, besides the lesser 
f'CHucid globules which constitute the large globules of the red blood, there 
1(Lalso in the blood certain angular or saline and earthy parts. 
Father more than a century later, in 1846, Dr. Carpenter2 assures us 
. blood corpuscles “ are to be regarded as nucleated cells, conform- 
Y| 111 general character with the isolated cells which constitute the 
' lc'le of the simplest plants.” And of this there can be, says this emi- 
author, no reasonable doubt. From this we should infer that they 
j!vT do power of reproducing themselves ; and the recent observations 
Dr. Barry and other microscopists seem to confirm the statement 
Ude long ago to that effect by Leeuwenhoek. The first change said to 
ave place is the appearance of delicate radiating lines between the 
Uc eus and the periphery, dividing the disk into several segments, 
six in number. The margin is soon observed to be crenated by 
at corresponding points, and these indentations become 
eeper until a complete separation takes place, setting free six young 
j sor disks which seem to have been formed around the border of the 
lleleus of the parent cell. And therefore should we expect to find, as 
1 Translated by John James Garth Wilkinson. 
2 Principles of Human Physiology, 3d ed., p. 107. 472 
JOHNSTON, 
we do meet with, every size intermediate between the small newly gene- 
rated disk and the full-sized corpuscle. To sum up, therefore, with regard 
to the appearance in question of the red blood disk being constituted 
of six parts (Leeuwenhoek1) in the usual state, or divisible into seven 
parts (Barry, Carpenter, and others), six around the assumed nucleus, p 
may be fairly stated that now-a-days the crenation of the red disk lS 
regarded as the evidence of parting life, or of the earliest post-mortem 
change. 
If we now turn to form, we meet with two varieties of colored corpus- 
cles in vertebrated animals, the elliptical and the circular, the former 
occurring in fishes (with the exception of a few Cyclostomata, which 
have circular disks), all amphibia, and birds, and, among mammals, iff 
the Camel and Auchenia ;2 and the latter characterizing the blood ox 
man and other mammals with the exceptions noted. The red blood disk9 
of all mammals are, according to Rollett, smooth, and give no indication 
of any difference in the index of refraction of their several parts.3 111 
birds, amphibia, and fishes, however, the colored corpuscles do not appear 
homogeneous, but offer a prominence on either side of the long edge 
when viewed in profile, which corresponds to a central area somewhat 
whitish or less deeply tinted when seen on its face. This prominence xs 
absent in Amphiuma.4 It appears, then, continues Rollett, that we may 
divide the blood corpuscles of animals into “two classes, the nucleated 
and the non-nucleated, for the behavior of the central spot is so different 
from the remaining substance of the corpuscle, but shows so great an 
agreement with the structure termed the nucleus in other animal cell 9? 
that we designate this structure as the nucleus of the blood corpjuscle. 
On this point, as we shall see, Rindfleisch offers a conclusive observation* 
And we may add our own experience as with Amphiuma, in the staining 
with magenta and carmine of the large granular nuclei of the colored 
r5 # #Oc!s # 3 
blood corpuscles in even measure with the nuclei of the giant ciliated 
epithelial elements of the mouth. Yet before proceeding further it lS 
necessary to recall attention to the fact that nucleated colored corpuscle9 
characterize the embryonal blood of man and other mammals. 
Gulliver classifies all blood disks of vertebrates as the PyrensematoU9 
and the Apyrensematous, which divisions correspond to the oviparou3 
and non-oviparous groups, the corpuscles of all the latter being circuit 
in form and flattened, with the exception of the Camel’s and Auchenia9’ 
which are oval but still apyrensematous, whereas the colored disks of al* 
oviparous vertebrates are nucleated. But Henle, even in 1843, \vbffe 
claiming the human red blood disks among the nucleated in their early 
condition, utters words which strongly remind us of the modern Beal0 
in reference to formed and germinal matter. Henle5 says, “We haveyet 
to show, with regard to the higher vertebrates, as man, that when tbo 
coloring matter accumulates in the blood corpuscles, and when tboll 
envelope is flattened, their nuclei are dissolved or resorbed, and that con- 
sequently the cellule of the blood, arrived at its perfection, is a simp e 
vesicle containing a fluid.” 
The color, and especially the structure of the disks which we are com 
sidering, have greatly occupied the scientific world from the time wb011 
Malpighi saw “globulos quasi subluteos in quibus non vidi motum rotm 
1 Transactions Philosopliiques, 1674; see Henle, Anat. G6neraie, p. 497. 
2 Roliett, p. 265. 
4 Author. 
3 Rollett, p. 266. 
5 Henle, Anat. Gen£rale; Paris, 1843, p. 491- MICROSCOPY OF THE BLOOD. 
10uis’ until the present time.1 In man they have been declared to be of 
a pale-yellow or a reddish-yellow color, quite in opposition to experience 
sewhere, which is that no mass of either yellow or reddish-yellow could 
e^er so behave with light as to assume the scarlet hue deep and glowing 
the human blood. For this reason we hold the yellow hue in doubt, 
11 y because no observer can ever with unaided eye ascertain the true 
yyor of a single colored disk. The microscope, in enlarging surface, 
(. lrPs its brightness, and also dilutes or attenuates its color, so that while 
t is altogether possible by apparatus below the stage of the microscope 
0 compensate for loss of light by the higher powers, no art can restore 
color to a disk, probably crimson, when its image is amplified ten, a 
hundred, or a thousand times in diameter. How what holds good for 
obtains in all probability with the lower orders.2 In evi- 
faice of this statement it will be remembered that the eosenic red of a 
®Jogle corpuscle intensifies if a number of corpuscles lie superposed in 
field. In the lower animals the color of the blood, or, what is the 
sanie, of the colored corpuscles, varies to some extent, and were our ap- 
preciation of the cachet of the tints of crimson sufficiently discriminating, 
,Le might by recognizing them also identify, probably in this way alone 
J dimensions failed to aid, the several possessors of the-colored disks, as 
asserts that the bloods of many creatures have been distinguished 
’°m one another by their characteristic aura. 
Leaving color we encounter structure, and here most probably begin 
lle real difficulties of our task. The corpuscles of the blood of mam- 
bialia, by reason of their size, do not afford facilities for the solution of 
he first problem as to whether the disks have a limiting capsule. But 
me larger blood cells of amphibians would seem to otter themselves as 
easy solvents of the question, especially the frog’s ovate bodies and the 
Slant colored and largely nucleated corpuscles of Araphiuma tridactylum. 
b however, microscopists are not in accord upon several 
points, nor is disagreement confined to them alone. We have 
mready noticed the composite structure attributed to the “red globules” 
w-s they were called by Leeuwenhoek), referred to by Swedenborg, and 
Reproduced by Drs. Barry and Carpenter. But for more than a century, 
r°m the time of Malpighi himself, who saw the circulation of the blood 
anfi its corpuscles, the idea of an investing membrane and its contents 
RVas debated in science, having been suggested most probably by Robert 
mooke’s description of the cellular structure of plants in 1667. Indeed 
}Te find it implied by writers of a later period, as Mandl in 1839,3 or dis- 
Pictly expressed, as by Bound,4 who, in 1844, speaks of the blood disks 
as being “flattened vesicles containing a more or less fluid substance.” 
Hfid be speaks of the substance of which the vesicle is composed as being 
0l an albuminous nature. 
Kolliker5 entertained the same view, for in 1854 he says “that the 
jood corpuscle is constituted of a very delicate but nevertheless tolera- 
Jfy firm, and at the same time elastic, colorless cell membrane.” “ The 
c°rpuscle is consequently a vesicle, whence the name blood-cell is to be 
Preferred.” More recently Gulliver, in the Proceedings of the Zoologi- 
°af Society, February 25, 1862, speaks of “ the embryonic corpuscles as 
1 Malpighi, Opera Postlmma, p. 92. 
2 Quarterly Journal of Microscopical Science, 1855. [C. J.j 
3 Mandl, Traits pratique du Microscope ; Paris, 1839, p. 113. 
4 Al. Donn6, Oonrs de Microscopie; Paris, 1844, p. 66. 
5 Manual of Microscopical Anatomy; Philadelphia, 1854, p. 704. 474 
JOHNSTON, 
constituting a first or temporary set.” “These cells,” continues the dis- 
tinguished author, “both in structure and size are the true analogues ox 
the red corpuscles of oviparous vertebrates.” And again “ the corpus- 
cles of the second set are those which replace the first, and, subject to 
waste and supply, are the red corpuscles of the blood during the greater 
part of utero-gestation and until death. The corpuscle is not homo- 
geneous, but is composed of a colorless membranous part or basis, sepa- 
rable by water, with a fluid viscid matter in which color resides.” 
We cannot here enumerate the great authorities who have entertained 
or who still entertain the view above quoted ; it suffices for us to present 
it as one which still finds favor with many. The contrary opinion, more 
bold in its enunciation, because at variance with accepted laws, finds its 
able exponent in Beale, among others. He says in “ How to Work with 
the Microscope,” p. 134, that “ by drawing a needle across the thin glass 
under which the red corpuscles are placed, they may be divided into many 
small globules. This proves that the red blood corpuscles consist of o 
mass of soft viscid matter, the outer part of which is somewhat hard- 
ened.” Or again, several red corpuscles may, under certain circum- 
stances, coalesce, and even crystallize without exhibiting indications of 
any cell wall whatever. Besides the subdivision into small spheres oi’ 
spheroids, the same author1 adduces other reasons, as that the mass of the 
germinal matter in the case of the nucleated blood corpuscle of the frog 
and other vertebrates, or a portion of it, may pass right through the red 
viscid material of which the outer part of the corpuscle is composed, 
without the rupture of any membrane. How Bollett2 declares that, 
“after the cautious addition of water,” it frequently happens in the 
nucleated ellipsoids that the nucleus changes its position in the cor- 
puscle with a jerk, and then lies eccentrically in the corpuscle. Finally 
Beale remarks, “ when water is added to blood corpuscles they swell up 
just as a piece of jelly would swell up, but they do not burst as is gene- 
rally stated.” 
Whichever way we incline, we have fair grounds for our belief, as 
also excellent authorities and companionship; but we are disposed t° 
favor the modern view, as being more consistent with observations upon 
fresh blood and blood dried on slides, and as being entirely in accord 
with what we know elsewhere of protoplasm, especially in the pyren#' 
matous colored corpuscles. 
Of the leucocytes, what shall we say ? What are they ? Whence 
come they? Whither go? And do they appear pathologically under 
the form of pus? Whatever interest may attach to the red disks, the 
white equally claim our attention; for, in the language of Rindfleiscb, 
“ the red blood corpuscles would form one pole, the amoeboid colorless 
cells the other, and, between the two, formation and deformation go con- 
tinually to and fro.” 
The colorless morphological constituents of the blood, according h? 
Max Schultze, are of several kinds;4 “ first, round cells, less than the red 
blood corpuscles, composed of a thin layer of cell substance investing oue 
or two nuclei. With these may be associated other forms, equalling 111 
size the ordinary red blood corpuscles, and like the former possessing 
1 The Microscope in Practical Medicine, 1867, p. 170. 
2 Loc. cit., p. 277. „ 
3 Experiment. Stud. u. d. Histol. d. Blutes, v. Dr. Edward Eindfleiseh; Leipzig, 186 , 
p. 41. 
4 Bollett, p. 288. MICROSCOPY OF THE BLOOD. 
475 
bpclei. Lastly, finely and coarsely granulated amoeboid cells are met 
and various intermediate forms between them.” “In freshly drawn 
ylood,” continues Rollett, “ these last appear as more or less rounded or 
irregularly shaped forms. At a temperature of from 95° to 104° F., 
mely movements resembling the creeping motions of an amoeba occur.” 
ouch cells,” says Frey,1 “ have been seen to pass out (after the manner 
P au amoeba) through the walls of the capillaries (A. Waller, Cohnhein 
land Col J. J. Woodward, M.D., in his beautiful photograph of inflam- 
mation of the mare’s stomach]), towards or through the lining tissue, and 
0 take up into their contractile cell-like bodies small particles, such as 
m°lecules of indigo, aniline, cinnabar, and carmine, the finest milk glo- 
bales, and even extravasated colored blood corpuscles.” 
Ihese inclusions of red corpuscles by amoeboid leucocytes are not to 
e confounded with “the so-called cells containing blood corpuscles,” 
mentioned by Rindfleisch,2 who declares that “ the opinion only appears 
f) nie admissible here that a secondary separation of fibrin has formed 
acout a group of blood corpuscles.” And Preyer3 saw portions of the 
e* . blood corpuscles of extravasated blood in amphibia, taken up by 
bfiite blood corpuscles, and thus explained the nature and mode of occur- 
Jence of the bodies that had been previously called blood corpuscle- 
-ling cells. But themselves or their analogues are to be found, ac- 
ting to M. Cornil,4 in the blood of the spleens of patients who have 
J-d in the third week of typhoid fever, in the form of white globules in 
arge numbers, inclosing red globules to the number of five, six, or even 
TV* r\ • ' O O 1 ' 
. 10l>e m a single cell. Although, continues the reporter, the existence 
|ll Bie blood of these large cells containing red globules is nothing new, 
levei’theless Cornil is the first to insist upon their multiplication in 
typhoid fever. 
Besides the remarkable properties of the white corpuscles above men- 
others equally surprising are most readily brought to the notice 
J. Bie observer. The migration of these bodies in a drop of the blood of 
ie newt or frog, placed in a moist cell, beyond the limits of a coagulurn 
0 the circurnvallating zone of serum, has been shown by Rollett5 to 
*CUIb and he points out the advantage of this method of isolating the 
cells,J and suggests that “ the migration of the individual cells 
llclers it clear that the individual movement is the chief if not the ex- 
■j tylv.e cause of their emigration.” In confirmation of the alleged amce- 
°l<a inclusive movements of the white corpuscles, the famous experi- 
erß pf Cohnheim was done in the manner to be indicated; “ A small 
P anßty of finely granulated coloring matter, suspended in water, is to 
ty I'dected by a Pravaz’s syringe on several consecutive days into one of 
: .e ‘ai'ge lymph spaces which lie under the skin of the frog. On exarn- 
rillng a drop of blood, a considerable number of the colorless cells will 
°ty be seen to be stuffed with the granules.”6 
de °ur chief matters of interest in connection with the white corpuscles 
®ci've at least passing notice in this place; 
d voq Bheir origin, which elicited from Rollett7 the following summary; 
hether the colorless corpuscles always undergo multiplication within 
2 h? Microscope, etc., Dr. Heinrich Frey; New York, 1872, p. 102. 
s -n lext-book of Pathological Histology; Philadelphia, 1872, p. 65. 
4 Pollett, p. 290. 
Monthly Microscopical Journal. May, 1876, p. 233. 
J Bollett, loc. cit. ‘ 
ley, Ihe Microscope; New York, 1872, p. 231. 7 Rollett, loc. cit., p. 292. 476 
JOHNSTON, 
the blood itself, and by what mode of cell genesis they multiply, are still 
open questions. It is certain,” says that author, “ that a large number 
of white corpuscles are added to the blood, not only during the period of 
development and growth of the animal organism, but also throughout 
life by the agency of the lymph current, the corpuscles of this current 
originating in localized germ-producing organs situated external to the 
blood (lymphatic glands).” Our own observation of the blood of a young 
seventeen inch long Amphiuma tridactylum, goes to show that the leu- 
cocytes had greatly multiplied in number after the head had become 
much inflamed in consequence of repeated attempts of a larger AmplE' 
uma to swallow that which was the subject of experiment. Again, the 
pathological process of leukaemia,1 so called, seems to be associated with 
an increase in volume of the spleen, and often at the same time of the 
lymphatic glands, although but seldom caused by the enlargement of the 
latter organs alone. 
(2) Their transformation into red or colored corpuscles, for which 111 
the frog we have the authority of Recklinghausen, Sclarevvsky, and 
Golubew, but which if it do occur in the human subject, happens very 
slowly in convalescent leucocytheemic patients. The intermediate form9 
met with in the blood of the frog were known, but not correctly referred, 
by the earlier observers, as Wharton Jones and Hensen.2 Besides 
have also the authority of Bizzozero and Neumann3 for the statement 
that the transformation of the lymphoid cells may be seen in the red 
bone-marrow of mammalian animals ; and this bone-marrow itself, lS’ 
according to some authors, as Frey, one source of origin of the colories9 
cells of the blood. 
(3) Their relative proportion to the red corpuscles cannot be regarded 
as fixed, for the averages of the best observers, as Welcker and Mol0' 
schott, differ sensibly. Thus, Welcker states his average as one whit0 
corpuscle to three hundred and thirty-five (335) red, while Moleschoß 
finds one in three hundred and fifty-seven (357). The proportion als° 
varies with age, their number being greater in the young than in adult9? 
and, according to Hirt, they increase during full digestion, but diminish ill 
fasting. And lastly, Hirt4 “ found the number of white corpuscles seenl' 
ing greatly to differ in various parts of the vascular system; thus in the 
splenic vein they are as one to sixty (60) red ; in the splenic artery as on0 
to two thousand two hundred and sixty (2260); in the hepatic vein ono 
to one hundred and seventy (170); and in the portal vein as one to seven 
hundred and forty (740). 
(4) The migration of the lymphoid cells into the space of the conne0' 
five tissue, and their relation to the pus cells. In this connection t^6 
great name of Cohnheim immediately rises before us. His observation9* 
confirming the older views of A. Waller, possess, says Frey, “an extrf1' 
ordinary range, and have rapidly called forth an entire literature.” 
connection, however, with this subject, interest may be awakened by 
reference to the conviction of Mandl, expressed in that “ wesdeinom 
strafe the perfect identity of globules of pus and of the fibrinous global0® 
of the blood ... as we understand it.” Ilenle6 soon after declare1 
that he had “ shown that the nuclei of the lymph corpuscles go throng 1 
the same metamorphoses as those of pus ; they differ by their volmlIC 
1 Frey, op. cit., p. 232. 
3 Frey, op. cit., p. 307. 
5 Mandl, op. cit., p. 120. 
2 Eollett, loc. cit., p. 291. 
4 Hirt, apud Eollett, p. 290. 
6 Henle, op. cit., p. 509. MICROSCOPY OF THE BLOOD. 
477 
And in a note added by Prof, Strieker to the American edition 
i . 1118 Histology, 1872, page 47, that eminent scientist assures us that 
118 “ later investigations have shown that the process of division of 
Us. ceHs can be directly observed under the microscope.” Put most 
are the general conclusions arrived at by Mandl in his Memoir, 
pHd before the Societe Medicale d’firaulation, June 3, and found in the 
mzette Medicale de Paris, July, 1840. They are as follows:1 “I. The 
13 nno us globules of the blood, the globules of mucus, and those of pus, 
identical. 2. All the globules are the product of the coagulation of 
*e fibrin in the serum, which has transuded through the walls of the 
mood vessels. 8. The liquid in which the globules swim constitutes the 
'Terence between pus and mucus. 4. If the fibrinous globules remain 
, Xed to the surface of the membrane where they are secreted, they 
ecorne the nuclei of epidermoid cells, which constitute the elements of 
le epidermis. 5, If, on the contrary, the fibrinous globules remain free 
the surface of the membrane, they are expelled by the organism, and 
errn an element of pus and mucus. 6. These two elements are simply 
bered blood; that is to say, they contain the elements of the blood, 
exfept the globules, the serum at the same time undergoing chemical alter- 
ation.” ° ° 
p opposition, in Virchow’s Archiv, Bd. ixii. S. 47 (1876), we find that 
i'° lessor J. Arnold discovers “the white corpuscles themselves in the act 
1 escaping in an inflamed tissue, through the cement substance, that is 
le stigrnaia, and that gelatine and vermilion also pass through the cell 
at the position of the stigmata and cement substance.”2 Plow well 
xjyndl saw, but failed to interpret, may be understood by a comparison 
j flis conclusions, in 1840, with the beautiful researches of Waller, Cohn- 
Jeirn, Wood ward, and J. Arnold, in later years. 
As soon as the corpuscles of the blood were an assured acquisition to 
Science, they very naturally attracted and received great attention for 
lemselves as wonderful objects on account of the roles which they were 
SuPP°sed to play in physiology, and because of the very great importance 
pnch their possibly positive recognition in the several classes or genera 
r,,. aijinials would necessarily assume in medico-legal investigations, 
j 16 interest in these elements has continued unabated until the present 
°Ull mid all the resources of art have been put in requisition to insure 
l,°t only their detection under all and difficult circumstances, but also to 
make certain their specific identification. RIo this end many devices 
tlVe been put in practice, such as bettering the modes of presenting the 
?urpuscle in every state for investigation; the use of high powers, and 
improvement in the quality of the objectives employed in their study; 
1e 1 v exact mensuration, relative and positive ; their enumeration ; the 
establishment of the normal proportion existing between the colored 
lpuscles a?id the leucocytes ; and, finally, an appeal to the spectroscope, 
' ncli might discover in the minutest trace of cruorin the ghost of even 
''A^eparted red disk which had yielded up its form. 
A ith regard to the first of these efforts, the best condition under which 
little bodies may be thoroughly investigated, we have nothing to 
*n,behalf of the various preservative fluids which have had fortune 
j, 1 miicroscopists, being satisfied that, as far as our own experience ex- 
(-mds, the question is not as to how excellent a substitute may be pro- 
Wcroscopieal Journal, 1841, p. 80. 2 Monthly Microscopical Journal, June, 1876, 478 
JOHNSTON", 
video! for the liquor sanguinis, but rather how greatly superior is the 
liquor sanguinis itself. Of course, this view involves the necessity for a 
limited range of observation by each of the scattered students of compara- 
tive haematology, for it is not given to each and several of these to push 
inquiry with all the special bloods in their living or immediately recent 
state. Amphiuma, proteus, and the musk deer, are not only strictly 
local, but are very widely separated geographically; the standard bloods, 
however, are almost everywhere accessible, for the frog, the horse, the 
cat, and the dog, fishes and newts, are almost passim; and thanks to 
itinerant menageries and fixed zoological collections, many strange ani- 
mals are assembled in unfamiliar districts. Besides, we can have, or 
ought to have, human blood at our own finger ends. 
For use as artificial standards, the corpuscles, mounted dry on the 
under surface of the thinnest cover, are decidedly of the greatest service, 
for as all mammiferous red disks, and perhaps a few of the other smaller 
forms, confessedly shrink but little, and as in medico-legal investigations 
the expert has usually to deal with dried hemorrhagic stains or clots, 
like is directly compared with like, as could also easily be done if excep- 
tionally immediate blood were obtainable as food for the microscope or 
spectroscope. But let it be well understood that we greatly prefer the 
recent, the living blood, if possible, on every account. Form is unal- 
tered ; all physical qualities are unchanged; characteristic behavior 
at the normal temperature, and in presence of such reagents as magenta, 
acetic acid, water, or an alkali, is conspicuous; and heat, or life, or light, 
or other modes of motion, start up in microcosmic play. 
With regard to the methods of perfecting objectives, we propose to be 
silent, leaving the problems which these create to our own Tolies and 
Spencer, to Powell and Lealand, and the Becks, to Wales and Boss, to 
Zeiss and Seibert, to Scheik and Plossel, and last, but not least,to Wood- 
ward, and Wenhara, and Keith. But we accept the superb work of the 
great artist-scientists of the day, and we rejoice in the splendor of then’ 
instruments. 
More germane to our subject is an expression of opinion as to the 
degree of amplification requisite for exhaustive and conclusive study oi 
the blood; and at once the microscopist is struck with the necessity l°r 
the employment of high powers for all research excepting only what 
might be called a general view of the field. For enumeration of the 
corpuscles, a medium power suffices; for acquiring a collective idea o* 
blood, either in the vessels, or freshly drawn, placed on a slide, and sub- 
jected to changes of temperature and the action of reagents, moderate 
amplification offers the best hope; but for higher views, higher objectives 
must be put to use, and an immersionl T'g, -d(J, or even ys- inch objec- 
tive, of the best maker, and of large angle, in the hands of a really good 
manipulator, will afford a demonstration of all that is at present attaina- 
ble. If size alone be in question, it is unscientific to hope to distinguish, 
under low powers, human red corpuscles with an average diameter °t 
g.Jg-jjOf an inch from those of the dog with an average measurement 
of of an inch;2 and it is worse than unscientific to obtain large 
images by forcing low objectives with short eye-pieces. We hold, there- 
fore, that, with the results of mensuration of the blood-corpuscles, all the 
conditions attending the measurements must be given, if their authors 
1 Woodward. 
2 Prof. Theo. G. Wormley, letter to author, May IG, 1876; New Measurements. MICROSCOPY OF THE BLOOD. 
479 
TXKPeCt t0 win and maintain the confidence of the world of science. 
nus Prof. Theo. Gr. Wormley regards the condition of his material as 
‘ tached to the under side of a thin cover; the thickness of that cover; 
le temperature of the slide, by averaging measurements made at ail 
easons of the year; the position of the collar of adjustment of the ob- 
J ctive; and the identical disposition of the light in all observations; 
<lnd he employs a p.j inch objective. Besides, he has repeatedly tested 
e burned value of each of the divisions of his micrometer, and confined 
to the employment of that or those only of which he has assured 
1 itself as being absolutely true to the standard. 
Before proceeding further with mammalian blood, let us not lose sight 
xvhat is most probably quite as important as size, namely, the cachet, 
~r stamp of individuality possessed by each of the kinds of blood disks, 
determination °f which is or will be a matter of necessity in micro- 
CoPj simple or applied. In support of this view, we would ask a serious 
of two similar bloods on the same slide, of a feline, and 
an herbivore. Difference in diameter under a tenth objective may 
P c oe a striking feature of the contrast, but a sentiment of something 
ey°nd, for which we may not as yet account to ourselves, immediately 
ut stealthily takes possession of our senses. 
, B was with the intention of arraying in the opposition of contrast 
vlllll an blood and the dog’s, and human blood and the cat’s, that that well- 
ftown scientist, Dr. Joseph Gr. Richardson, flowed drops of blood from dif- 
erent animals so nearly in contact on a glass slide, that portions of the two 
P'°ps appeared in the same field, and could be photographed together.1 
jl; C. Leo Mees, assistant to Prof. Wormley, in Columbus, Ohio, modified 
118 plan, spreading the bloods by the present writer’s method, a half field 
,P°u a slide, and another half field upon a cover, which is then turned 
. °Wn and placed directly upon the slide. The method consists in catch- 
es a small drop of blood with the true edge of a well-ground slide, and 
drawing it, that slide being inclined, over the face of another 
Kle or cover. Dr. Mees obtains half fields by scraping. “In this 
fanner,” says Prof. Wormley, “ we obtain the bloods virtually upon the 
<ltße plane for powers under the i inch.” But after inspection, we fear 
f°r the assumption “virtually upon the same plane,” even for a 
g iye angle, inch ; nor are we prepared to admit the availability of 
Cll slides for Prof. Wormley’s very fine inch objective. And besides 
re arp persuaded that the cachets of the two bloods, if they ever can be 
0 e°gnized as distinctive, will hardly bear comparison when the disks of 
ane, present their attached and flat surfaces towards the observer, 
* *l(j. Ie °fher disks their free, and, in the instance of circular mara- 
.lari disks, their excessively concave sides. 
dc^S measiu'ement °f the blood-corpuscles, colored and pallid, is nowa- 
j c Berutinized by the keen eyes of microscopical science and ot the 
e We propose to offer in this paper some of the best modern and most 
terul observations. But as a preparation for accepting the results of so 
Uch. patience and labor, and great skill, we beg to present a list of 
of the human blood in Hodgkin’s and Lister’s Micro- 
p aI Observations, contained in the Philosophical Magazine, vol, xi. 
■* ' Oas given in the Microscopical Journal for 1841. It is as follows; 
1 American Naturalist, May, 1876. 480 
JOHNSTON, 
H odgkin 
• Was of an inch. 
Jurine . 
1 u 
• £24?) 
Jurine . 
. -r“ (Second measurement. 
Bauer . 
i 
• 17 (TO 
Wollaston 
1 u 
• 3 (5 (J o 
Young . 
• BoVs 
Kater . 
1 u 
* 40(55 
Ditte 
• boW 
Prevost and Dumas 
* 4 oV B 
Nasse1 . 
I “■ 
• 3105 
A difference so remarkable as that between the T7Vo and the o' °h 
an inch, inspires little confidence in the means and the method, and such 
series of observations must be now regarded as curiosities of microscopy* 
Passing over the great hiatus separating the year 1840 from thettieme 
in which we live, we would deal directly with four papers relating 
comparative measurements of the colored blood disks of vertebrates, tw° 
of which are from the pen of Joseph G. Richardson, M.D., of Philadel- 
phia, one by Col. J. J. Woodward, M.D., U. S. A., and the last and most 
recent, by Prof. George Gulliver, F.R.S. In the first of these2 “On the 
value of high powers in the Diagnosis of Blood Stains,” an article of much 
merit, the author “ endeavored to work out a conclusive answer to the 
question,” “whether practically we can or cannot discriminate the stale9 
of human blood from those made by the blood of oxen and sheep.” “ I’} 
conclusion,” he says, “I submit that the results of my experiments above 
narrated, prove that since the red blood-globules of the pig of a’l 
inch), the ox the red deer the cat (?the horse 
(WoVO? hhe sheep (53V0;/), and the goat are all so much smaller* 
than even the ordinary medium size of the human red disk, as measured 
in my investigations, we are now able, by the aid of high powers of tbe 
microscope and under favorable circumstances, to positively distinguish 
stains produced by human blood from those caused by the blood of aW 
of the animals just enumerated ; and this after the lapse of five years 
from the date of their primary production.” “We may add to these* 
the average measurements, those of recent blood disks procured from 
blood spot moistened with a one per cent, solution of common salt, a»d 
stained with a drop of [red ?] aniline solution. Thus the mean of ten cm’' 
puscles so treated was expressed by the fraction gAs °f an inch, the inilll' 
mum being of an inch, and the maximum of an inch.”3 ot' 
withstanding the expression of belief4 that the red corpuscles “rarely 
contract,” the author gives the maximum gmT of an inch, minimum 
Woo °f an inch, and mean 3A55 °f twenty recent red corpuscles of a 
white male aged thirty. But again, and on the opposite side, “g? 
measurement of twenty corpuscles from part of the same specimen drie( 
in a thin film upon a slide gave a maximum of 38Vo-, a minimum of gg'D’ 
and a mean diameter of -gTgj of an inch.”5 And in the Oswego Grec11 
field trial, in June, 1876, Dr. Richardson' testified that “ drying dim111' 
ishes all kinds of corpuscles.” 
The second paper, by Col. J. J. Woodward, M.D., U. S. A., almost e*' 
haustive in reference, and most ably presenting the author’s research am 
observations, appeared in the Monthly Microscopic Journal of 
1875, five months after the valuable article just noted, and was suggest°l 
by it as the first line distinctly assures us. The title is as follows: “m 1 
1 Valentin’s Repertorium, 1840. 
2 Monthly Microscopical Journal, September 1, 1874. 
3 Loc. cit, p. 140. 4 Loc. cit., p. 137. 5 Loc. cit, p. 135. MICROSCOPY OF THE BLOOD. 
481 
\e similarity between the red blood corpuscles of man and those of cer- 
am other mammals, especially the dog, considered in connection with 
m diagnosis of blood stains in criminal cases.” The general tenor of 
,lls paper is a dissent from the conclusions reached by Dr. Richardson, 
the most striking points of stress of Col. Woodward, is the state- 
ment: “ For myself, after repeated measurements of the blood of the dog 
mid of human blood, I can only say that I find no constant difference 
etween them, whether the fresh blood or thin layers dried on glass be 
■ emeted for measurement. The mean of fifty corpuscles, taken at hazard, 
seldom twice the same, and sometimes that of human blood and some- 
-111168 that of the dog’s blood is a trifle the larger.” In the same con- 
llection, a little further on, the author gives two tabulated records of 
measurements of red blood corpuscles, which very remarkably substan- 
mte the afore-mentioned doctrine, the one being measurements of red 
l°rPuseles of human blood and the other of the same elements of the dog. 
11 both cases the blood was obtained from five individuals ; fifty cor- 
puscles formed the basis of each observation; of the thirteen specimens 
human blood measured, four were moist; of the nine of dog’s blood, 
were moist, and, singularly enough, “ in each of the measurements” 
m the two bloods “ the great majority of the corpuscles ranged from 12 
0 17 divisions of the eye-piece micrometer: that is, from .00024 to .00034 
'-01'4 Ag to of an inch.” 
~ljeforequitting this important field, Col. Woodward reminds the reader 
oat “the variations between the mean diameters assigned to human 
mod by different observers are quite as great as the variations recorded 
y any of them between the blood of man and of the dog, or even greater.” 
there is admitted to be “ no constant difference” between the 
IVet and the dry corpuscles, when fresh and used moist, or quickly dried 
1)11 thin glass, it is denied that a differential diagnosis can be possible in 
le cuse of “ blood dried en masse, when sprinkled on weapons, clothing, 
y.°o(i, etc., for no one will pretend that it can be any easier to make the 
’ugnosis of such stains than it is in the case of moist blood or of thin 
ms dried on glass.” 
Id the same Journal, for May, 1875, Dr. Richardson replies to the 
So*' Col. Woodward, but states explicitly his “ full corroboration” 
Col. Woodward’s assertions, and declares that “ there is at present (1875) 
known to science for discriminating, microscopically or other- 
wUv c^ Cloocl of a human being from that of a dog, monkey, 
abbit, musk-rat, elephant, lion, whale, seal, or in fact any animal whose 
measure more than 40V0- of an inch in diameter.” With this 
/ mission we would fain conclude our notice of the article, but fairness 
6mands that the criticism of Col. Woodward, which we have reproduced, 
1 ,°uld be followed with an explanatory statement from Dr. Richardson, 
JlO Sajs: “ I wish to insist most emphatically that all my statements 
11 Regard to the diagnosis of blood stains are applicable to stains only, 
t^notto masses of dried blood clot.” And we here would call attention 
0 the fact that in the case of State v. Lodicia and Albert Friedenburg, 
-T1 the murder of Orlo Davis, tried in Utica, in November, 1875, Dr. 
a l ur(^SOn testified1 that he had examined certain spots on an axe helve 
or ,Uhad come to the conclusion that the corpuscles, or red blood disks, 
p §l°bules, were those belonging to human blood.” And again in the 
menfield trial, held in Oswego, in June, 1876, Dr. Richardson, after 
1 Utica Morning Herald, Friday, November 19, 1875. 482 
JOHNSTON, 
examining dark spots on some chips belonging to the rail of a bedstead, 
testified as follows: “If the question is narrowed down to whether th|s 
is human blood or sheep’s blood, I can say positively that this is man s 
blood. Because the corpuscles are such as could never circulate in the 
veins of a sheep.”1 
In opposition to such testimony and teaching, we find in Dalton s 
Treatise on Human Physiology, sixth edition, 1875, an expression of 
views which will meet with favor with the majority of advanced obser- 
vers and thinkers. He says; “If a blood stain which in a watery solu- 
tion gives the common spectrum of hsemoglobuline, be found to contain 
oval nucleated globules, this would show it to be the blood of a bird, 
reptile, or fish ; and the oval form alone would show that it was not 
human blood. The question, therefore, whether a particular specimen 
be composed of human blood may often be decided with certainty in the 
negative by microscopic examination. But if the specimen contain cir- 
cular globules without nuclei, it will be impossible to say positively ifl 
any instance that they belong to human blood, and not to that of some 
animal, such as the ape or dog, whose red globules nearly approach the 
human in size. In most of the domesticated quadrupeds the globules are 
smaller than in human blood, but in both the sloth and the elephant they 
are larger. If it were only required to decide whether a given specimen 
of fresh blood belonged to man or to the musk deer, for example, or even 
the goat, no doubt the difference in size of the globules would be suffi- 
cient to determine the question. But within nearer limits of resemblance 
it would be doubtful, because the size of the red globules varies to some 
extent in each kind of blood; and, in order to be certain that a particu- 
lar specimen were human blood, it would be necessary to show that the 
smallest of its globules were larger than the largest of those belonging 
to the animal in question, or vice versa. The limits of this variation have 
been tolerably well defined for human blood, but not sufficiently f°r 
many of the lower animals to make an absolute distinction possible. 111 
the examination of stains or blood spots the difficulty is increased by the 
fact that the drying and subsequent moistening of the globules intro- 
duces another element of uncertainty as to their original size.” 
The last paper we propose to notice, and the most remarkable of its 
kind which science possesses, is entitled Observations on the Sizes and 
Shapes of the Red Corpuscles of the Blood of Vertebrates, with draw- 
ings of them to a uniform scale, and an extended and revised tabic 
of measurements, by George Gulliver, P.R.S.; and appeared in the 
Proceedings of the Zoological Society of London, for June 15, 187 m 
The “present purpose” of this extremely sagacious and very laborious 
production “ is to give simply the averages, with brief explanatory com- 
ments, of numberless measurements all made by me,” sa}'s Prof. Gul- 
liver, “in the hope that they may be useful towards further researches ot 
the same kind.” “The measurements now recorded show the labors of 
many years,” and consist of “ many additions and revisions by new ob- 
servations made since publication, upwards of a quarter of a century 
ago,” of Prof. Gulliver’s tables of measurements, which originally 
peared in the Proceedings of the Zoological Society, in 1845. 
Simple as is the announcement, the variety and originality of the obser- 
vations, inferences, comparisons, and deductions would be very surprising 
were it not for a knowledge of the author, and of the fact that they are the 
1 Oswego Daily Times, Saturday evening, June 10, 1876. MICROSCOPY OF THE BLOOD. 
483 
eveloped germs of more than, thirty years of toil. It is foreign to our 
purpose to follow this observer in all the paths that he has trod, but we 
u°ntine ourselves to the matter of measurements, and in this circle alone 
Ve fiud abundant food for careful thought. Although the table of 
Averages “ has been deduced from innumerable and generally correct ob- 
e|'Vations,” the red corpuscles are found usually to differ among them- 
Uves in every field of vision, commonly to the extent of one-third larger 
P.1 smaller than the mean. And when we reflect upon “the real varia- 
°ns in size produced in the bird alternating between rest and excite- 
ent; the probable diversities in some vertebrates at different times and 
asons; the possible ones influenced by climate, rest, and violent exer- 
periodical rise of temperature—as in python, sex, the system— 
nether arterial or venous, the ever-varying state of the liquor san- 
mis,1 pathological or septic changes,” it need not surprise us that the 
thor advances the proposition “or fact that in a single healthy species 
e corpuscles are so prone to minute variations of size that no two ob- 
rvers, nor even one observer, can be certain of obtaining precisely the 
ame average measurements.” Nevertheless “ the relative value of the 
masurements, though probably not unexceptionable, may be entitled to 
m'e confidence as fair approximations to the truth.” 
it L 6 aPpbcations °f what has preceded are extremely numerous, and if 
bad been possible to extend the scope of this paper their number 
'°uld have been measurably increased. But we will here refer to but 
1 °> as perhaps the chief among them, the physiological and the medico- 
Xn the former connection we encounter bodies doubtless of the 
. significance and function, but which differ strikingly in size, cachet, 
1(1 form, and what is more remarkable the almost perfect correspond- 
lee established between a majority of2 mammalian vertebrate and 
Pyrensematous red blood corpuscles, having a discoid biconcave form, 
pj between oviparous vertebrate and oval pyrenseraatous blood disks. 
ut while the oval blood disks of the exceptional camel conform in small- 
of size to the circular corpuscles of other mammalia, they are non- 
j. ormable to the oval pyrensematous type of oviparous vertebrates. 
I general, with regard to size in apyrensemata, we are called upon to 
‘ as “a rule that the largest corpuscles occur in the large species, 
X (...the smallest corpuscles in the small species of a single order or 
bl. rai,y-. It extends to the whole class of birds, but neither to reptiles, 
la(;hians, nor fishes, except in some partial instances which seem to 
father indeterminate or accidental than regular.” 
o form and size, we naturally encounter number, which conspicu- 
-jp. sv has importance in relation to physiological or pathological action. 
Schmidt3 we assume the blood mass in a human subject to weigh 
e lj llogrammes (26 pounds 9 ounces, troy), then the sum of the blood 
• 8 would amount to 56 billions 570,000 millions. But this vast figure 
f()'eS us 110 advantageous information, and its consequence fades out be- 
t).ler^Je more practical efforts of Yierordt (1852) and Welcker (1858), 
OpG. ormer of whom counted all the red disks in a known cubic measure 
re, by successive instalments poured and dried upon a slide, and 
a ,Ucing bis calculation to one millimetre, obtained at first 5,171,400, 
Co,_ a iater period 5,055,000. Welcker, both by counting the red 
lpuscles in blood diluted with albumen, with the aid of a crossbar 
' Also Kolliker, op. cit., p. 605. 
Kolliker, op. cit., p. 569. 
2 Gulliver, loc. cit., p. 482. 484 
JOHNSTON, 
ocular micrometer, and by comparing diluted blood with an established 
color scale, fixed his estimate at 4,600,000 corpuscles in a cubic milb' 
metre for a healthful person, 3,800,000 in an hysterical person, and 
2,400,000 in a patient far advanced in consumption.1 
We next refer to the advance made by Potain2 in estimating the num- 
ber of red corpuscles contained in a cubic millimetre, by counting a small 
portion of diluted blood, and to the labors of Melassez3 in blood count- 
ing. The hasrnatimbtre of Hayem and Hachet, recently described by 
Melassez,4 in the hands of Drs. E. L Keyes and L. A. Stimson, gave J3 
an average of 83 counts the number of red corpuscles in one cubic milll' 
metre as 4,990,550, a table derived from exceptionally good sources* 
“The above estimate,” says Dr. Keyes, “of nearly 5,000,000 blood cor- 
puscles for the cubic millimetre, I believe to be a high average tor 
Americans in the neighborhood of Hew York, during the summer and 
autumn.” 
“ To compare the above results with those obtained by other investi- 
gators, we find that Hayem5 places the mean at about 5,000,000 more or 
less, for the blood of the finger of the healthy adult male ; Vierordt 
established as a mean for his own blood something over 5,000,000 * 
Welcker7 estimated it at 4,600,000; Cramer at 4,726,000. Melassez 
gives the lowest average, placing the number at something less than 
4.500.000, but he is not very definite upon the subject of healthy average* 
being more interested in bis writings in a description of the instrument 
and in considerations of diseased blood.” “In the most extreme cases oi 
anaemia (excepting only two cases), Hayem never counted less than 
3.000. In this respect my own experience, concludes Dr. Keys3’ 
“ has been similar to his.” 
In this last connection it deserves to be noted that Dr. Ordenstein, 01 
Paris, suggests the possibility of a connection between leukaemia and 
hereditary syphilis, and in a case of his own exhibited Van Swieten 3 
-solution of bichloride of mercury for several months with surprising 
benefit.8 And finally we feel constrained to mention the conclusion3 
arrived at by Liegeois and Wilbouchewitch, as quoted by Keyes, and 
those of Dr. Keyes himself: (1) that syphilis diminishes the number 0| 
red corpuscles below the healthful standard; (2) that mercury in sniad 
doses, continued for a short or for a long period in syphilis, alone or with 
iodide of potassium, increases the number of red corpuscles in the blood* 
and maintains a high standard of the same ; and (3) that mercury de- 
creases the number of red cells when given in excess, especially in hos- 
pitals.9 
Hot less interesting, and certainly not less important, than the phy31' 
©logical, is the medico-legal application of what the microscope 
teach. The law calls upon the expert to be thoroughly an fait in all tha 
modern science has established with regard to the blood in its living ujl 
in its dead state, in its youth and adult periods, in its pathology, iu 
different and indifferent conditions of preservation, in dryness and 111 
moisture, in heat and in cold ; and the character, size, form, and num- 
ber of the corpuscular elements in all attainable classes, orders, specie 3* 
,and families of the zoological series. Hor will his attainments be i’e' 
1 Kolliker, op. cit., p. 704. Note by Da Costa. 
2 E. L. Keyes, Am. Journ. Med. Sciences, January, 1876, p. 21. 
s Ibid. ✓ Ibid- 
-5 Gazette Hebdomadaire, Mai, 1875, p. 295. 6 Kolliker, op. cit. 7 Id- °P' 
8 Medical Times and Gazette,.November 13, 1875. 9 Keyes, loc. cit. MICROSCOPY OF THE BLOOD. 
485 
girded as determinative, unless he be also master of micro-chemistry 
| d familiar with absorption bands, and the expression of their wave 
awakened in ghostly shapes in the spectroscope made an ally 
the microscope. In short, accusing justice, and defensive crime or 
aocence, claim not only an absolute recognition of blood, as distin- 
& Mshed from all other matters or elements whatsoever, but the specific 
of the kind of blood, as well as a positive acquaintance 
i. 1 all the disturbing agencies of time, heat, dryness, and moisture, as 
acting the cruor offered in condemnation or exculpation, 
faat microscopical science is so assured in her varied knowledge, even 
ds application be restricted within very narrow limits, cannot be as- 
From what has preceded it must appear that even for human 
.blood disks there is no fixed and established standard. The obser- 
vations of Gulliver upon the variations in size of the red corpuscles in 
l(fs, under the different circumstances of excitement and repose, and 
positive statement of Col. Woodward that “ the blood disks of dif- 
fent persons, and even of the same persons at different times, vary 
°re in size than the ordinary difference between human and dog’s 
°°d,” are germane to this issue. But we would consider our task as 
& ariugly incomplete if we failed to give becoming prominence to the 
verages of the most perfectly conducted work of our distinguished 
‘ jend, Prof. Theo. G. Worrnley, M.8., of Columbus, Ohio, and to state 
• expression of his variance with Col. Woodward’s record, that “this 
certainly contrary to all our own experience.”2 With Dr. Wormley’s 
mission we offer a few of his measurements, which were furnished in 
e course of a recent correspondence:— 
Human blood, average of all averages, including over 2000 
measurements ......... 
3255 
inch. 
average of averages 
ysVff 
“ 
Cat, 
U 
1 
4 3 7 2 
U 
Rat, 
a a 
75 fi's 2 
U 
Horse, 
u a 
J 
4 2 (T 2 
u 
Jack, 
Mule, 
a a 
a a 
J?1(5’7 
37 s a 
u 
Ox, 
Opossum, 
U kl 
4 I1! 3 
1 
3143 
a 
u 
Muskrat, 
a a 
32V 3 
a 
these measurements the following is added as a note: “You are 
‘ vare, I believe, that in getting our standard for micrometry every pos- 
-6 care was taken to have it correct. The ordinary scales are subject 
p c°nsiderable variation.” In acknowledging the favor of the above, we 
add that we have seen the whole record of the admirable aver- 
‘ §es of Prof. Worrnley, the work of many years, which evidences the 
n,I(,iUstry, the patience, the intelligence, and the scrupulous fidelity of the 
author. 
a a(l been our purpose here to close this essay, but we pause to notice 
ri^aPer by Col, Woodward, read at the Centennial meeting of the Arne- 
Medical Association, which lias for its title “ The Application of 
pictography to Micrometry, with special reference to the Micrometry of 
to°oc* Criminal Cases.” By the plan proposed, which may be destined 
supersede all others, and to abate the value of all former more labori- 
‘'5 and less exact procedures, “ the blood is placed on a glass stage 
1 Sorby, Monthly Microscopical Journal, May 1,1875. 
2 Letter to Author, March 28, 1876. 486 
JOHNSTON, 
micrometer, and photographed with any convenient power;” and in the 
elegant photographs offered in illustration “ both blood and micrometer 
appear sharply defined. The measurements are then made on the nega- 
tive.” “For the purpose of soaking out blood stains” the able author 
prefers to “ use a strong solution of caustic potash, as described by Vir- 
chow in 1857.” The development of this mode of fixing the averages 13 
insisted upon by the distinguished microscopist, who now regards the 
eye-piece micrometer as a “snare and a delusion,” and claims that the 
negative on glass possesses an exactness which may be expressed in mil' 
lionths of an inch, and may be tested at leisure by any number of per- 
sons. And another point of interest attaches to these light pictures, i- e-> 
the equal delineation, under high powers, of all corpuscles, whether large 
or small, of normal shape or deformed. 
Remotely related to the subject are the “ micro-photographs of the 
blood in disease,” recently issued by Dr. E. Cutter, of Cambridge, and 
Dr. G. B. llarriman,of Boston. 
In conclusion we beg to remark that the copious literature of this ex- 
tensive subject, the Microscopy of the Blood, is nowhere complete in this 
country outside of its Capital; and that, in spite of the distinguished 
courtesy of the eminent scientist in charge of the Army Medical Mu- 
seum, this treasury of knowledge cannot always be made available by 
the busy professional men who reside at a distance. 
Discussion on Dr. Johnston’s Paper. 
After the reading of the preceding paper, Dr. J. G. Richardson, of Phila- 
delphia, said:—l should like to offer an explanation in reference to my testi- 
mony at the trial in Herkimer County, New York. I did not state absolutely 
that the corpuscles were those of human blood, but that they corresponded 
to those of human blood. Microscopy has long been employed as an aid to 
the administration of justice; and serves easily, for example, to distinguish 
human blood from that of a fish, because the corpuscles in the former afe 
round, while in the blood of the fish they are oval. At first the legal authori- 
ties demanded no more than this, but when the facilities for microscoplo 
examination became more complete, we began to draw a still sharper hn® 
of distinction—that is, one between human blood and that of the musk-dee1 
or goat. Now, with improved immersion lenses, we are, I contend, able to 
distinguish between the blood of a human being and that of an ox, horse? 
or other animal having corpuscles of similar size; but when circumstances 
do not thus narrow down the demands of justice in a trial, I would neve* 
attempt to discriminate the kind of blood with certainty. Our power to ah 
justice in this matter is due to the fact that when a man is arrested vrff 1 
blood-stains on him, and tries to explain how they got there, he generally 
alleges that he has been in a position to be stained by the blood of some a 1 
mal; and then, by microscopic examination, we can distinguish between hum1111 
blood and that of the ox, pig, or sheep, to which the suspicious stains 
usually attributed. 
Dr. Johnston said:—That would not be a positive recognition of human 
blood-disks, which is what the courts desire ; for the blood might be that ot a 
dog or guinea-pig, and not of a human being. . . 
Dr. Henry D. Didama, of Syracuse, N. Y., said ;—I know of a case in whic 1 
the question presented was, whether the blood was that of an ox or human 
being; and though, in such a case, an expert might not be able to say that 
blood was human, yet he could prove that the statement made by the crimma MICROSCOPY OF THE BLOOD. 
487 
as untrue. I wish to ask Dr. Johnston whether, if he should find a blood- 
*.| v usW of an inch in diameter, he would be willing to swear that it was not 
|e blood of an ox or pig? because, as I understand the matter, the blood- 
® Jldes of the ox and pig never reach that size. 
*’■ Johnston said:—Where the variations were not exceedingly great, I 
uid he unwilling to give an opinion. 
• . r- Richardson said;—[ understand Prof. Johnston to say that, on exam- 
l^.lng some unlabelled slides of man’s, dog’s, and guinea-pig’s blood, offered 
on by Dr. J. J. Woodward, he found himself unable to discriminate between 
tiem- Thi 
s is what I should expect; but I would like to ask Prof. Johnston 
tether, if a person of unproved veracity should bring him a specimen of 
°°d, covering the name, and telling him that it was from a sheep, and he 
di‘°uld find, on measurement, that the corpuscles averaged 3^„ of an inch in 
a meter, be would not feel justified in contradicting the statement? 
j r« Didama said;— Would not Prof. Johnston, if he found blood-disks of 
of an inch, be certain that they could not have circulated in the capilla- 
Ues of a sheep? 
rr* Johnston said:—lt is a very difficult question to answer, as both vessels 
cl corpuscles are extremely elastic, and capillaries constantly allow eorpus- 
es to pass through them, which are larger in diameter than the capillaries 
tllemselves. 
h' James Tyson, of Philadelphia, said:—lt seems to me that this is an 
•j, n,iguous mode of putting the question, because, as Dr. Johnston says, even 
"c could assert that a particular blood was not that of a sheep, we could not 
that the corpuscles could not have circulated in the capillaries of a sheep, 
Uj fCeount the property of elasticity correctly attributed by Dr. Johnston 
1 J h°th corpuscles and capillaries, to nothing of the varying size of the 
‘ ter. Rut the fact is that the peculiar organization of the human mind 
/ 8 s°mething to do with the drawing of conclusions. Some persons would 
jy at liberty to draw the same conclusions from the premises named by Drs. 
tdaina and Richardson as they, while others would not. I, for example, 
be willing to say that such blood was more likely to be that of an ox 
tll s.heeP than that of a man, while I might not be willing to say absolutely 
’ls is the blood of an ox or sheep,’’ and not that of a man. 
jjr.S. E. Chaille, of New Orleans, said :—I desire to ask two questions; 
be lUlk We agree with Prof. Johnston that human blood corpuscles cannot 
Positively distinguished from all others; but frequently, in court, some 
it -nesses assert that a particular stain is human blood, while others say, no, 
w|lS le of an ox. The Court asks the microscopist, “ Can you decide 
it p lev this is human blood or that of an ox—or, let ns say, of a sheep ?” Is 
u11 Johnston’s opinion that such a decision could be made, and would he, 
( er such restricted circumstances, feel justified in saying whether the blood 
as that of a sheep or of a man ? 
, v- Johnston said:—l could answer negatively, that the blood was not 
h«naan. 
said:—My second question is this: I have been told that cer- 
ahle to discriminate between them. I would ask of Dr. Richardson if such 
18 the fact? 
0l 1 r* Richardson said:—Such was the case, not in one series of specimens 
th Vibut *n tw°J The number of samples in each series was tlu;ee; one being 
alff } °fi an °x, one that of a sheep, and the other human blood. 1 was 
1 u to distinguish between them by microscopical examination alone, 
to 1 I'^ohnston said :—There is more than the mere diameter of the corpuscles 
Y considered; we must consider the cachet, or the stamp of individuality 
ot the blood. 
nit‘i’ican Journal of the Medical Sciences, July, 1874; also, London Monthly 
Microscopical Journal, Sept. 1874. 488 
JOHNSTON, MICROSCOPY OF THE BLOOD. 
Dr.L. S. Joynes, of Richmond, Ya., said:—l would like to ask Dr. Richar- 
dson as to the relative ease of distinguishing between different bloods when dry 
and wet. Can we restore dried corpuscles so certainly as to distinguish 
whether they are human or otherwise ? It is difficult to know how far blood 
corpuscles on the clothing are altered from their original condition. 
Dr. Richardson said:—My experience has been that in dry blood-stains there 
is a shrinkage of from five to ten per cent. That is, that the fresh blood 
corpuscles of man average of an inch, while in stains they measure fro#1 
4° jtoo- The blood corpuscle of an ox, which averages of an inch, 
when fresh, would measure or after re-moistening. 
Upon the conclusion of the discussion, Dr. Richardson said:—As strong 
evidence of the presence of a true cell-wall in red blood corpuscles, upon the 
existence of which the value of my method for the diagnosis of blood-stains 
largely depends, I invite the members of the Section to inspect, beneath 
Holmes’s class microscope, a red disk of the Amphiuma tridactylum, in which 
the imperfectly crystallized cell-contents occupy the upper end, while the ova* 
granular nucleus fills the inferior extremity, leaving the membranous capsule 
relaxed and wrinkled longitudinally, hanging like part of a half-flaccid ballooU 
between them. (Fig. 1.) I also show, as corroborative testimony, a slide 
Fig. l(X 400) 
Fig. 2 (X 400). 
bearing a blood corpuscle of the Menobranchus, which displays, within what I 
deem to be its limiting membrane, a single crystal made up of all the cell-coß' 
tents except the nucleus.1 (Fig. 2.) 
1 See Trans. Am. Med. Association, vol. xxi., 1870, p. 271. 489 
THE EXCRETORY FUNCTION OF THE LIVER. 
BY 
AUSTIN FLINT, Jr., M.D., 
1 ROFESSOR of PHYSIOLOGY AND PHYSIOLOGICAL ANATOMY IN THE BELLEVUE HOSPITAL MEDICAL 
COLLEGE, NEW YORK. 
I Have selected as the subject which I shall have the honor to present 
0 tlie Section on Biology, the Excretory Function of the Liver, for the 
Gason that it seemed to me better to discuss a question concerning which 
Had made personal and original investigations, than to recite the obser- 
vations of others, however interesting and important the latter might be. 
Have ventured to assume that the views which I have to offer are not 
x dhout importance; and they are certainly not so familiar as many other 
°lncs which I might with propriety have selected. I shall, therefore, 
dfeavor to bring to your notice, in the simplest manner possible, what 
Have myself learned with regard to the liver as an organ of excretion. 
. Ht is now well known that the liver has a of important func- 
C°Hs with which physiologists are more or less completely acquainted. 
_1 Produces a substance which is converted into sugar and is carried 
cdvay in the torrent of the circulation. It secretes bile, which performs 
aH important office in digestion. In addition to the digestive function 
t the bile, I think I have shown that this fluid serves as the vehicle for 
,le elimination of at least one excrementitious principle, which is dis- 
i larged in a modified form in the feces. If the liver serve as an organ 
excretion, it is evidently of great importance, from a pathological as 
leh as a physiological point of view, that we should have an accurate 
knowledge of the mechanism of this function. For a long time, many 
1 thoiogicai conditions have been attributed to defective or perverted 
IGn °f the liver; still, the terms,“ liver complaint,” “ biliousness,” etc., 
ave failed to convey any definite pathological notion, and it is probably 
He that the liver has been accused of numerous sins of omission and 
°namission without any positive scientific reason. Many medical writers 
ave assumed, in an indefinite way, that the liver possesses an excretory 
action ; but, so far as I know, no physiologist had ever described any 
GHnite excrementitious substance eliminated by this organ prior to my 
there are certain general laws applicable to secretions and to excre- 
-0l)s, which it is important to consider in discussing the probable func- 
tl0Hsof the bile 
as ®ecrefi°nß have some useful purpose to serve in the economy, and, 
Ptl ruU, they are not discharged from the body in health. Excretions 
tl|e no function in the economy and are discharged from the body. 
c U The flow of secretions from the glands is usually intermittent, oc- 
is 
H^ually either constant or remittent, 
q- f*. Fhe production of excretions depends upon the general process of 
Humiliation, which is constant. The production of secretions has no 490 
FLINT, JR., 
relation to disassimilation, but is connected with processes which 
usually take place at intervals. 
IV. The elements of secretion, which give to secreted fluids their cha- 
racteristic physiological properties, are formed de novo in the glands them- 
selves out of materials furnished by the blood, and they do not pre-exist 
ready-formed in the circulating fluid. The elements of excretion pre- 
exist in the blood, being taken up by the lymph or by the blood from 
the tissues, and they are separated from the blood by organs which have 
no part in their actual production ; except that excrementitious sub- 
stances may be changed one into another, as creatine into creatinine, or 
uric acid into urea. 
V. When secreting organs are removed or destroyed, there is no vica- 
rious production of the peculiar elements of the secretions; these ele- 
ments do not accumulate in the blood ;. and the system sutlers simply 
from the absence of the function of the special secretion. When excret- 
ing organs are removed or destroyed, there may be a vicarious elimina- 
tion of the excrementitious principles by other organs, or the system 
may sutler toxic effects from the accumulation of excrementitious matters 
in the circulating fluid. 
VI. The characteristic elements of true secretions are generally reab- 
sorbed by the blood ; but they are taken up in a modified form, so that 
they are not to be recognized in the circulating fluid. Elements of excre- 
tion are with difficulty reabsorbed by the blood after they have once 
been separated by the proper organs. 
The applications of the foregoing general laws may be readily made to 
the pancreatic juice as contrasted with the urine, which two fluids vre 
may take as types respectively of secretions and of excretions. Before 
we make an application of these laws to the bile, we may consider the 
simple question as to whether it can be shown that this fluid has a nse' 
ful function to perform as a secretion. If the bile have no such function? 
an animal would live and maintain its normal condition if the bile were 
diverted from the intestine and discharged from the body. This question 
has been made the subject of experimental observation by simply cutting 
off the bile-duct, and making a fistula into the gall-bladder, by which the 
bile is discharged. The operative procedure involved is not difficult, bnt 
is very apt to be followed by fatal peritonitis, so that few experiments 
of this kind have succeeded. In the experiments which have succeeded? 
in the hands of Schwann, Bidder and Schmidt, Hasse, Bernard, and 
myself, the dogs have lived for thirty or forty days, dying with all the 
symptoms of inanition. In one remarkably successful experiment per' 
formed by myself, the dog lived for thirty-eight days, had a voracious 
appetite, and died at the end of that period after having lost about foflr' 
tenths of his weight. In this experiment, the bile-duct was ligatured in 
two places, and the intermediate portion was exsected. A fistula was then 
made into the fundus of the gall-bladder, which was kept open. The 
animal ate well the very day of the operation, and there was very liß*® 
peritonitis. The only observation in which contrary results were obtained 
is one made by Blondlot.1 In this case, a fistula was made into the gn*b 
bladder after the bile-duct had been divided. The animal lived for flve 
years, and, after fifteen days following the operation, was in good tieß'1 
and apparently suffered no inconvenience from the discharge of the bi‘e 
’ Blondlot, Essai sur les fonctions dn foie et de ses annexes, Paris, 1846, page 55, et seq■ > 
and Inutilit6 de la bile dans la digestion, Paris, 1851. EXCRETORY FUNCTION OF THE LIVER. 
491 
l’om the fistula. During the first fifteen day7s the animal licked the bile 
10’a the fistula, but this was afterward prevented by a muzzle. After 
a tune he made no attempt to lick the bile. Blondlot attributed the 
eglaciation which occurred during the first fifteen days to this licking 
. the bile. When the animal died, more than five years after the opera- 
tloa, an examination of the parts was made in the presence of several 
Physicians and students of medicine, and no communication could be 
pUnd between the bile-duct and the intestine. From this observation, 
plondlot concluded that the bile had no function in digestion, and that 
Was a purely excrementitious fluid ; and he assumed that the cause of 
heath in other experiments of a similar kind was the licking of the bile 
as it flowed from the fistula. In my own case of biliary fistula, in which 
he dog died after thirty-eight days, the animal was prevented by a muz- 
z 6 from licking the bile. 
The only point to consider, as it seems to me, in this single experiment 
p Blondlot, is whether or not a communication had been re-established 
between the bile-duct and the intestine. If such a communication 
Existed, it would be easy to explain the survival of the animal. The fol- 
°wing experiment, which I undertook for a different purpose, satisfied 
upon this point:— 
I attempted to estimate, in a dog, the entire quantity of bile dis- 
charged in the twenty-four hours. With this object in view, I cut down 
llPon the bile-duct, emptied the gall-bladder, secured acanula in the duct, 
apd attached a rubber-bag to the canula,for the purpose of collecting the 
bde. Twenty-three hours after the operation, the bag was in place and 
bearly fu]] 0f bile. Just before the end of the twenty-four hours, how- 
ev.cr, the animal ruptured the bag, and the experiment, as far as its 
ol’ginal object was concerned, was a failure. I then simply pulled the 
Cailula from the wound and set the animal at liberty. In about four 
beeks, after the wound had closed and the feces had become of normal 
c°W, the anima]? being in a perfectly normal condition, was killed, and 
be parts were carefully examined in the presence of several assistants. 
is well known that, in dogs, ducts that have been divided have a 
lernarkable tendency to become re-established. In this case, inasmuch 
as 110 bile was discharged externally, and the feces Avere of normal color, 
| Was certain that the bile was discharged into the intestine. Heverthe- 
ess5 I searched for more than an hour for the communication before it 
as discovered. The only reasonable way, as it appears to me, to recon- 
b'le the single experiment of Blondlot with thoseof other observers, is to 
Buppose that, in his observation, a communication between the bile-duct 
(Pm Bitestine had become established, which he failed to find. The 
’faculty which I experienced in finding the communication in ray own 
0 servation led me to conclude that a communication existed in the 
Case reported by 7 Blondlot, which he did not discover. 
It is in accordance with ray own observations, as well as with those of 
ier physiologists, to conclude that the bile is a secretion, and that it 
!as a function to perform in connection with the digestive process, which 
11 action is essential to life. 
that the bile has an important and an essential office in 
is it not possible that it may also serve the purpose of elimina- 
|lolh a”d contain elements of excretion? This is a view which has not 
gGen advanced by physiologists, who have regarded the bile either as a 
ecretion or an excretion, and have not imagined that it could serve both 
11 actions. Before I take up the experimental facts bearing upon this 492 
FLINT, JR., 
question, I propose to consider the arguments to be drawn from a study 
of the composition of the bile, and its discharge into the intestine. It 
•was this idea which first led me to investigate the physiological rela- 
tions of cholesterine. 
The bile certainly has an important function as a secretion ; and its 
flow, although not intermittent, is more abundant during the process ot 
intestinal digestion. The peculiar biliary salts (the glycocholate and the 
taurocholate of soda) are formed in the liver and do not pre-exist in the 
blood. When the structure of the liver is invaded by disease so as to 
interfere with the production of bile, the biliary salts do not accumulate 
in the blood. The biliary salts are reabsorbed in a modified form in the 
intestine; for the quantity of one of their elements (sulphur) found i'l 
the feces is very much less than the amount discharged into the intes- 
tine. 
On the other hand, with regard to one constant constituent of the 
bile (cholesterine), we do not know that it has any function in connec- 
tion with digestion. The secretion of bile is continuous, although its 
flow is increased during digestion. Cholesterine, while it is an invariable 
constituent of the bile, exists in the blood and in certain of the tissues 
of the body. 
The questions to determine experimentally with regard to cholesterine 
are the following:— 
Is cholesterine produced in any of the tissues of the body ? 
Is cholesterine separated from the blood by the liver? 
When the liver undergoes structural change in disease, does choleste- 
rine accumulate in the blood? 
Is cholesterine reabsorbed in the intestine or is it discharged, either 
unchanged or in a modified form, in the feces? 
o " £ 
These are the questions which I endeavored to answer by a series o1 
experimental investigations, made in the spring of 1862, and published 
in October of the same year, in the American Journal of the Medical 
Sciences. 
Process for the Estimation of Cholesterine in the Blood.—The following (s 
the process which I fixed upon, after a number of trials, for the quanti- 
tative analysis of the blood for cholesterine: The entire blood, serunj 
and clot, is evaporated to dryness. The dry residue is then pulverized 
in an agate mortar, and treated for from twelve to twenty-four hour3 
with ether, in the proportion of about one fluidounce of ether to on® 
hundred grains of the original weight of blood. This is filtered, and 
the ethereal extract, which contains cholesterine and fats, is evapo' 
rated. The residue of this evaporation is then extracted with boiling, 
alcohol, in the proportion of one fluidraehm for one hundred grains <n 
the original weight of blood. This extract is filtered while hot, and the 
filtrate is evaporated, leaving the cholesterine and a certain quantity ot 
saponifiable fats. To remove the saponifiable fats, add to the residue a 
weak solution of potash, and allow it to remain for about two hours; then 
dilute with water, filter, and wash the filter with water until the liqidd 
which passes through becomes neutral. Dry the filter; wash it with 
ether; evaporate the ether; extract the residue with hot alcohol as be- 
fore; evaporate the alcoholic extract, and the residue will co’nsist oi 
cholesterine, perfectly pure, as can be determined by means of the micro- 
scope. Using this process for the determination of cholesterine, a number EXCRETORY FUNCTION OF THE LIVER. 
°f observations were made upon dogs, from winch I select the following 
as typical, the results having been repeatedly confirmed. 
I. Experiment showing an Increase in Cholesterine in the Blood passing 
through the Brain. (The dog was not etherized.) 
. -tfiood from the carotid, 140.841 grains, contained 0.108 grain of choleste- 
or 0.768 part of cholesterine per 1000. 
blood from the internal jugular, 97.811 grains, contained 0.092 grain of 
° 12|esterine, or 0.947 part of cholesterine per 1000. 
the increase in the proportion of cholesterine in the blood in passing through 
le brain was 23.309 per cent. 
This observation, which was frequently repeated with the same gene- 
*al result, seems to show that the blood gains cholesterine in its passage 
/trough the brain. It is well known that cholesterine is always present 
111 nervous substance—not in a crystalline form, but in a state of mole- 
hlar union with nitrogenized and other matters. In order to verify 
.bis fact, I examined the brains of two subjects wrho had been killed 
blatantly by accident while in perfect health, in one case finding a pro- 
portion of cholesterine of 7.729 parts per 1000, and, in the other, 11.456 
parts per 1000. 
The experiment just detailed was made with a view of determining 
Whether or not the brain gives up cholesterine to the blood as it circu- 
ates through this organ ; and the following experiment was made to 
f otermine whether the venous blood of other parts contains an excess of 
cholesterine. Theoretically, the blood of the femoral vein should contain 
a httle more cholesterine than arterial blood, this excess being derived 
l°m the nerves of the extremity, although the increase would probably 
e n°t so great as in the blood of the internal jugular, which comes 
irnost exclusively from the great nervous centre. 
Bs- 11. Experiment showing an Excess of Cholesterine in the Blood of the 
internal Jugular and Femoral Veins over the Arterial Blood. (The dog was 
b°t etherized.) 
Tlood from (he carotid, 143.625 grains, contained 0.679 grain of cholesterine, 
r 0.967 part of cholesterine per 1000. 
, blood from the internal jugular, 29.956 grains, contained 0.046 grain of 
olesterine, or 1.545 part per 1000. 
blood from the femoral vein, 45.035 grains, contained 0.046 grain of choles- 
ei''|e5 or 1.028 part per 1000, 
4 be increase in the proportion of cholesterine in the blood in passing through 
i'“rain was 59.772 per cent. 
|.j _ e increase in the proportion of cholesterine in the blood in passing 
lough the lower extremity was 6.308 per cent. 
TMs experiment confirms the previous observation upon the increase 
• Cholesterine in the blood in passing through the brain, and it shows, 
1 addition, that the blood gains cholesterine in other parts. Inasmuch 
ej |le nervous tissue is the only tissue in the extremities which contains 
'olesterine, it is probable that the excess contained in the blood of the 
rnoral vein over the arterial blood was derived from the nerves, 
co V°9curred 4o me that cases of old hemiplegia would present favorable 
tpndltiona for verifying in the human subject the observations made on 
n e animals. It has been ascertained that, when the function of 
®rv?s_ is permanently abolished, they soon become degenerated and their 
'hion modified; and it seems probable that, if cholesterine be one 494 
FLINT, JR., 
of their important products of disassimilation, the amount of cholesterine 
in the blood from paralyzed parts should be very small. Taking the 
blood, for example, from the paralyzed arm of a hemiplegic, this blood, 
coming from paralyzed parts, should contain less cholesterine than the 
blood from the sound arm. Of course, the blood from the arm contain3 
no blood which has passed through the brain, which is assumed to be 
sound upon the paralyzed side. I examined, therefore, the blood from 
both arms in three cases of hemiplegia in the Charity Hospital on Black- 
well’s Island:— 
Case I. Sarah Rumsby, set. 47, is affected with hemiplegia of the left side. 
Two years ago she was taken with apoplexy and was insensible for three days* 
When she recovered consciousness she found herself paralyzed on the left side. 
She says she had epilepsy four or five years before the attack of apoplexy* 
She has now complete paralysis of motion on the affected side, with the excep- 
tion of some slight power over the fingers. Sensation is not affected. The 
speech is perfect and her general health is good. 
Case 11. Anna Wilson, set. 23, is affected with hemiplegia of the right side. 
Four months ago she became unconscious, and recovered in one day, with loss 
of motion and sensation on the right side. She is now improving and can 
use the right arm slightly. The leg is not so much improved because she wm 
make no effort to use it. 
Case 111. Honora Sullivan, set. 40, is affected with hemiplegia of the right 
side. About six months ago she became unconscious, recovering the next day 
with paralysis. The leg was less affected than the arm from the first. He** 
condition is about stationary as regards the arm, but the leg has somewhat 
improved. 
A small quantity of blood was drawn from either arm in these three 
cases. In each instance it was drawn from the paralyzed side with dith- 
en] ty, and but a small quantity could be obtained. 
The specimens were all examined for cholesterine, with the following 
results:— 
Obs. III. Quantities of Cholesterine in the Blood of the Paralyzed and the 
Sound. Sides in three cases of Hemiplegia. 
Cases. 
Blood. 
Cholesterine. 
Cholesterine per 1000 parts. 
Case I. Paralyzed side . , . 
Sound side .... 
Case II. Paralyzed side . . 
Sound side .... 
Case III. Paralyzed side . . 
Sound side . . . 
Grains. 
55.458 
Grains. 
The watch-glass contained 0.031 
128 407 
18.381 
0.062 
grain of substance, but tl*e 
most careful examination wit 
the microscope failed to show 
crystals of cholesterine. 
0.481. 
Same as Case I. 
66.396 
21.842 
0.062 
0.808. 
Same as Case I. 
52.261 
0.031 
0.579. 
The conclusion from the experiments upon dogs and the three observa- 
tions upon the human subject is inevitable, that cholesterine is produced 
in the substance of the brain and in the nervous tissue generally, as tin 3 
substance is not contained in the muscular tissue or in any other part3 
except the crystalline lens, the liver, and the spleen. The question noyv 
to determine is the relation of cholesterine to the nervous system. I 3 1 EXCRETORY FUXCTIOX OF THE LIVER. 
495 
lle of the products of disassimilation of its tissue? If this be the fact, 
_‘olesterine is an excrementitious product, and it must be separated from 
le tdood by some organ or organs and discharged from the body. Inas- 
i. Ucn as the bile always contains cholesterine, we naturally look to the 
Jer as the organ for its elimination ; for it is not found in the product 
0 any other gland. 
fi eipployed essentially the same method in studying the question of 
• e eHrninatiou of cholesterine as that used in determining the seat of 
production, analyzing the blood going to and coming from the liver. 
h?n P0” I made a number of observations, the general results of 
bich were invariable. The following: experiment is a type of these 
ol»ervatious:— 
. Experiment showing that Cholesterine is separated from the Blood 
in its Passage through the Liver. (The dog was etherized.) 
Arterial blood, 159.587 grains, contained 0.200 grain of cholesterine, or 
• 57 part of cholesterine per 1000. 
l°°d of portal vein, 168.257 grains, contained 0.170 grain of cholesterine, 
1-009 part of cholesterine per 1000. 
o °°d of hepatic vein, 79.848 grains, contained 0.077 grain of cholesterine, 
0.964 part of cholesterine per 1000. 
the loss in the proportion of cholesterine in arterial blood in passing through 
O liver was 23.309 per cent. 
Ibe loss in the proportion of cholesterine in the portal blood in passing 
r°ugh the liver was 4.460 per cent. 
The bile always contains a certain proportion of cholesterine, which I 
°hnd, in a specimen taken from the gall-bladder of a subject who had 
®ei| killed instantly while in perfect health, to be 0.618 part per 1000. 
I have demonstrated that the blood gains cholesterine in its passage 
iiougp the brain and probably also from the general nervous tissue, that 
olesterine is separated from the blood in its passage through the liver, 
• lly that cholesterine is invariably found in the bile and is discharged 
j. 0 the intestine, it seems to be proven that one of the functions of the 
rts to eliminate this principle. If it can be shown that the choles- 
b 11ne thus separated from the blood by the liver is discharged from the 
the fact that it is apparently produced in the nervous tissue and is 
/l en.up by the blood would point strongly to the conclusion that cho- 
q- erine is an excrementitious principle and is one of the products of 
Assimilation of the nervous matter. 
' iercorine.—l made repeated examinations of the normal feces, with a 
tl/'V determining the presence of cholesterine and its quantity. Al- 
j °ugh it is often stated by authors that cholesterine exists in the feces, 
qJVas Unable to find it after the most careful examination, and I subse- 
ts entlT tailed to discover any writer who had actually extracted it from 
tp0 normal dejections. The process which I employed was essentially 
ext'Sanio as that used in examinations of the blood, except that the 
Were decolorized by filtering through animal charcoal, and the 
theV-r extract was treated with potash for one or two hours at nearly 
W‘i °ding point. Treated in this way, the feces gave an extract which 
but which did not crystallize for several days. It 
29g0 at a temperature of about 97° Fahr., while cholesterine fuses at 
g,,* V a few days, delicate, needle-shaped crystals began to appear, 
to c Ua,ly increasing in number and breadth, and, as they became 496 
FLINT, JR., 
broader, becoming split at the points and edges. These crystals pi’6' 
sented all the characters of the crystals of a substance extracted from the 
serum of the blood by Boudet, in 1833(Annales de Chirnie et de Physique)? 
which he called seroline. In some of my earlier observations upon the 
blood, I obtained these crystals; but I came to the conclusion that the so- 
called seroline was not a normal constituent of the blood, but was formed 
during the process used for the extraction of cholesterine. With this 
view, finding the so-called seroline a constant constituent of the normal 
feces, I called the substance stercorine, regarding it as one of the eX- 
crementitious principles of fecal matter. Crystals of stercorine m’e 
shown in the accompanying figure (Fig. 1). The rounded drops arc 
probably composed of the same substance, as they disappear when the 
crystallization is complete. The idea that these crystals obtained from 
blood result from the transformation of cholesterine, is strengthened by 
the fact that the cholesterine of the bile is changed into stercorine in hs 
passage through the alimentary canal. Stercorine, like cholesterine 
is soluble in ether, very soluble in hot alcohol, and strikes a red colot 
Stercorine from normal human feces ( inch objective). 
with strong sulphuric acid. The points of distinction are the l°'v 
fusing point and the form of the crystals. 
I obtained from the feces of the twenty-four hours of a perfectly 
healthy man 10.417 grains of stercorine. It is estimated by Dalton tlm 
the total quantity of bile in twenty-four hours is 16,940.00 grains, m 1 
the total quantity of cholesterine, according to my estimate of O.oq 
parts per 1000, is 10.469 grains, giving a difference between the 
mated quantity of cholesterine and the actual quantity of stercorine eX 
tracted from the feces of only 0.052 of a grain. This sustains the me‘ 
of the change of the cholesterine of the bile into the stercorine of D 1 
feces. o.e 
Observations made by myself and others seem to show that the cnan» 
of cholesterine into stercorine is incidental to the process of digesting 
Cholesterine is found in quantity in the feces of hibernating aninm 
and in the meconium, when, of course, there is no intestinal digeatmm 
but when the bile is none the less discharged into.the alimentary p 
I made an examination of human meconium and found cholesteriim 
the proportion of 6.245 parts per 1000, and no stercorine. I examm6 EXCRETORY FUNCTION OF THE LIYER. 
497 
le human feces in a case of simple jaundice from obstruction of the 
de-duct, the feces being clay-colored, and found neither cholesterine 
110l’ stercorine. Nineteen days after, when the jaundice had disappeared 
‘ . the color of the feces was normal, I found stercorine and no choles- 
®riue. In the feces of a dog which had been deprived of food for forty- 
hours, I found stercorine and a small quantity of cholesterine. As 
‘tr us can be learned from these facts and observations, then, it seems 
iat the cholesterine of the bile is discharged in the feces unchanged 
uen no digestion takes place, but that it is discharged in the form of 
ercorine under the ordinary and normal conditions of the digestive 
Process. 
Pathological Relations of Cholesterine ; Cholestemmia.—A knowledge 
the relations of urea to nutrition bears so directly upon the pathology 
renal diseases, that the pathological relations of any newly-discovered 
crenientitious principle assumes at once the greatest importance.* If 
oe true that cholesterine, like urea, is a product of disassimilation, 
ICI that it is eliminated by the liver as urea is eliminated by the kid- 
we should expect to find, in cases of serious structural disease of 
)e an accumulation of cholesterine in the blood, or cholestersernia, 
1 We have uraemia in certain stages of extensive organic disease of the 
iclneyg. It has long been observed, indeed, that, although simple jaun- 
ice due to resorption of the coloring matter of the bile is usually a 
llvial affection, there are cases of extensive change in the structure of 
Je liver in which there is apparently a toxic condition dependent upon 
. 16 presence of some excrernentitious or poisonous substance in the 
°°d. Pathologists have examined the blood in such cases with a view 
r pertaining the nature of the supposed poisonous matter. Frerichs 
pi others repeatedly examined the blood in cases of grave jaundice, 
xpecting to discover the biliary salts or acids, but they never detected 
.ny substance which would react with Pettenkofer’s .test.1 Becquerel 
111. &odier examined the blood in a case of jaundice and found “ choles- 
excessively abundant,” but they did not recognize the significance 
this fact.2 In such cases pathologists have looked for the biliary 
1( 8 and their derivatives, and not for cholesterine. In order to throw 
rj rne light upon the pathology of grave jaundice, Muller,3 Kunde,4 Leh- 
Rinn,5 nud Moleschott6 have extirpated the liver in frogs and kept the 
iuo-111^8 a^'lve f°r severa-l days, or even two or three weeks. On exarnin- 
rp g the blood, these physiologists failed to discover the biliary salts. 
to>7 niade no analyses of the blood for cholesterine. I hope to be able 
in conclusively, by observations upon cases of disease of the liver 
in t] uman subject, that there may be an accumulation of cholesterine 
s . 10 bi°od, or cholesterseraia, and that this occurs in certain cases of 
I,ous structural disease of the liver, 
of m Cas.es °f simple jaundice, there is resorption of the coloring matter 
*0 bile from the excretory passages, 
tq u of grave jaundice, which almost invariably terminate fatally, 
eie 18 cholesteneraia, or accumulation of cholesterine in the blood. 
2 lerichs, Diseases of the Liver; New Sydenham Society, London, 1860, vol i. p. 95, 
3 MeTerel Pokier, Traite de chimie pathologique; Paris, 1854, p. 210. 
4RU i Manuel de Physiologic; Paris, 1851, tome i. p. 122. 
s r u,n< e’ Hepatis Extirpatione; Berolini, 1850. 
s f ?mann) Physiological Chemistry; Philadelphia, 1855, vol. i. p. 476- 
0 e®chott, Comptes Rendus; Paris, 1855, tome xl. p. 1040. 
o2 498 
FLINT, JR., 
There are cases of structural disease of the liver, in which there is u° 
jaundice, but nevertheless there is cholestersemia. 
In the following cases, having first determined the proportion of cho- 
lesterine in normal blood, I examined the blood for cholesterine with 
reference to the points just stated : 
Obs. Y. Proportion of Cholesterine in Normal Blood. 
Male, set. 35 . . 0.445 part of cholesterine per 1000. 
“ “22 . 0.658 “ “ “ 
“ “ 24 . . 0.751 “ “ “ 
Obs. YI, Case of Jaundice dependent probably upon Duodenitis.—This case 
presented the symptoms of simple jaundice from temporary obstruction of the 
bile-duct. June 21, 1862, 212.428 grains of blood were taken from the arm* 
The proportion of cholesterine per 1000 was 0.508, which was within the limits 
of health, according to the results obtained in my examinations of normal 
blood. The feces, which were clay-colored, were examined, and I found neithei 
cholesterine nor stercorine. July 11, the patient had entirely recovered ; there 
was no jaundice; and the feces had become normal. 
Obs. YII. Case of Grave Jaundice with Cirrhosis.—This case presented 
intense jaundice, ascites, great general prostration, and, toward the close o* 
life, symptoms of blood-poisoning. The patient was admitted to the Charity 
Hospital on Blackwell’s Island, June 16, 1862. On June 21, 50.776 grains d 
blood were taken from the arm. This blood contained a proportion of 1.850 
part of cholesterine per 1000, an increase of 146.838 per cent, over the max1* 
mum quantity obtained from normal blood. The patient died June 27, 1862- 
There was double vision six days before death, and stupor for the last three 
or four days. The liver, examined after death, was in a condition of cirrhosis* 
The gall-bladder was contracted and contained but about twm drachms d 
bile. The fibrous substance of the liver was increased in quantity, and the 
liver-cells were shrunken. The feces were taken a few days before death. The 
amount was small, only 272.1 grains in twenty-four hours, and contained o.oi 
of a grain of stercorine. 1 found 10.417 grains of stercorine in the feces of the 
twenty-four hours in a healthy male. 
Obs. YIII. Case of Cirrhosis vnth Ascites and considerable affection of 
General Health.—ln this case there was general prostration, confining the 
patient to the bed. After a tapping, the liver was explored and found to be 
considerably diminished in size. 1 i 7.193 grains of blood were taken from the 
arm, containing a proportion of 0.922 of a part of cholesterine per 1000, d 1 
increase of 22.769 per cent, over the maximum proportion obtained in d.V 
examinations of normal blood. In this case there were no nervous symptom8* 
Obs. IX. Case of Cirrhosis ivith Ascites and slight Constitutional DlS' 
turbance.—This patient had suffered from ascites for eighteen months and hd 
been tapped about thirty times. He is immediately relieved by tapping an 
goes out the next day. July 1, 1862, 251.567 grains of blood were taken from 
the arm, which gave a proportion of cholesterine of 0.246 of a part per 1000? 
or 44.719 per cent, less than the minimum obtained in my examinations of n°1' 
mal blood. 
The cases just detailed, taken in connection with my observation9 
upon animals, are certainly very striking. In the case of simple jaUll' 
dice, which recovered, the proportion of cholesterine in the blood 
within the limits of health. In the case of ascites, the patient not std' 
fering much disturbance, the proportion of cholesterine in the blood 
considerably below the normal standard. In the case of grave jaundY6’ 
which terminated fatally with symptoms of serious disturbance ot th 
nervous system, the proportion of cholesterine in the blood was enof' EXCRETORY FUNCTION OF THE LIVER. 
499 
jously increased, being nearly three times greater than the maximum 
gained in my examinations of normal blood. In the case of cirrhosis 
considerable affection of the general health, the proportion of cho- 
lerine in the blood was considerably above the maximum obtained in 
ni}’ examinations of normal blood. 
literature hearing upon the “ New Excretory Function of the Liver” since 
the Publication of my Observations in 1862. 
October, 1862.—My researches were published in the “American Journal of 
*c Medical Sciences.” 
J-868—A translation of m 3' memoir into French was published in Paris and 
I csented to the Academy of Sciences for the Monthyon prize. 
c 869 The commission from the French Academy of Sciences reported 
Pon my observations and awarded an “honorable mention” with a “recom- 
pense” of fifteen hundred francs. 
1869—Grollemnnd (These de Strasbourg) made observations upon the injec- 
°n of the biliary salts into the blood in large quantity in dogs, and noted 
itain disturbances of the nervous system. 
69—Tincelin (These de Strasbourg) made observations in which he failed 
"obtain an}'- marked nervous disturbances following the injection of the biliar}' 
a‘ls into the blood in dogs. 
1869—Pages (These de Strasbourg) injected the bile-duct in dogs with a 
mtiou of sulphate of iron, which he thought destroyed the epithelium of the 
, er and interfered with its eliminative function, producing accumulation of 
c Mesterine in the blood. 
1810—Feltz and Ritter (Journal de PAnatoraie, Paris, 1870) confirmed the 
*“fl,lts obtained by Pages with the sulphate of iron. They found no marked 
pets following the injection of the biliary salts, taurine, or glycochol into the 
eins. They also injected cholesterine in soap and water. The cholesterine 
as not dissolved, and masses of cholesterine were found in the small pulmo- 
ajV vessels, producing death by embolism. 
1872.—Picot (Journal de PAnatomie, Paris, 1872) noted an accumulation 
cholesterine in the blood in a case of acute, yellow atrophy of the liver, which 
e*niinated fatally. He found a proportion of cholesterine in the blood in this 
ase of 1,804 part per 1000, more than double the maximum which I obtained 
II examinations of normal blood. 
r r^l3.-—Koloman Miiller (Archiv fiir experimentelle Pathologie und Pharma- 
.°gie, Leipzig) made an elaborate series of experiments upon dogs. No 
|eiloUs or marked results followed the injection of the biliary salts or taurine 
n 0 the blood. He rubbed cholesterine with glycerine and made a solution in 
ap and water. He injected 2.16 fluidounces of this solution, containing about 
f grains of cholesterine into the veins. In five experiments he produced 
a complete picture of the symptoms of grave jaundice,” 
y delusions of Koloman Muller.—“ It appears to me to be certain that those 
i.eiebral symptoms which accompany severe jaundice and many diseases of the 
Ve.l’> le general manifestations of which have been called ‘cholmmic intoxi- 
a jon,’ are produced by an abnormal accumulation of cholesterine in the blood, 
of ac?umulation of cholesterine is contingent upon that alteration ol the tissue 
, liver, which, in such cases, it suffers more or less.” 
and 1876.—Feltz and Ritter (Journal de PAnatomie, Paris, 1875 and 
i . ) I*l opposition to their former experiments, conclude that the biliary salts 
Jected into the blood produce grave changes, mainly in the blood corpuscles. 
a f corpuscles become diffluent, change their form, the luemaglobine transudes 
ttdrP and the power of absorption of oxygen progressively di- 
p Tl,e general results of observations bearing upon the physiological re- 
cl lons °1 cholesterine, made since 1862, are confirmatory of my observa- 500 
FLINT, JE., 
tions. As regards cholestenemia, the experiments of Muller are the most 
important. Indeed, they supply the only missing link in my chain of 
experimental evidence ; and they show conclusively that the symptoms of 
“grave jaundice,” which I connected with cholestenemia, may be pr°' 
duced by the artificial introduction of cholesterine into the circulation. 
As an inevitable result of my observations, confirmed by others and 
extended by Koloman Muller, I can now confidently repeat the conclu- 
sions which I published in 1862. 
Conclusions.—l. Cholesterine exists in the bile, the blood, the nervous 
matter, the crystalline lens, and the meconium, but does not exist in the 
feces in ordinary conditions. The quantity of cholesterine in the blood 
of the arm is from five to eight times more than the ordinary estimate. 
11. Cholesterine is formed, in great part if not entirely, in the sub- 
stance of the nervous matter, where it exists in great abundance, from 
which it is taken up by the blood, and constitutes one of the most im- 
portant of the effete, or excrementitous products of the body. Its forma- 
tion is constant, it always existing in the nervous matter and the circu- 
lating fluid. 
111. Cholesterine is separated from the blood by the liver, appears as a 
constant element of the bile, and is discharged into the alimentary canal- 
The history of this substance, in the circulating fluid and in the bile? 
marks it as a product destined to be gotten rid of by the system, or au 
excretion. It pre-exists in the blood, subserves no useful purpose in the 
economy, is separated by the liver and not manufactured there, and, i* 
this separation be interfered with, accumulates in the system, producing 
blood-poisoning. 
IY. The bile has two separate and distinct functions dependent on the 
presence of two elements of an entirely different character. It has a 
function connected with nutrition. This is dependent on the presence 
of the glycocholate and faurocholate of soda, which do not pre-exist in the 
blood, subserve a useful purpose in the economy and are not discharged 
from it, are manufactured in the liver and peculiar to the bile, do not 
accumulate in the blood when the function of the liver is interfered with? 
and are, in short, products of secretion. But it has another function 
connected with depuration, which is dependent on the presence of cho- 
lesterine, which is an excretion. The flow of bile is remittent, being much 
increased during the digestive act, but produced during the intervals 
digestion for the purpose of separating the cholesterine from the blood 
which is constantly receiving it. 
Y, The ordinary, normal feces do not contain cholesterine but contain 
stercorine (formerly called seroline from its being supposed to exist only 
in the serum of the blood), produced by a transformation of the choleste- 
rine of the bile during the digestive act. 
YI. The change of cholesterine into stercorine does not take place when 
digestion is arrested, or before this process commences; consequently’ 
stercorine is not found in the meconium or in the feces of hibernating 
animals during their torpid condition. These matters contain cholesterine 
in large abundance, which also sometimes appears in the feces of anima|s 
after a prolonged fast. Stercorine is the form in which cholesterine 19 
discharged from the body. 
YII. The difference between the two forms of jaundice with which n7® 
are familiar, the one characterized only by yellowness of the skin ano 
comparatively innocuous, while the other is attended with very grav® 
symptoms and is almost invariably fatal, is dependent upon the obstruction EXCRETORY FUNCTION OF THE LIVER. 
501 
• *Te bile in the one case, and its suppression in the other. In the first 
stance, the bile is confined in the excretory passages and its coloring 
hitter is absorbed, while, in the other, the cholesterine is retained in the 
a>id acts as a poison. 
]. There is a condition of the blood dependent upon the aceumu- 
c tion of cholesterine, which I have called cholestersemia. This occurs 
~niy when there is structural change in the liver, which incapacitates it 
,olil performing its excretory functions. It is characterized by symptoms 
a grave character referable to the brain and dependent upon the poi- 
°noug effects of the retained cholesterine on this organ. It occurs with 
1 -jTjthout jalm(]iee. 
YY. Cholestersemia does not occur in every instance of structural dis- 
(Se of the liver. Enough of the liver must be destroyed to prevent the 
Ue elimination of cholesterine. In cases in which the organ is but mode- 
f teJy affected, the sound portion is capable of performing the eliminative 
of the whole. 
i .-j"* In cases of simple jaundice, when the feces are decolorized and the 
ie is entirely shut off from the intestine, stercorine is not found in the 
acuations; but in cases of jaundice with cholestersemia, stercorine may 
Je found, though always very much diminished in quantity, showing 
Oat there is an insufficiency in the separation of cholesterine from the 
° though its excretion is not entirely suspended. After death, but 
SlOall quantity of bile is found in the gall-bladder. 
Discussion on Dr. Flint’s Paper. 
T the reading of the preceding paper, the President, Dr. John C. Dal- 
p?NT’ of ew York, said ;—We have ail listened with the greatest pleasure to the 
aper which has just been read. Though the subject is not entirely new, yet 
ij.e aj’c almost exclusively indebted to Dr. Flint for the latest light we have upon 
■ I hose of us who are devoted to physiology are forced to select some par- 
Clnar department, and are therefore apt to be more interested in the develop- 
c|jen.f °f that department than of others; but lam certain that if we make any 
between the departments of physiology, physiological chemistry 
t,Us|; be given the lead, for the study of the ingredients of animal forms lies at 
obtundation of all physiological study. We cannot claim that we are thor- 
jghly familiar with physiology until we know the component substances of 
tl°( les'—what they are, how they get into them, and what they do after getting 
Th ’ wbat changes they undergo; and under what forms they disappear. 
T changes and operations of these substances constitute nutrition. Choles- 
lne, it x recollect aright, was discovered nearly a hundred years ago in gall- 
ac°n?S’ Was f'oun(l to be extraetible by hot alcohol, and was supposed to be an 
deposit in an accidental, morbid form. But slow progress was 
is.a( c, and further discovery, until investigation proved that cholesterine ex- 
Si(,er bi fhe liver. It was afterwards found in fresh bile, and then, alter a con- 
ye e!able apse of time, was shown to be an ingredient of the blood. Some 
ted H subseTuently a curious discussion arose as to whether the nuclei of the 
c °°d globules were not formed of cholesterine, and it was afterwards dis- 
Suj that both the blood globules and the liquor sanguinis contained this 
ijq stanee, which was ultimately found in morbid exudations in all regions. 
cho/1 Can?e bb’- Flint’s investigations in regard to the comparative amounts of 
tio e,S^er'ne g°ing to, and coming from, the organs. In this way the investiga- 
self riaS »olle on for nearly a hundred years, and I suppose that Dr. Flint hirn- 
exl W° not consider that the entire history of cholesterine has been yet 
atlsted. There is a great deal of work still to be done in this field to ascer- 502 
FLINT, JR., EXCRETORY FUNCTION OF THE LIVER. 
tain the amount of cholesterine in the blood, and the different conditions and 
circumstances which determine its precipitation in morbid products. As we 
now know, it also forms an ingredient in some common articles of food. The 
stud}7 of cholesterine seems to me of the greatest importance in regard to 
excrementitious matters. I think we sometimes misrepresent to ourselves the 
character of the excrementitious process, in describing it as a process of destruc- 
tion. But excrementation and disassimilation are not destruction; when food 
is taken into the stomach it undergoes a change there, and a further change iu 
the blood, and so on, until it finally appears as carbonic acid or as choles- 
terine. Then comes the process of excrementation. The food has accom- 
plished its duty in the nourishment of the body, and is wanted no longer. e 
could illustrate the process very well by all the steps upwards from the sowing 
of a cotton-seed to the manufacture of the cotton into cloth, and the final use 
of the rags in the manufacture of paper, and then the return of all the products 
back again to the soil. There are difficulties in the way of these investigations, 
and therefore we ought to feel ourselves very much indebted to those who help 
them on. 
Dr. J. Gr. Richardson, of Philadelphia, said :—Dr. Flint’s experiments estab- 
lish three important facts in science, and complete a physiological chain iu 
regard to the formation of cholesterine in the brain, its entering the circulation 
and being abstracted from the blood by the liver, and its being carried thence 
by the bile into the intestines where it is converted into stereorine. I would 
ask Dr. Flint whether he has made any experiments in regard to the formation 
of cholesterine in ovarian fluid? 
Dr. Flint said:—l have not done so, but cholesterine is liable to be found 
in almost all the pathological formations of the body. 
On motion, the conclusions of Dr. Flint’s paper were adopted as expressing 
the opinion of the Section. Report of investigations made under the direction 
OP PROFESSOR ZAVARIKINI, AT THE INSTITUTE OP 
NORMAL HISTOLOGY OP ST. PETERSBURG. 
COMMUNICATED BY 
PROFESSOR REDREW. 
The Structure of the Sweat G-lands in Man, in the Horse, and in 
the Sheep. 
Dr. Galani. 
The epithelium of the sweat glands in man consists of very minute, 
vai cells, which are polygonal, and which are disposed in two layers, 
Hiniediately under which lies the membrane consisting of fusiform ele- 
Hients with oval nuclei. By means of reagents we discover that these 
T*8 are simply muscular fibres. In the sweat glands of the scalp we 
nd that these muscular fibre cells are intermixed with cells having the 
C T,racfers of connective tissue. 
-O'e epithelium of the sweat glands in the horse and sheep forms only 
HHe layer, while in all other animals there are two layers. The cells of 
*lB epithelium, viewed from the surface, have an hexagonal appearance, 
'i •11|e from the side they appear of cylindrical form. Beneath the epi- 
helium of the horse lie only the cells of connective tissue character, and 
‘ese cells are so disposed one to another as to resemble in form a house 
1 e* _ Beneath the epithelium of the sheep is found a membrane which 
c°nsists of muscular fibres. 
I°r the investigation of sweat glands we have employed the lens 
Hder which we have been able to separate the particles of the glands, 
• for the recognition of the muscular tissue we have used the follow- 
y1 n re.agents, viz., a 36 per cent, solution of caustic potassa, chloride of 
palladium, carmine, and picric acid. 
11. Upon the Termination of Rerves in the Pleura of the 
Rabbit, Bog, and Cat. 
Dr. Lebedeff. 
The nerves, after separating into different arms and branches, termi- 
nate in a network in which it is sometimes possible to discover nervous 
Cells of various sizes. Beneath the endothelium the network is com- 
posed of regular rhomboidal nooses, within which are found sometimes 
cells of the endothelium, in numbers from one to five. Between the 
8 °I fPe endothelium are disposed the fibres, which sometimes envelop 
le cell, and sometimes enter the cell and surround the nucleus. The 
g1 eater part of the nerves possess nerve cells between their fibres, in 
humber from two to fourteen, and this is especially observed in the 
}Th Some nerves do not terminate in the network, but in pear- 
snaped cells. 504 
ZAVAEIKINI, 
111. Upon the Microscopic Anatomy of the Nervous Apparatus of 
the Bronchi and Lungs in the Frog, the Rabbit, the Dog, the Cat? 
the Horse, and the Mouse. 
Dr. Santchich. 
There are within the pleura many nerves which permeate the paren- 
chyma of the lungs. The nerves form a double network, one being ante- 
rior and the other posterior. In each network are disposed from one to 
seventy cells, and the distributions are to the walls of the bronchi, the 
walls of the vessels, and the pulmonic pleurae. The greater number ox 
these cells are bipolar, and some few of them are even multipolar. All 
the nervous fibres emerging from the cells ramify to different parts o± 
the lungs, and form networks. The nervous fibres found in the bronchi 
form two networks, one of these serving for two layers of the bronchi? 
and the other forming a surrounding network. The nervous fibres 
which go to the epithelium of the bronchi form a network exactly under 
the epithelium, and some of them at the same time penetrate the epithe- 
lium itself. If we isolate the epithelium cells, we observe that the 
nerve fibres are in intimate connection with the protoplasm of these 
cells. In the cartilage of the bronchi, viz., in the perichondrium, we 
find the minute fibres of the nerve, which sometimes penetrate into the 
upper part of the cartilage, but are more generally confined to the peri- 
chondrium. The glands of the bronchi are surrounded with a network 
of nerve fibres, which sometimes enter into the epithelium of the glands. 
In the bronchi and in the tissue of the lungs we meet with the termina- 
tions or ends of the nerve, in the form of either round or pear-shaped 
cells, and sometimes we find nerves which terminate in rhombic bodies, 
the nature of which is not at present known. The nervous fibres and 
networks are surrounded with the periaxial space, which space is covered 
with the epithelium cells. For examination the lung is stained with & 
solution of chloride of gold, one-half to twelve per cent., and sometimes 
with nitrate of silver and osrnic acid. 
IY. Upon the Termination op Nerves in the Human Skin. 
Dr. Santchich. 
In the fibrous layer which lies immediately under the epithelium ex- 
ists a nervous network of an extremely close and fine construction, the 
rhomboid meshes being very minute. This network does not contain 
nerve cells, except in very few cases, but within the fibrous meshes are 
to he found epithelium cells, in numbers from one to seven. The nerves, 
after permeating the Malpighian layer, terminate under the horny layei’* 
If the epithelium cell with its nervous fibre be examined under the 
microscope in an isolated form, the fibre will be found in intimate con- 
nection with the protoplasm or body of the cell. Besides the network 
of nerves interlaced between the cells of the epithelium, there are seen 
minute fibres which do not take any part in the formation of the net- 
work, but which are also connected with the epithelium cells. 
Within the outer sac of the root of a human hair is found a network 
of nervous fibres, some of which possess a pulp while some have none. 
Some of these fibres permeate the inner sac, and terminate in a minute 
network around the capillary vessels, while others pass through to the CONTRIBUTIONS TO NORMAL HISTOLOGY. 
505 
epithelium, and here end between the epithelium cells. The papilla of 
hair is supplied by the same network of nerves as the other parts of 
lhe hair follicle. 
. 111 ay at this point describe the nerves appertaining to the fat glands 
J.*d sweat glands of the skin. Around both, the nerves form a network. 
, dh the fat glands some of the nerve fibres lie either immediately 
Jeueath the epithelium or between the epithelium cells, and we have 
Pceasionally been able to distinguish how the nerve fibre, after passing 
lnto the fat gland, terminates in a body similar to a mulberry, with two 
01 four nuclei. The networks of nerves which are disposed between the 
epithelium cells anastomose with each other, so that we can observe how 
foPT njG^ °h fhe papilla is combined with the nerves of the hair 
1 re have worked under the microscope with chloride of gold solution, 
per cent., and for the isolation of epithelium cells we have used a 10 
fer c®nt. solution of common salt. 506 
ON FUNGOUS GROWTHS IN SOLUTIONS FOR HYPODERMIC 
MEDICATION, AND THEIR PREVENTION BY 
SALICYLIC ACID. 
BY 
JOS. a. RICHARDSON, M.D., 
ATTENDING PHYSICIAN TO THE PRESBYTERIAN HOSPITAL, PHILADELPHIA. 
Among the minor inconveniences of medical practice, few are more 
annoying to the careful physician than a failure to afford the hoped or 
prayed-for relief from pain, by the subcutaneous injection of morphia. 
therefore venture to occupy a few minutes of the time of the Section with 
a brief account of a new method for preventing diminution in the strength 
of morphia solutions, in so far as it is due to the common cause of such 
deterioration, namely, the formation in the fluid of fungous growths, 
which necessarily develop at the expense of the contained solid ingre- 
dients. 
If we examine under a microscope of high power one of the white fioc- 
culent masses which appear after a week or two of warm weather in our 
ordinary Magendie’s solution of morphia, we will commonly find it made 
up of an immense number of branching threads, on an average about 
sJob of an inch in diameter, often distinctly septate,and probably recog' 
nizable as the mycelial condition of one of the genera of the Mucorini °r 
siphonaceous plants. 
Complete identification of the exact species is only possible, even for 
the professed mycologist, by investigation of its aerial fructification* 
We, however, often find, as it develops entirely beneath the fluid, an evi- 
dent attempt towards the formation of some sort of reproductive body? 
and in many cases are to be seen in active motion, near the filaments, spore- 
like bodies, analogous to the antherozoids of the unmistakable algfe and 
fungi, which have doubtless escaped from broken fragments of the aquatic 
mycelial threads. 
The atoxic quality of salicylic acid, as demonstrated by the moderate 
and even large doses administered in thousands of cases of acute rheu- 
matism, etc., suggests at once its employment for the purpose of prevent- 
ing the growth of these fungi; and I think it quite probable that it has 
already been so used by others of my fellow-practitioners as well as by 
myself. No exact observations upon this subject have, however, I believe? 
as yet been published, at least in our own country. 
In order to determine the precise amount of this anti phytic agen 
required to produce the desired effect, I prepared on the first of Angus 
last, now five weeks since, one dozen two drachm vials, each containing 
one fluidrachrn of a solution of acetate of morphia (gr. xvj to f|j), such a® 
is usually employed for hypodermic medication. These samples were nurn- 
bered from 1 to 12, and after the acetate, except impurities, had been dis- 
solved by the aid of a small quantity of acetic acid, I added to Nos. 2 anc 
4 each one-sixteenth of a grain of salicylic acid, to Nos. 6 and 8 each one- 
eighth of a grain of the same substance, and to Nos. 10 and 12 each one- PREVENTION OF FUNGOUS GROWTHS. 
507 
garter of a grain of the like material. Nos. 1, 3,5,7, 9, and 11 were left 
a mixed with other ingredients, and all were corked tightly and equally 
xposed to the light, and to the unusually elevated temperature of our 
ciitennial summer. At the end of one week, small whitish flocculi, evi- 
eutly composed of filamentous tufts, were visible in the bottles the con- 
'ds of which were unrnixed with salicylic acid, and similar minute 
peeks, in much less quantity, had made their appearance in Nos. 2 and 
? which contained each one-sixteenth of a grain of salicylic acid. 
Under the microscope, specimens of these tufts were seen to be made up 
t mycelial threads, probably of some species of physomycetous fungi, 
jas I have already described. At the present time, after five weeks 
lave elapsed, those vials which were not protected by salicylic acid pre- 
set every one large masses of fungous growth, as each member of the 
* e°tion may see for himself by inspecting them upon the table. Nos. 2 
11(*. 4, in each of which it will be remembered that one-sixteenth of a 
vlain of the acid was dissolved, display small tufts of mycelial threads. 
m 8 shows a mere trace of fungous growth, whilst Nos. 6, 10, and 12 
. xhibit to the naked eye (as they do also under a one-fifth objective) no 
Wheat ion of living fungi in the slight deposit of brownish impurities let 
a| at the bottom of the glass. 
49 specimens of similar morphia solution, containing one-eighth of a 
Shim of salicylic acid to the fluidrachm, carried in the hypodermic syringe 
ease, and used from time to time in my daily practice during three months 
} cooler spring weather, no flocculi of living fungi were discoverable with 
le naked eye or under the microscope. Further, no unusual effects of 
any kind were observable in patients, some of whom received as much as 
at a qose> Injections made into my own arms for the purpose of 
esting the fluids in Nos. 10 and 12, produced but little smarting sensa- 
,lon, and afforded the ordinary anodyne, with no uncommon nauseating, 
aepressing, or disagreeable effects of the drug. 
4 therefore recommend the preparation of a fluid for hypodermic injec- 
ts according to the following formula; Morphise acet. vel sulph. gr. 
y,vj 5 acid, acetici (No. 8), gtt. ij ; acid, salicylic, gr. iss ; aq. destillat. f3j. 
* a sediment is left undissolved, this liquid should be filtered, or, after 
landing a few days in a vial, or preferably a conical glass, the clear fluid 
rilay be drawn off by means of the hypodermic syringe itself, and pre- 
Sei'ved for use. By employing such a preparation, the practitioner is 
almost certain to avoid the disappointment in the relief of pain liable to 
ailse from injecting a solution, the strength of which has deteriorated, 
tlml he will also escape that danger of producing abscess by the insertion 
Bingous elements beneath the integument, against which we have 
een cautioned by some authorities, although perhaps without sufficient 
cause for the warning. 
4n conclusion, I would suggest that a similar application of salicylic 
acid to the preservation of watery preparations of quinia, atropia, etc., to 
delations of bromide of potassium, citrate of potassium, etc., and to vege- 
able infusions, when it is desirable to avoid the employment of even 
small quantities of alcohol, may prove of great value to the pharmaceutist 
as well as to the physician. 508 
RICHARDSON, 
Discussion on Dr. Richardson’s Paper. 
After the reading of the preceding paper, the President, Dr. John C. Dad- 
ton, of New York, said:—Dr. Richardson has referred to two disadvantage9 
that might result in the hypodermic use of solutions of morphia without this 
precaution, but in language which leads us to suspect that perhaps he does not 
think much of the danger of producing an abscess. I would like to inquire 
whether there is any definite information in regard to the danger, or whether 
in liis opinion the danger exists at all ? 
Dr. Richardson said :—Theoretically I have felt inclined to suppose that 
danger would exist, but in order to test the theory I have tried several experi- 
ments, injecting my own arm with a solution containing fungi, and in no case 
has an abscess been produced. 
Dr. Dalton said :—Of course it would be more agreeable to inject a fluid not 
containing fungous growths ; at the same time ought we to anticipate that 
these growths would continue their development in a subcutaneous tissue ? 
My attention was once very directly called to the difficulty that might arise 
from such development. I made .a series of observations in order to determine 
how many definite kinds of microscopic fungi might be derived from ordinary 
atmosphere. Taking fresh slices of boiled potato, I placed them on a plate 
that had been immersed in boiling water, and covered them with a bell-glass, 
under which also a moist sponge was placed. A considerable variety of these 
microscopic growths showed themselves from time to time, of various colors; 
and notwithstanding their minute size and apparent want of specific character, 
they had differences in form and size and structure. A few weeks after finish- 
ing the experiment, 1 found one day on the back of my hand a spot which was 
irritable and itching; this spread, two or three other spots appearing, until 
finally I was compelled to give attention to the matter, and on examination I 
found that my hand was the seat of a tricophyton, which was finally removed 
after treatment for four or five weeks. It then occurred to me that perhaps I 
had inoculated myself while engaged in the experiments. I had been raising' 
microscopic fungi, and I had unknown to myself been infected with them. Fur- 
ther, upon the same subject, Dr. Yandoren told me that in a series of expel'1' 
ments he had demonstrated that the ovum of the mosquito is not deposited 
directly in the water, but floats in the atmosphere, and is brought down by the 
rain. So it would seem that in reality there are a larger number of germs, 
both vegetable and animal, that may arrive at their destinations through the 
elements. My impression is that this fact in regard to the ovum of the mos- 
quito is new. 
Dr. Richardson said:—My recollection is that our natural histories gave 
us pictures of the mosquito in the act of laying eggs in the form of a boat which 
floated upon the surface of the water for some days or weeks before hatching* 
I think the experiments mentioned are entirely novel. 
Dr. Dalton said:—ln regard to the boat in which the eggs are contained,19 
it barely possible that Dr. Richardson may be thinking of the mosquito itsed 
coming out from the integument of the larva? 
Dr. Richardson said:—No, sir; that is a subsequent performance. But \ 
wish to ask Prof. Dalton in respect to the infection of which he spoke, whether 
his health had been deteriorated in any way ? I make this inquiry because one 
of the most difficult questions in regard to the development of these ento- 
phytic and epiphytic diseases is whether the health is first deteriorated, so that 
a suitable nidus for the fungi to grow in is afforded, or whether, on the con- 
trary, the fungi are the primarily active agents which deteriorate the health. < 
Dr. Dalton said;—l can testify, with the greatest confidence, that I was im- 
perfect health. 
Dr. Richardson said;— Some years ago I had an interesting case bearing 
upon this point in my own family. On the chin of my little daughter appeal’d PREVENTION OF FUNGOUS GROWTHS. 
509 
small pimple, which became inflamed, and seemed to have a yellow head upon 
In examining it I was struck with its remarkably dry appearance, and its 
1 Phur-yellow rather than brownish hue. I placed a portion of it under the 
R'roscope, recognized the presence of the fungus of Favus, and soon cured the 
s^ase with corrosive sublimate solution. The child was in perfect health, 
■ . I could only account for the attack by supposing that she had leaned her 
a ’!1 on the sill of a car-window, where some person infected with achorion 
, cil°nleinii had accidental!}’ left a few spores of the disease. I would like to ask 
question, whether there has been any corroboration or disproof of the 
; periments described by Simon in regard to the dependence of ocular diphthe- 
a uPon micrococci developing in the cornea of rabbits; where two punctures 
ei;e lnade, in the one side with a diptherized needle, and in the other side with 
c ean needle, in every case the result having been that the cornea infected 
as Marked with brownish streaks, which under the microscope displayed 
fungus spores. I look upon it as exceedingly important to know whether 
le fungi can develop in an internal portion of the system, secluded from the 
b and that in a previously healthy part of the organism. 
n>r. Dalton said:—l am not familiar with any corroboration of those experi- 
ents. I tried some experiments of a similar kind, two or three years ago, with 
suits which convinced me that it did not require for such parasitic growths 
le Previous existence of a morbid condition of the recipient. The experi- 
ents were with regard to the ordinary decomposition or rotting of fruit. It 
ciU no longer be maintained that rotting is a continuation of the ripening pro- 
ess* An external wound is absolutely necessary to the rotting of any fruit 
1 a hard integument, such as the apple and the pear, though it is not 
solutely necessary with other fruit, like the orange. I tried the experi- 
j ents with apples, and proved that they could be kept for any length of time, 
uninjured, and also that rotting was contagious. The rot could plainly be 
een to spread away from the point of contamination. 1 have exposed a dozen 
Pples, half sound and half broken, to the ordinary atmosphere, and the rot 
> began at the point of injury. The spores came in from the atmosphere. 
Uueed, an injured apple can be kept from rotting by being protected from the 
uiosphere. I have taken a sound apple, and made a little cut in it, and then 
bllt it under a bell-glass, and kept it an indefinite time. The experiments can 
e easily tried, and are most convincing, 
in i ?,ICHARDSON said:—You speak about the rot starting from the wound 
the integuments of the apple in a way that resembled the spread of erysipelas 
°'u the edges of a wound in the human body. Did it ever occur to you to 
i, 2er_the wound in the apple with carbolized putty before exposing it to the 
Action of the fungi which cause decay, and thus throw a ray of light upon 
of the great surgical problems of the day? 
r- Dalton said :—I never did so, but I think that it might be an interesting 
exPeriment. 
Dr. Richardson said ;—I w’ould ask Prof. Rudnew whether these experi- 
®uts of Oertel and Nassiloff (the latter, I believe, a Russian observer), nar- 
i,t hi Prof. Simon’s report, have been confirmed or disproved by others of 
hl® countrymen ? 
bit Dudnew, of St. Petersburg, said :—I have studied these investigations, 
1 have made no similar researches myself, and believe that the views of those 
'Piemen are still considered sub judice. 510 
THE MECHANISM OF JOINTS. 
BY 
HARRISON ALLEN, M.D., 
PROFESSOR OF COMPARATIVE ANATOMY AND ZOOLOGY IN THE UNIVERSITY OF PENNSYLVANIA) 
SURGEON TO THE PHILADELPHIA HOSPITAL, SURGEON TO ST. JOSEPH’S HOSPITAL, BTC. 
The1 limb being subservient to both support and motion,it is reasonably 
to expect that in certain joints the former function should be observed? 
and in others the latter. When the apparatus for support is conspicuous 
the joint may be said to be of static value. But when this purpose lS 
subordinate to flexion (i. e. deviation from the axial line of the limb), the 
joint may be said to be of dynamic value. 
The most striking distinctions between the static and dynamic articd' 
lations lie in the relations of the opposed surfaces. To explain this p°r' 
tion of my remarks a few words of a general character are necessary. ' 
premise that the typical “ ball and socket” joints consist of well-defipeC 
balls embraced by perfect sockets. Ro such joints are found outside 
of the vertebral column. The articulations between the bodies of 
vertebrae, although spoken of as amphiarthroses, are in truth “ban® 
and sockets.” The central intervertebral mass is the “ballthe op' 
posed vertebral surfaces and the peripheral interlacing fibrous band 
of the disk make up the “ socket.” I also premise that the siropleS. 
forms, or at least the first forms, of joints appear in the vertebra 
column, since this structure answers to the axial line of the bojy- 
The movable union between any pair of segments or bodies of tb1& 
axis may be taken as typical of what is possible under more comply 
conditions elsewhere. If it is remembered that a rod or axis cann° 
be projected far without segmenting, the best basis is secured up°u 
which to rest any consideration of arthrosis. Obviously motion betwee’1 
a pair of bony segments is the main fact to consider in every problem- 
The questions which I believe can be asked with reference to further 
development of this theme are, in what way is support secured throug 1 
a series of such mobile joints, and how can the apparatuses of 'motion 
varied ? 
The limb is a special structure appended to the body. It moves chiefij 
at the joint between its first and second bones. This joint, in both the 
anterior and posterior extremities, is a ball and socket, as usually d® 
scribed. But it evidently in each instance is a portion of a ball opp°seL 
to a partial socket; since only small portions relatively of the head 0 
the humerus or femur can be brought in relation to the socket at 011 
time. So generally throughout the limbs (although in less marked de- 
gree), it is found that segments of spheroids play within concave 
faces. I propose to call all such surfaces modified balls and sockets dJ 
type of which is exhibited only in the vertebral column), and proceed 
define the two main varieties, named above, to wit: (1) Where the rela 
1 [This paper is an abstract of a more elaborate study which the author reserves tb 
right of publishing hereafter in a separate form.—Editor.] MECHANISM OF JOINTS. 
511 
10118 between the two surfaces are such that the ball lies in its socket, 
nc suggests rest. (2) Where the ball is suspended from the socket, and 
uggests motion. The occipito-atloid articulation is an example of the 
lmi the temporo-maxillary of the second variety. 
the dynamic joints are apt to be crossed by powerful muscles, if in- 
eed it may not be said of them that the muscles aid to a great degree 
* maintaining the efficacy of the articulations. Thus if the muscles 
°ut the shoulder-joint are divided, the humerus breaks contact with 
e. scapula, and the joint is destroyed. This is also true of some other 
aJticulations ,as the temporo-maxillary, in part. In some other instances 
0 the same variety, the relation while not maintained by muscular action 
strengthened by the presence of muscles crossing the joint, as at the 
ankle and wrist-joints. 
y intermediate ones. Some joints, as the knee and elbow, do not 
. Rurally fall within either static or dynamic kinds. The elbow- 
JOlnt is especially difficult to study, it being varied from its type to a 
markable degree. The knee-joint, although exceedingly intricate, is 
in its several portions to static and dynamic functions, the 
’’Uctural modifications from typical points being pronounced. In the 
arne way the first or swinging joints in the respective limbs, while of the 
ftnie variety, since the ball is suspended from the socket in both, differ 
'°m each other in that the hip-joint is more fixed than the shoulder-joint. 
11 a word the hip-joint is a dynamic joint, modified or specialized to do 
atic work. In order that the work can be done effectively, stout bands 
moss its capsule, and the head of the femur is received within the aceta- 
umni in such wise that the weight of the body is borne, not upon the 
Centre of the head of the bone, but upon its upper surface. 
these general statements be remembered in studying the etiology of 
aeture and dislocation, more especially in examples of indirect violence, 
'vbl be recognized that a static joint will not be apt to be dislocated 
If long as the weight of the superincumbent mass presses directly within 
ale. s°cket. Thus a dislocation at the occipito-atloid articulation is rare, 
818 dislocation of the astragalus. But if the force be obliquely directed, 
arising the weight to be received violently against the side of the socket, 
1011 the joint may easily be luxated. 
■ yu the many positions assumed by the body, it often happens that an 
t°JUry may be sustained from a reversal of the normal or typical rela- 
Thus while the extremities are described from the shoulder down, 
P 111 hands free (the main idea of the entire limb being motion), it 
. eeomes a different subject when studied with the limb suddenly assum- 
t'M' a supporting use—as for example when the body falls forward, and 
0 and strikes the ground while the limb is extended. Here the head 
of f*6 llUrnei’us is driven up against its socket by the downward weight 
the body, and the idea of swinging is lost. In a word, a dynamic 
is abruptly called upon to be a static one. A natural result is 
1 x.a^19n. the shoulder, or, if the muscles about the joint be particu- 
*• rigid, fracture of the clavicle. In less degrees of violence, the force 
expended nearer the hand, the wrist is either luxated or the radius 
g ?>en* In medium degrees of violence, particularly seen in young 
tj )Ject8> the outer condyle of the humerus will break by the weight of 
doe b°dy being thrown through the convex radial head of the humerus 
thZn^vd ul3on the fixed concavity of the head of the radius, provided 
a le arm be forcibly extended. If the arm be partially flexed, the 512 
ALLEN, 
weight of the body being transmitted to the forearm at an angle, the 
humerus will he apt to break transversely a little above the elbow-join^ 
I do not speak here of the frequency of such fractures induced by ni- 
di rect violence, but only of the way in which the articular surfaces a 9 
described would in my judgment behave under the circumstances de- 
tailed. 
The lower limb, however, is always prepared for the conduction ot 
lines of force so exceptional in the upper. The whole limb, while ex- 
pressing motion, is also designed to sustain the weight of the body* 
Hence the greater strength of the joint surfaces, as well as the more 
prop-like appearance of the limb. In walking, the weight of the body 
is sustained for one moment at the astragalo-scaphoid joint in a nearly 
straight line, embracing, in the limb, the femur, tibia, and astragalus* 
The scaphoid bone and the inferior calcaneo-scaphoid ligament constitute 
a socket which receives and sustains this enormous weight. In falls from 
a height, which terminate by the foot striking, the weight not being 
received directly within the centre of the socket may be deflected, and 
luxation of the astragalus may occur. Hut from the rarity of this acci- 
dent I infer that the mere exaggerations of the lines of force acting 111 
its accustomed directions, are less injurious than the same kind of fore0 
acting upon the superior limb which is taken at a disadvantage. 
The remainder of my remarks will be in application of the above data 
to the study of joints, including new observations of some special form9 
of articulation. 
In the knee-joint, for example, I think that it can be shown, from the 
shapes of the articular surfaces, that the outer femoral condyle is the 
static or axial half, and the inner is the dynamic or swinging half. Tl‘l9 
study involves many details which would occupy too much time to elabo- 
rate.1 Suffice it to say, however, that when a person stands erect, the 
femur rests upon the tibia as a ball in its socket, chiefly through h9 
outer condyle. In flexion, this condyle is “switched off” (for the most 
part through the action of the popliteus muscle upon the outer semilunm 
cartilage), while the swinging of the inner condyle of the tibia upoll 
the inner femoral condyle is initiated—not, it is true, by a ball suspended 
from its socket, as much as by a gliding of a shallow concave tibial sur- 
face upon a slightly convex femoral surface. 
The term “switching off,” as applied to the outer femoral condyle.11! 
passing from extension to flexion, needs explanation. The outer tibim 
condyle is observed to be convex toward the tibial spine. It is evideu 
that, if any portion of the convex surface of the femoral condyle com69 
in contact with this convexity, no support is possible. This is wha 
takes place when the knee is flexed. Hut when it is extended, the femora 
condyle is placed firmly in a tibial concavity, the inner boundary °, 
which is now formed by this eminence. As above stated, the outer semi- 
lunar cartilage is the factor producing the change. The outer tibial coo- 
dyle is a true saddle surface, modified by the presence of the serniluua 
cartilage. The best example of a pure saddle surface is seen on th 
proximal surface of the trapezium. Here the convexity increases ak 
toward the inner border. The first metacarpal bone of the thumb may 
be described as lodged upon this convexity in flexion of the thumb, all 
] The details embrace the study of the cancelli of both femur and tibia, the shapes of 
femoral, tibial, and patellar facets, the shapes and motions of the semilunar cartilageB' 
well as a refreshened account of the so called crucial ligaments. MECHANISM OF JOINTS, 
513 
relaxed or “ switched off'” in extension. It is evident that this lodg- 
eilt and relaxation must be limited by appropriate ligaments. Inordi- 
ate or uncorrelated motions determine dislocation, 
fo the limbs of some lower animals, special adaptations in joints are 
eeogi)ized, which result in fixing or locking some of the facets. The 
result of such locking is to conserve muscular power. Ap- 
f Nations of this principle to some joints in the human frame may 
prove useful. Thus the knee-joint is nearly immobile at forced flexion 
forced extension, but is freely movable at points between. It is 
Probable that a careful study of other joint-surfaces will show similar 
Peculiarities. 
fo>e facets upon the ends of bones are arranged in the order of the 
Recession of the bones themselves in a given limb. The most evident 
arrangenient is to have a facet upon the proximal and distal surfaces of 
ach bone, in such wise as to allow the longitudinal axis to answer to 
foe centre of each facet. These may be termed primary facets, since 
toley are the most constant in any series of studies, and are least subject 
q change in special apparatuses. Assuming that the generalization of 
is correct, that a process sent from the main shaft of a bone, as 
°ni the ribs of fishes and birds, may be termed a rayed process or actino- 
P°physis, I will suggest that the same term may be given to the analogous 
P1 °cess in a forked rib. If this be conceded, I think it not improbable 
~ Jah in the event of the shaft of a bone and its actinopophysis becoming 
acet-bearing, such ray-borne articular surface should receive the name 
, actinic, or secondary surface. I believe that the inner femoral con- 
-3 k is an instance of such a surface. I also believe that the surfaces 
i i}on the sides of certain bones, as those between tarsal and metatarsal 
°nes, and between the tibia and fibula, or between the radius and ulna, 
10 of subordinate value to the primary facets, since they appear to be 
by mutual compression of the bones themselves, and hence may 
0 fer. lateral or tertiary facets. 
joint may be said to be at rest when the least pressure exists be- 
• Weeri its opposed facets. The supine position will tend to rest static 
gOts, since it diminishes the pressure of the weight. It will not, neces- 
aii]y, SQ reg£ comp]etelj dynamic joints, since the muscles may be more 
g1 less active in the supine position. The lower jaw, for example, is not 
k° tested. It is evident that to place in absolute rest a joint of this 
f()lnC ’ niuscles must be kept from contracting. Any apparatus, there- 
tlle’- fo keeP a joint at rest, must include all the muscles influencing 
a|e joint. When it is recalled that in the lower extremity the muscles 
le so disposed that the contraction of those arising from the hip effects 
p Ja»ges in portions beyond the knee, and even down to the foot, it may 
e concluded that to make quiet any one, or part of one, of these surfaces, 
*c entire limb should be kept quiet.1 
°e on one side is larger than that on the other, those portions at any 
nie not in use, may be said to be at rest. Thus, in the knee, some por- 
fl01!8 °f the condyles are at rest in extension, while others are at rest in 
p>gXlo.n* fo follows from this that, in diseased action, products of patho- 
& aesis will be absent from surfaces removed from pressure or friction. 
and tffo18 Perhaps best secured at semi-flexion, i. e., at the point at which extension ceases, 
Point i>xlon lla.s but just begun. All parts are then relaxed. This, while a theoretical 
ni some joints, has fixed value at the knee. 
33 514 
ALLEN, 
How pressure long continued will destroy tissue, while friction will iO' 
duce hypernutrition. It can be seen when a diseased joint is examined, 
with this fact in mind, at which points the pressure, and at which the 
friction has been. Thus in a knee-joint long the seat of chronic rheumatic 
arthritis, the outer condyle of the tibia will be found reduced in size, 
while the inner will be exaggerated. Also knee-joints flexed in diseased 
conditions will have points of pain localized at the inner side, while knee- 
joints extended in similar conditions will have like points developed upoll 
the outer side. 
If the outer condyle is axial, it will so remain, no matter what p°r' 
tion of the axis is reserved for articulation. So that in motion, attei 
excision of the knee-joint, the line of axial support is preserved, and il 
good limb for standing is secured. But in consequence of the special 
apparatus for flexion having been removed, the limb below the knee is & 
mere wabbling appendage during attempts at bending. 
Discussion on Dr. Allen’s Paper. 
After the reading of the preceding paper, the President, Dr. John 
Dalton, of New York, said :—The paper contains much that is new to I*l6’ 
while many things previously unexplained are now made clear. It has, ho"' 
ever, occurred to me, as it undoubtedly has to the author, that he might havC 
extended his principle also to the ligaments. I recall that while dissecting 
joints, as a student of medicine, after removing the external ligaments a*l( 
retaining the capsule only, on bending the members making up the joint, 
was impossible to say when certain parts were on the stretch and when HotJ 
It appears to me that this could also be explained by supposing the intern*1 
concave surface of the capsular ligament to be made up of a large number 0 
facets operating in succession. 
Dr. Allen said:—The occasion demanded that a single topic only should he 
discussed. Had time permitted, much could have been said upon the relating 
that articular surfaces bear to ligaments, both intrinsic and extrinsic. '] *‘e 
fasciae and muscles of every limb are also interested in every joint moti011’ 
and of the latter more particularly those that cross more than one joint. 011<3 
series of these problems blends into others that the line drawn bet’wee'1 
any two of them must necessarily be arbitrary. As Emerson has said, 
answer to one riddle is another riddle. All our conclusions are relative, **n 
invite renewed investigation. With reference to the ligaments of the k'iee 
joint, it may be remarked that the great variety of function assigned to the'11 
by different writers is proof that their actions are not thoroughly understqo 
Dr. Burt G. Wilder, of Ithaca, N, Y., having asked permission, as a visit01’ 
to comment upon Dr. Allen’s paper, said :—I understood Dr. Allen to say tll£l 
the primary or fundamental movement of the limbs, among mammals, 'va 
forward and backward as with most quadrupeds, but that man had the p°'v 
of raising the arms away from the trunk by means of the deltoid muscle, afl 
that the head of the humerus presented a peculiar and characteristic fa°e ’ 
indicative of this movement of the limb. I would remind Dr. Allen of certai 
facts in embiyology and comparative anatomy, well known to him of coulS ’ 
but apparently not present in his mind at the time of preparing his paper- 
At a certain period of development, the forearm of man is in a state of P1 g 
nation, as it is permanently in most quadrupeds, and afterwards acquires 
power of complete supination, which seems to be correlated with the peCtl ‘ 
action of the entire limb alluded to by Dr. Allen. But, at a still eat \ 
period, when the limbs have first appeared as little buds from the sides ox 
body, their narrow borders are forwai’d and backward, while their flat surf*10 MECHANISM OF JOINTS. 
515 
e ovlt\vavd and inward. Were any movement possible at this period, it is 
_ oent that to be effective it would have to be not forward and backward, but 
tjMVard and downward, that is, dorso-ventral, and thus similar to that of which 
In ]• lman arm Ig capable in its greatest perfection in man’s adult condition, 
ike manner, as far as we know, are developed the limbs of all Vertebrates; 
/ the dorso-ventral or primitive motion is retained with most fishes and 
1 the marine turtles. It is likewise persistent throughout life with the 
Viatic mammals, as the whales and porpoises, the manatee and dugong, the 
and beaver, and the curious duck-bill, or Ornithorhynchus, of Australia, 
may be worth while to examine the shoulder-joint of these forms for the 
culiar facet which distinguishes man from the ordinary quadrupeds, 
Hie 1’ aS l' J^en bas sta^e(l? distinguishes the upper and nobler arm from 
ieg, and is likewise peculiar to man in his adult and perfect condition, in 
Vrast with the monkeys and ordinary quadrupeds, should be also the 
P Cordial movement of both the arms and legs of all mammals, as indicated 
in nJle eaibest condition of the limbs, and that it should likewise be retained 
r 10 case of certain low forms. In other words, the highest estate of man 
ails his earliest condition, and suggests his relationship to the lowest 
fibers of his class. 
„ r;; Allen said:—While the act of walking expresses the swing of the 
iy .eri.or extremity, a yet better example of the characteristic motion of this 
f 18 swimming. This act, as performed by a man, is essentially different 
o,u the same act as essayed by a quadruped. In man, the arm is at one 
sfi116 fo.rcibly abducted by a powerful deltoid. This muscle, in its distinctive 
aPe, is not developed in the lower forms of animals, and in consequence the 
*UIa* play of facets between the scapula and humerus is, with them, absent. SECTION ON SURGERY. 
PRESIDENT OF THE SECTION. 
JOSEPH LISTER, F.R.S., 
OF EDINBURGH. 
J. A. GRANT, M.D, 
TIC E-P RESIDENTS. 
JOHN ASHHURST, Jr., M.D., 
OF OTTAWA. 
SECRETARY. 
OF PHILADELPHIA. 
JOHN H. PACKARD, M.D., 
OF PHILADELPHIA. 
taking the chair, Professor Lister said : 
: 
pr I am well aware that the time of this Section is exceedingly 
j ec.lous, I cannot refrain from expressing my deep sense of the honor I have 
eived, an honor as great as it was entirely unexpected, in being called upon 
8i Pl>eside over the Surgical Department of this great International Congress, 
He as does in the chief centre of medical instruction on this vast conti- 
m eric an surgeons are renowned throughout the world for their inven- 
e genius, and boldness and skill in execution. It is to America that we 
hi)6 the greatest boon ever conferred upon suffering humanity by 
ameana ; from America came the ligature of the common iliac artery for 
sj eui’ism; the ligature of the internal iliac for the same disease; the “exten- 
il;?ri fieatnxent” by the weight and pulley for fractures of the thigh, and other 
and diseases; the reduction of dislocation of the hip-joint by rnanipu- 
to n'1 ’ fbat Tn°del of ingenuity, which I cannot mention without alluding 
blit 18 llame °b ds inventor, Sayre’s splint for morbus coxarius. These are 
hav SaUlples °b what surgery owes to this country, and it might, therefore, well 
sid 0 een fbat some American surgeon should have been called upon to pre- 
hion°Ver Section of the Congress. Yet I assure you, gentlemen, that 
Per .aS est,eem fids honor, it is the more gratifying to me, because lam 
siuuled that it has not been conferred on account of any special merit of 
Sa .°Wn’ but in consequence of the interest felt by the profession in Antiseptic 
st I^ei’3,i with which my name happens to be connected. It was the circum- 
thpnCe observing in the programme of the business of the Congress that 
A.Bobject8object of Antiseptic Surgery was to come on first for discussion, that led 
■tyj. ° oross the Atlantic; and 1 should be pleased, indeed, if the discussion 
of pi I*s ab°ut to take place should have the effect of strengthening the belief 
Prb pr°bession in the truth, the value, and the practical application of the 
lciples of Antiseptic Surgery. 518 
ANTISEPTIC SURGERY. 
BY 
JOHN T. HOHGEN, M.D., 
PROFESSOR OF SURGICAL ANATOMY AND OF FRACTURES AND DISLOCATIONS IN THE ST. LOUIS 
MEDICAL COLLEGE, ST. LOUIS, MO. 
Putrefaction is a decomposition experienced by animal substance3 
when deprived of life and placed under special circumstances. The pr°j) 
ducts of putrefaction are the results of the retrograde metamorphosis 0 
nitrogenized substances. The process bears a striking resemblance 
similar retrograde changes that occur in vegetable matters, resulting 111 
the production of carbonic acid, alcohol, acetic and butyric acids, etCo 
while the products of the decomposition of animal substances are repl'6' 
sented by carbonic acid, ammonia, butyric acid, leucine, sulphurette 
hydrogen,1 and many other matters whose chemical characters are n° 
well established, and yet which cannot but be recognized as active ageU9 
in the production of septicaemia. Pasteur has shown that neither 1,1 
vegetable nor in animal substances can putrefaction occur rapidly with' 
out the presence of living germs.2 . 
Tyndall has, by the aid of electric light, and by almost innumerah 
experiments in reference to the development of living organisms, shoW11 
that the germs, without which putrefaction cannot be induced, and w* 
out which living organisms cannot be made to appear in vegetable Jll 
animal infusions, are found in unnumbered multitudes in the atm°9 
phere.3 The observations of Rindfleisch make it appear that these pid 
factive and infusorial germs are abundant in water (terrestrial waterb 
and less abundant,4 and perhaps not even present, under ordinary circa*11 
stances, a few hundred feet above the earth’s surface.5 Tyndall ha9’ 
1 The Antiseptic System, by A. E. Sansom, p. 31. Nitrogen, hydrogen, ammonia; s. 
phuretted, carburetted, and phosphuretted hydrogen ; carbonic acid ; carbonic oxide; ace 
butyric, and valerianic acids, and various other phosphorus and nitrogen bases T „ 
2 Quarterly German Magazine, 1872; Mildew and Fermentation, by A. I)e Bary. ;.on 
ing yeast cells capable of growing and budding are absolutely necessary to the introduc 1 
of fermentation. ... In dead substances in which we find bacteria, they are undoubte 
the vital promoters of decomposition. 
3 British Medical Journal; abstract of paper read before the Royal Society, January 4 
1876, by Prof. Tyndall. f, 
4 Yirchow’s Archiv, 1872, Bd. liv. S. 402. Examination of Lower Organisms, by 1J 
Rindfleisch, of Bonn. Inaugural Thesis by Lothar Jasper, of Berlin, 1873. Treatm®11 
Wounds by the Open Method and by Antiseptics Atmospheric air carries , 
organisms which produce suppuration. .. . The air does not contain the organisms v j 
produce decomposition, these are contained in terrestrial water and on all objects moist61 
by it. _ 1054 
5 See The Antiseptic System, by A. E. Sansom, in which Schrceder and Dusch (i° 
and 1859) testify that air passed through cotton-wool, which acted as a filter, was free 1 
organisms, (p. 36.) “In 1860 M. Pasteur . . . filtering the air through a quantity or £ 
cotton, dissolved the latter in ether, and thus obtained in a small space a number of b°^flC[ 
whose appearance announced them to be organized.” (p. 35.) ... He sowed the germBj g 
produced organisms. “In some places the air was more fruitful than in others; especial Jjn 
fertility diminished in proportion to the altitude from which it was obtained.” (p- 36.) 
the air of sick rooms, hospitals, crowded halls, etc., many fungoid organisms have j 
noted by Trautman, Brittau, and Swayne, Dundas Thomson, Rainey, Lund, Lemaire, ANTISEPTIC SURGERY. 
519 
Moreover, shown that, in the absence of currents of air, the germs do not 
Vea?h infusions contained in vessels terminating in bent tubes, the ends of 
Teh are directed downwards, showing that germs must fall, or be carried 
• y currents of air, into infusions, if they reach them at all, and establish- 
ing beyond a doubt that the specific gravity of the germs1 is greater than 
th«t of the atmosphere. 
asteur has determined that the ferments present different physical 
peculiarities,2 so that the one may be distinguished from the other, and 
'at they feed upon albuminoid substances.3 Prof. Tyndall filled 100 
u )es with infusions, and from the irregular manner in which the con- 
erds of the individual tubes were smitten, concludes that the germinal 
Matter of bacterial life is not uniformly distributed in the air,4 and thus 
apcounts for the difference in the behavior of different wounds similarly 
3 
fhe atmosphere of hospitals seems to be pervaded by living germs, and 
le walls and ceilings seem to be encrusted with them. Chaivet6 found 
Putrescible matters in the atmosphere and on the curtains, the windows, 
16 walls and the ceilings of the Hospital Saint Louis. He also states 
'at the vapor of water condensed near a suppurating wound is charged 
'uth irregular corpuscles resembling dried pus. “ The experiments of 
uauveau and Burdon Sanderson demonstrate that if a septic fluid capable 
j producing toxaemia when injected into the veins of a living animal 
• e drained through a porcelain filter, the liquor so filtered may be in- 
jected with impunity, whereas the solid residue remaining on the filter 
Retains in full force all the septic properties of the original fluid matter.”7 
Lund found bacteria in the air of the Manchester Royal Infirmary.8 
Septicaemia, in the surgical sense, expresses that condition of the blood 
'Mich is induced by the presence of the products of putrefaction, a con- 
flict! of the circulating fluid that unfits it for the proper performance of 
j Unction. Putrid matters may enter the circulation through any of 
. mucous, serous, or cutaneous surfaces, or from any part of the body 
11 which the}7 may be present.9 
Li surgery, the meaning is limited to the presence of putrid matters 
ansorne. More recently Dr. Maddox lias carefully examined the particles derived from 
a °. atmosphere,” . . . and “ found pollen grains, minute germs of fungi or protophytes, 
dt/ excessively minute bodies, ‘ molecules,’ ‘ globules,’ etc.” (p. 59.) “ Dr. Percy found the 
fjijS °f the British Museum to contain 50 percent, of inorganic [Qu. organic?] matter. 
folT ■ est investigations of this subject have been made by Mr. Tichborne, P.C.S. The 
p °Wlng were the results of analyses : Street dust in Dublin contained organic matter 31 
Du t<rlk 'iust from places of Public Concourse contained organic matter 32 to 53 per cent. 
strong Nelson’s Pillar, 134 feet in height, contained organic matter 29 per cent.” (p. 60.) 
Put -f6 Ll6 Antiseptic System, by A. B. Sansom, p. 58. Pasteur and Lister find that 
2' mactive germs are arrested in bent tubes, 
of '6e ®ailsom, p. 36. “By further researches Pasteur concluded that the different kinds 
met with in putrefying solutions differed widely in the conditions of their 
convglon their vitality. Some absorb oxygen and excrete carbonic acid ; others the 
Pat/ s^ur> Annales de Chimie et de Physique. Burdon Sanderson, Transactions of the 
nic ,10j°»ical Society of London, vol. xxiii., 1872. Cohn, Quarterly Journal of Microsco- 
i 1873, p. 156. 
s pUp°fb P- 36; Pasteur’s experiments. 
j„ r°‘- I'yudall’s recent researches; Abstract of paper read before the Royal Society, 
s 1876. From the British Medical Journal. 
7 la‘yct, Memoires de l’Acad6mie Imp6riale de Medecine; Paris, 1863, tome xxvi. 
Vli-i**! Lecture on Septicaemia, delivered January 26, 1876, by S. Messenger 
g Ihjq’ L-R-C.S., Surgeon to the Manchester Royal Infirmary. 
Pathology and Morbid Anatomy, by T. Henry Green, London, 1876. HODGEN, 
derived from the decomposition of the solids and liquids of the body 
itself; and these putrid matters may be formed either in parts in direct 
contact with the air, or in those with which the air does not come directly 
in contact.1 Common observation indicates that absorption of these noxious 
matters takes place more rapidly in recent wounds,and in the early stages ot 
inflammations, while the experiments of Billroth attest that after healthy 
granulation is fairly established, absorption of putrid matters goes on 
so slowly (if at all) that the phenomena of septicaemia are not presented. 
He says,2 “Certain circumstances are necessary for putrid matters to be 
taken into the blood of man. Such substances are taken through tb® 
healthy skin and mucous membranes when the putrid substances have J 
destructive or cauterant action, or an active power of penetrating, lik® 
fungi and infusoria.” “Diseased skin or wound-surfaces take up such 
putrid matters more readily, but even they only do so under certain cir- 
cumstances ; for instance, germs do not readily pass through well organ- 
ized, uninjured granulations.” “If we dress a nicely granulating wound- 
on a dog with charpie dipped in the filthiest putrid matter, if the latter 
contains no cauterant substance that may destroy the granulating surface 
the animal will not sicken; nothing will be absorbed. ... If the 
septic poison be introduced into fresh tissue, it not only excites sever® 
local inflammation, but quickly induces general fever.” 
Putrid pus is found in abscesses in many parts of the body ; near the 
alimentary canal or respiratory passages, and in the soft tissues of tb® 
extremities, as well as in and about the bones, and, indeed, in every part 
of the body. A destructive inflammation may be set up about these col- 
lections, and the protecting walls may melt away and furnish more mat- 
ter to undergo putrefaction, while the conditions left by their destruc- 
tion will favor the absorption of septic matter. And it is probable that 
the septicaemia that so frequently follows the discharge of large coll®0' 
tions of putrid pus is due, not so much to the admission of air and fresh 
agents active in the production of putrefaction, as to the rekindling ot a 
destructive inflammation in the walls of such abscesses. This renewiu» 
of inflammatory changes may be due to the increased flow of blood t° 
their walls, permitted by suddenly removing the pressure that may hav®’ 
for an indefinite period, acted as a barrier to its entrance. The renewal 
of inflammatory processes from any cause in tissues surrounding coll®0' 
tions of putrid matters is apt to be followed by septicaemia. 
Certain conditions of the solids and liquids of the body are essential t®, 
the ready action of septic substances. In the physiological processes 01 
the body, disintegrations and retrograde metamorphoses are constant]/ 
occurring as a consequence of vital actions, and the elements of the tis- 
sues assume a condition of fitness for putrefaction ; all of the excretion3 
are examples of these products. Febrile states, inanition, over-exerci3®? 
all induce changes in the organism that favor putrefaction in the solids 
and liquids of the body. 
The impregnation of the tissues with certain substances tends to p1’0' 
vent putrefaction. Prof. Polli, of Milan, found that the bodies of animals 
that had been fed on the sulphites resisted putrefaction longer than th°se 
of similar animals not so fed, and that urine passed after taking sulphit®9 
remained “fresh, acid, and clear, and did not undergo ammoniacal f®l' 
mentation for eight days during the hottest Italian summer.” According 
1 Joseph Bell, M.D., Edinburgh Medical Journal, 1869, p. 982, et seq. 
4 Billroth, Surgical Pathology, American Edition, 1871, p. 334. ANTISEPTIC SURGERY. 
521 
Polli, these salts do not destroy the ferments, do not directly kill living 
?ei'nis, but modify the tissues so that they are incapable of being acted 
HPOII by catalytic germs, and thus putrefaction does not occur.1 Prof, 
'-bungee’s process of preserving meat consists in impregnating it with 
caihonic oxide and sulphurous acid.2 
Any condition or any substance that opposes putrefaction is antiseptic, 
in its widest sense, this term includes many methods of action. In 
he surgical sense any agent which prevents those changes in the blood 
’vvbicli ordinarily result from the rapid absorption of large quantities of 
putrid matters, must be regarded as antiseptic. Filters, used to prevent 
ne contact of living germs with the putrescible discharges from wounds 
<lnd the tissues, furnish a most admirable method of preventing septi- 
cemia. A. Guerin, in 1870, used, at St. Martin’s Hospital, cotton-wool 
as a dressing after amputations.3 The great practical difficulty in the 
Successful use of cotton lies in the fact that we cannot be sure that the 
cotton-wool itself does not contain germs which may become active in 
‘e production of putrefaction.4 Attempts have been made to correct 
us possible condition by exposing the cotton-wool to air of an elevated 
crnperature, and also impregnating it with various substances, with 
ue hope that germs already existing in the cotton may be destroyed. 
.r°b Lister, in 1871, prepared cotton-wool by diffusing through it chlo- 
iine gas, sulphurous acid gas, carbolic acid vapor, and vapor of benzine.5 
.ls end is attained by Prof. Lister in the use of his antiseptic gauze, 
ffh the advantage that it is a material which may be much more neatly 
a,1(l easily applied, and more readily rendered antiseptic, being in thin 
Sheets, the fibres of which are all easily reached by the germ destroyer. 
, animal and vegetable, is one of the best of protective dress- 
lllSsi acting (if a sufficiently thick layer he used) as a filter, and also as 
an absorhent by which the discharges are held until they may be removed; 
mid, if putrefaction lias actually taken place, the fetid emanations are 
Jebl, and do not contaminate the surrounding air. Chalk, plaster of 
mris, and clay, serve the same purpose as charcoal, but less efficiently. 
°wdered madder root6 and Peruvian bark not only act as filters and 
of fetid gases, but actually prevent putrefaction by destroying 
le activity of living germs, and, perhaps, by altering the escaping liquids 
S° that they do not readily putrefy. Among the most valuable anti- 
optics are the metallic salts, as those of iron, copper, lead, zinc, mercury, 
aud silver.7 All of these used in a sufficiently concentrated state act as 
Rustics, and less concentrated they simply condense the tissues, and alter 
® solids and liquids so that they do not readily putrefy; in addition to 
n® action they destroy the vitality of the living organisms upon which 
<lpid putrefaction depends, and also destroy noxious products.8 
As a first application to a recent wound, perhaps, no substance of this 
h Observations on the treatment of zymotic diseases by the administration of sulphites. 
7 ,l( m the medical section before the annual meeting of the British Medical Association, 
“gust, 1867, by Prof. John Polli, M.D., of Milan. 
3 American. 
4 pXtrayts from Thesis of R. Hervey; Paris, 1873. 
s p °b Tyndall, paper read before the Royal Society, January, 1876. 
e Prit'sh and Foreign Medico-Chirurgical Review, October, 1875. 
de Medical Record, May 15, 1876 ; Antiseptic Properties of Madder Root, by M. 
a erimental investigations of the Action of Medicines, by P. Lauder Brunton, 1875. 
Xyvp leraPeutics, Materia Medica, and Toxicology, by H. C. Wood, M.D.; Philadelphia, 522 
HO-DGEX, 
class is better than chloride of zinc, which coagulates at once the super- 
ficial layer of the albuminoid substances with which it comes in contact, 
and, coagulating the blood and lymph while yet within the mouths oi 
the minute vessels, seems not only to prevent putrefaction, but also to 
render rapid absorption improbable. 
Since the prevention of absorption is as efficient as the prevention ot 
putrefaction1 in avoiding septicaemia, this and a similar class of sub- 
stances are among the very best antiseptics. Chlorine,2 bromine,3 iodine, 
and the alkaline sulphites are active destroyers of germs and preservers 
of flesh, while the permanganates and manganates are chiefly valuable 
as scavengers,2 as they hasten oxidation, and thus rapidly alter organlo 
compounds to a degree that renders them incapable of putrefaction- 
Quinine,3 salicylic acid,4 salicine, benzoic acid, and boracic acid,5 all 
destroy the vitality of bacteria,6 and prevent and check putrefaction- 
Carbolic acid, creasote, and thymic acid, not only devitalize the germs, 
but alter the tissues so that they do not so readily undergo putrefactive 
changes, and alter recently wounded tissues so that absorption does not 
readily occur, but they do not destroy the products of decomposition.7 
Drainage tubes8 cannot be neglected in enumerating the valuable 
methods of getting rid of putrescible matters ;9 so, also, the water-bath, 
in which the water is continually changed, dilutes and carries away the 
putrid matters,and so prevents their absorption;10 so,also,the contact oi 
currents of dry air rapidly desiccating the putrid discharges, prevents 
both putrefaction’and absorption. Alcohol and alcoholic tinctures11 have 
attained considerable eminence as antiseptics, and no doubt owe then’ 
efficiency to the power possessed by alcohol of coagulating the albumi- 
noid products of wounded surfaces, as well as of the tissues with which 
it comes in contact,12 and also to the fact that in the manner in which 
they are employed, they seem by repeated changes to remove the putres- 
cible matters before putrefaction can occur ; they are, no doubt, farther 
beneficial in preventing absorption, since the change they effect in the 
tissues would render these less liable to the entrance of matters from 
without. 
1 The Action and Use of Antiseptics in Surgical Practice, by Charles Roberts, F.R.C-A 
Assist Snrg. for the Victoria Hospital for Children; Lancet, vol. i., 1872. 
1 H. 0. Wood, op. cit. 3 Brunton, op. cit. 
4 New York Medical Journal, January, 1876; Gangrene, by Dr. N. G. McMasters- 
Folytechnisches Journal, July, 1876; Antiseptic Properties of Salicylic Acid, by Pro' 
Kolbe, of Leipsic. 
5 Lancet, May 20, 1876; Boracic Acid as an ordinary Dressing for Wounds, by ™r' 
Leonard Cane. 
6 Brunton, op. cit. 
7 Sansom, op. cit.; Mould and Mildew are rapidly destroyed by carbolic acid. • • •, v 
prevents the germination of the spores of the yeast plant. . . . Albumen precipitated D 
carbolic acid does not putrefy, (p. 24.) An infinitesimal quantity of carbolic acid instant J 
kills bacteria, vibriones, etc. (p. 25.) When carbolic acid is added to a putrefying solutio11’ 
it is observed that all infusoria present in that solution instantly die, and the cessation 0 
putrefactive change is coincident with their death. And when carbolic acid is added to * 
solution susceptible of putrefaction, but before the commencement of any putrefacti' 
decomposition, no organisms are developed, (p. 29.) 
8 British and Foreign Medico-Chirurgical Review, vol. liv., 1874, p. 1; Review by V • 
Callender. m 
9 Half-Yearly Abstract; Isolation and Treatment of Wounds, by G. W. Callender. F-R- 
-10 Memoir read before the French Academy of Medicine, 1870, by Dr. Leon de Fort. 
11 Pansement des plaies Chirurgicales ; par le Dr. Benjamin Anger, Paris, 1872. 
12 Alcohol and Alcoholic Preparations in Surgery, etc.; by F. J. Batailhfe and Ad. GUI 
let, Paris. 1860. See Amputations of the Thigh, by John Green, M.D., Boston Medici 
.and Surgical Journal, June, 1863. ANTISEPTIC SURGERY, 
523 
The value of the antiseptic treatment of surgical diseases is attested by 
Tany of the most eminent surgeons of Europe.1 The practice is infinite 
111 variety, extending from the simple protection of wounds from contact 
catalytic germs, to the purification of hospital wards, water-closets, 
and grounds. So general is the practice of antiseptic surgery, and so 
thorough the faith of the profession in the value of its observance, that 
find none so bold as to deny its value, or so reckless of the lives of 
ils patients as to dare neglect its teachings. 
One practises isolation as the surest method of preventing septicaemia, 
another has unlimited faith in ventilation and personal cleanliness;2 
°ne moves with deadly intent on the hosts of bacteria that infest his 
'vards, another keeps watch over his wounds with a fidelity that chal- 
enges admiration; one places a barrier to the contact of the dreadful 
Cause 0f putrefaction, another seals the absorbent surfaces and denies 
admission to the products of putrefaction; one leaves the wound open 
r°r the escape of the deadly enemy, another bars the paths of entrance 
s<-> that none but the pure shall enter; one washes and scrubs, another 
piasters and daubs—all seek the same goal but by a variety of paths. 
"W hen we consider the fierce contest that for years has been waged in 
Reference to the theory of the spontaneous generation of infusoria, and 
earn how difficult it is to prevent the entrance of germs into infusions ; 
}vhen we remember how difficult it is to prepare an infusion, and protect 
T, so that living matter shall not enter it from without, we cannot but 
lealize the utter impossibility of protecting wounds from the contact of 
catalytic germs. Accepting as true the doctrine now so thoroughly 
established by Pasteur and others that fermentation and putrefaction do 
llQt occur except in the presence of living germs, and recognizing the 
Presence of these germs in the blood of living human beings,3 and their 
action as attested by the presence of collections of putrid matter in every 
Part of the human body, we can readily see the utter hopelessness of a 
struggle to prevent by filters, plasters, or powders, their contact with 
ppeu wounds.4 Dr. E. Fischer found bacteria septica under Lister’s dress- 
Oigs jn every case, notwithstanding that all the cases, except one, had 
a favorable course.5 Ranke and Yon Birch-Hirschfeld found the same, 
it should not be forgotten that through the various channels of excre- 
!on, septic matter may be eliminated from the body, and that if absorp- 
lou is not more rapid than elimination, no poisoning occurs. If, there- 
ore, we can keep the absorption of septic matters within bounds, we 
V'rtually prevent septicaemia. The practice of washing out the cavity 
?, le uterus after the removal of fibroids affords a good illustration of 
le value of preventing a too abundant absorption of putrid matter,b as 
j,. p olkmann, Thiersch, Sigmund, Holmes, Syme, Lister, Nankivell, Kolbe, Bennett, 
lVlngton, Cane, Polli, Green, Hervey, Cadge, Bradley, Guerin, Jasper, Esmarch, Bell, 
Al°,(TaT Macnamara, Leisrink, Koenig, Holderness, Manson, Ross, Sansom, Hamilton, 
Bickersteth, Hnlke, Baker, Bartlett, Goodall, Sydney Junes, Saxtorph, Lund, 
a ton, Wells, Bastleto, Jessup, etc. 
by , r’tish Medical Journal, April 25, 1876 ; Prevention of Pyaemia in Hospital Practice, 
s pt?-.I'a(lge, Surgeon to the Norfolk and Norwich Hospital, 
p. ~ Results of Lister’s Antiseptic Treatment, and the Substitution of Salicylic for 
4M v^ Rmf- 0- Thiersch, Leipsic. 
Gerfi ~ times and Gazette, vol. ii., 1875; The Antiseptic System in Surgery, by 
s lip Thomson, M.D., Surgeon to Oldham Infirmary, 
and Zeitschrift flir Chirurgie, Feb. 1876, Bd. vi., No. 4, 5.319 ; Lister’s Dressing 
u uie Organisms found beneath it, by Dr. E. Fischer, Strasbourg, 
the «fUpatra-Uterine Fibroids; by J. Marion Sims, Surgeon to the Woman’s Hospital of 
ill,, , a,ie °f New York, 1874. Remarks upon the Enucleation of Uterine Fibroids, with 
sirative cases; by T. Gaillard Thomas, M.D. 524 
HODGEN, 
does also the washing out of the uterus after giving vent to accumula- 
tions of old menstrual fluid (Emmett). 
Some of the eminent German surgeons affirm that, during; the Franco- 
Prussian war, a large percentage of the fatal results in gunshot wounds 
of the peritoneum was due to septicaemia, and that good results were ob- 
tained by repeatedly washing out the cavity. 
Hervieux1 urges the value of washing out the uterus in cases of puer- 
peral metritis, and Fordyce Barker recommends the injection of carbolic 
acid solution four, live, or six times a day in the same disease. The 
washing out of the cavity of the chest after evacuation of pus, in empy- 
ema, the cleansing of putrid matters from abscesses and sinuses, all afford 
examples of the benefit of preventing the too rapid absorption of septic 
matter. 
Good results are said to be obtained also by favoring the elimination 
of septic matters through the various emunctories of the body. Sulphite 
of magnesia has been used not only with the intent of protecting the 
tissues and destroying the septic germs, but also as an aid to the elimina- 
tion of septic matters through the kidneys and intestines. 
In connection with antiseptic surgery, the antiseptic ligature2 cannot 
be ignored ; most favorable results have been reported after its use. The 
advantages claimed are: (1) That it does not cause suppuration; (2) 
That it becomes absorbed ;3 and (3) That the ligature becomes organized, 
1 The Puerperal Diseases, by Fordyce Barker, 1874 p. 322. 
2 On the Employment of Carbolized Catgut as a Ligature in Amputations and other 
Major Operations; by A. W. Nankivell, Resident Surgeon to Saint Bartholomew’s Hos- 
pital, Chatham ; Lancet, Feb. 19, 1876. 
3 I. On Ligatures made with Catgut; by D. Murinoff. Inaugural Discourse, St. Peters- 
burg, 1875; from Oentralbl. f. Chirurgie, 1875, No. 43. 
11. On the different kinds of Ligatures employed in the treatment of deep-seated Cuts; 
by Eliaschewitsch, Russian Military Medical Journal, June, 1875 ; Centralb. f. Chir., 1875, 
No. 43. 
I. The experiments, the conclusions of which we report here, have been made upon dog 3 
and rabbits. Simple threads of catgut, soaked in chloral, and “ catgut phenique” were 
employed in making the ligatures. All the ligatures on two or three dogs were soaked 
with juices ; on the seventh day they were swollen, soft, and covered with a thin transparent 
layer of connective tissue; the knots were adherent to the surrounding tissue. The finest 
threads were re-sorbed in ten days, the catgut No. 4, of Lister, in from twenty to thirty 
days. This disappearance is effected by the division of the thread into fibrils which grad- 
ually disappear upon the contact of granulations. It requires the same time to be accom- 
plished, whatever thread may be employed, provided that it is of the same dimensions. Ih® 
simple thread of gut does not irritate in the least the neighboring parts; the thread soaked 
in chloral irritates them a little ; the catgut a little more. As to consecutive hemorrhage3 
after section of a large arterial vessel between two ligatures, Murinoff gives the following 
statistics; catgut, 10 per cent.; thread of gut soaked in chloral, 25 per cent.; simp! 6 
thread of gut, 87 per cent. 
11. Eliaschewitsch has sought to establish by experiments upon animals the different 
influence exercised by the threads of the suture according to their nature. Relating t° 
inflammation, as to the influence which they exert upon the point of suture itself, he ar- 
ranges them in the following decreasing order: Cotton, linen, silk (waxed silk being leS® 
irritating than raw silk), metal (whatever it may be), Florence thread, crin vAgetal, catgu 
ph6nique. The thread in a cord of non-carbolized gut irritates less than that covered with 
phenic acid, but it is less resistant. The presence of Florence thread or catgut in the 
depth of a wound does not hinder its reunion by first intention. The greater or l<?sS 
rapidity with which sutures cut, depends upon the irritation produced by the thread itself, 
and its degree of tension, and finally upon the condition of the lips of the wound. In 
second series of experiments, Eliaschewitsch has endeavored to ascertain what becomes o 
catgut threads left in the wound. He has discovered that as soon as they come in contac 
with granulations they split up over their whole surface, and fibrils are detached which 
their turn are divided into bits finally constituting only a granular detritus. The pf°' 
cess began upon the fifth day in threads which had been used for ligatures of large arteries 
on a dog; at the end of a month no trace of a ligature was found. ANTISEPTIC SURGERY 
525 
becomes a ring of living tissue surrounding and occluding the ves- 
, . Lancet, April 3,1869. On Ligature of Arteries on the Antiseptic System ; by Joseph 
lsier, Esq., F.R.S., Professor of Surgery in the University of Glasgow 
h • • . . . In order to put the antiseptic animal ligature fairly to the test, I made 
following experiment; Ligature of the carotid artery in the calf on the antiseptic 
Uern with threads composed of animal tissues.—On the 31st of Dec. 1868, I tied the 
dK 't carotid about the middle of the neck in a healthy calf a few days old; the animal 
'enig under chloroform. Ligatures of two different kinds were employed at an interval of 
ollt an inch and a half, the sheath of the vessel being left undisturbed in the intervening 
L The cardiac ligature was of home manufacture, composed of three strips of peritoneum 
•oni the small intestine of an ox, firmly twisted together into a threefold cord. The distal 
11 cad was of fine catgut, called “ minikin-gut” by the London makers. Both had been 
‘°aked for four hours in a saturated watery solution of carbolic acid, which swelled and 
°Uened them so that the thread of my own making was too large to enter the eye of the 
fteurism needle, except near the ends, where it was thinner than elsewhere. This sub- 
antial ligature bore the strain of tying well, but the fine catgut broke as I tightened the 
00se; I did not, however, remove it, but, having a second piece at my disposal, passed it 
Urid at the same place, and with gentle traction completed the knot. There were thus 
'I? ligatures of the gut at the distal side. All were cut short except one end of the catgut, 
Hch I purposely left about three-quarters of an inch long to give a better opportunity 
ascertaining what would become of the foreign material ‘A month 
I Hrty days) after the operation, the animal, which had continued in perfect health, was 
Q leL and the soft parts of the neck, below to the spine, were removed for examination. 
11 dissection, I was struck with the entire absence of inflammatory thickening in the 
lcmity of the vessel, the cellular tissue being of perfectly normal softness and laxity. On 
" posing the artery itself, however, I was at first much disappointed to see the ligatures 
I there, to all appearance as large as ever. But had I borne in mind what I had 
observed in some of my earlier cases of compound fracture treated antiseptically, I should 
'u'e been prepared to find these threads present in appearance, though absent in reality, 
j 111 ay be well for me to quote from the account I have before given of one of these cases. 
Was a compound fracture of the leg produced by direct violence, with a wound of con- 
<-able size, and a great deal of extravasation of blood into the limb. In accordance 
fi,1 / practice which I then followed, a piece of lint soaked with undiluted carbolic acid 
tl) been placed over the wound, and had formed with the blood a firm crust. Nearly 
u|;e weeks after the accident, I was detaching a portion of the adherent crust from the 
VJ Jce of the vascular structure into which the extravasated blood beneath had been con- 
vted by the process of organization, when I exposed a little spherical cavity, about as 
a pea, containing brown serum, forming a sort of pocket in the living tissues which, 
a len Scraped with the edge of a knife, bled even at the very margin of the cavity. This 
l.Ppearance showed that the deeper portions of the crust itself had been converted into 
lie t*ssue- Lor cavities formed during the process of aggregation, like those with clear 
aA- contents in a Gruyere cheese, occur in the grumous mass which results from the 
ofti°11 carb°lic acid upon blood ; and that which I had exposed had evidently been one 
jj , lese> though its walls were now alive and vascular. Thus the dead but nutritious mass 
r ‘(. served as a mould for the formation of new tissue, the growing elements ot which had 
it aC materials absorbed, so as to constitute a living solid of the same form. Hence 
cal'r. * have been anticipated that the ligatures of peritoneum and catgut placed on the 
liv' S ca. would, after the expiration of a month, be found transformed into bands of 
hal"i? Lssue. Such was, in truth, the case, as was apparent on closer examination._ They 
Su. ’ lncieed, a deceptive resemblance to their former condition from the persistence in their 
office ot the impurities of the original materials, the dark adventitious particles being 
of lnera,l nature incapable of absorption, so that they had remained as a sort of tatooing 
ci Ule. new structure. Nevertheless a marked alteration in color had taken place, espe- 
U’l ligature, where the dirty gray of the softened catgut had changed to a 
as I/16 Wo P*eces of catgut which had been tied round the vessel at that part had become, 
Co , Tre’ luse<i together into a single fleshy band, inseparably blended with the external 
end ° artetT- the knots were nowhere discoverable, and the only indication of the 
u which had been left long at the time of the operation was a black speck here and there 
tyagU.a opbeate thread of cellular tissue in connection with the vessel. The cardiac ligature 
dis'i ln manner continuous in structure with the arterial wall. The short ends had 
grsjgPeare(l! but the massive knot was represented by a soft, smooth lump, which appeared 
rej-er eiltlre'y homogeneous, except that it was speckled with dark particles, as before 
le< to- On section, however, I discovered in the interior of the mass, and lying close 526 
HODGEJST, 
Prof. Lister says :—“Ample as was the evidence afforded to the naked 
eye of the organization of these ligatures, it was satisfactory to find 
to the wall of the artery, a small residual portion of the original knot, of comparatively 
firm consistence, and with the threefold twisted character of the cord plainly visible. P 
was quite distinct from the living tissues that surrounded it, so that it could be readily 
picked out from its bed with a pair of needles. A slender and irregular remnant of the 
noose was also found lying in a sort of tubular cavity, extending about half way round the 
vessel. Thus the process of organization had not yet quite invaded the entire thickness of 
the foreign solid, and it was a happy circumstance that the cord had been so constructed 
that the distinction between the old structure and the new could be plainly recognized- 
Ample as was the evidence afforded to the naked eye of the organization of these ligatures, 
it was satisfactory to find it confirmed in the clearest manner by the microscope. A bit of 
the knot having been teased out with the needles in a drop of water, presented, like a fresh 
piece of peritoneum, the wavy bundles of parallel fibres, characteristic of perfectly developed 
fibrous tissue. Adhering to the surface of the remnant of the ligature was some soft, 
opaque material, readily washed off with water, consisting of corpuscles of different forms, 
most of them caudate or fibroplastic, but some spherical, though not resembling pus; and 
here and there fragments of the original peritoneal tissue, affected more or less with inter- 
stitial cell development. At a short distance from the remains of the old thread, the 
fleshy material which had been formed at its expense proved to be a most beautiful 
example of fibroplastic structure, the coarse fibres which mainly constituted it being com- 
posed of very large elongated cells, often containing several nuclei, and presenting in their 
course branchings and thickenings of various forms. Here and there were some fibres 
more perfectly formed, and also cells of a more rudimentary character. Again, the band 
which had resulted from the organization of the two fine threads of catgut, which from the 
smallness of their bulk had no doubt vanished early, having had longer time to perfect it 9 
structure, was a comparatively well-developed form of fibrous tissue, consisting of coarse 
fibres rather than elongated cells, being thus intermediate between the merely fibroplastic 
condition of more recent growth and the completed texture of the original thread. For it 
is to be remarked that a piece of catgut exhibits, under the microscope, abundance of 
perfect fibrous tissue. 
A more favorable period for the investigation, with a view to establishing the nature of 
the change which ligatures of animal tissue experience under antiseptic management, could 
hardly have been selected. Between the parts tied, the calibre of the artery was occupies 
by adherent coagulum, which was for the most part decolorized, and exhibited, under the 
microscope, fibroplastic cells of irregular forms. A similar clot wras present between the 
distal ligature and a small branch that arose about a quarter of an inch beyond it. 
between the proximal ligature and the heart the formation of a coagulum had been entirely 
prevented by a large vessel taking origin immediately above the part tied, which had thus 
borne for a month the full brunt of the cardiac impulses. Yet the vessel, so far frorj5 
showing any sign of giving way, as it would inevitably have done had it been tied in such 
a situation without antiseptic precautions, appeared to have derived additional strength 
from the operation. The encircling ring of new tissue incorporated with the arterial wall 
must have had a corroborative effect, and within its grasp the inner coats which seemed t<? 
have been but imperfectly ruptured by the soft and substantial ligature were considerably 
thickened and' had coalesced, so as to form a strong cul-de-sac, the irregularities of which 
had been smoothed over by a little fibrinous deposit, which had assumed the characters o 
a firm fibrous tissue, and presented a free surface, undistinguishable from that of the lii>inB 
membrane of the artery. At the situation of the distal ligature, the structure of the vesse 
seemed entirely unaffected. The middle coat was seen in longitudinal section as a p'llK 
streak between two white lines, representing the external and internal tunics, neither thickar 
nor thinner than in the neighboring parts. The catgut threads had been tied too gen t v 
to produce rupture of the internal and middle layers, and their presence, and the constric- 
tion which they occasioned, whatever may have been their effect in the first instance, ha 
left no permanent marks of the disturbance; while the fleshy band which had rcplace + 
them, though in time it would doubtless have dwindled to an insignificant filament, was a 
least a temporary addition to the strength of the artery. These appearances at the di&ta. 
ligature are calculated to revive under a new aspect the old question whether it would n° 
be better always to avoid rupture of the internal and middle coats, which could easily b 
done by using a pretty thick piece of catgut, softened by steeping it in a watery solutub 
of carbolic acid. In this way the wall of the vessel would be left from first to last entire g 
intact. This, however, is probably a matter of indifference. Indeed, judging from t1 
condition of the artery at the cardiac ligature, the injury done to the vessel at the outs 
by tight tying seems to lead to changes which increase its power of resistance, which wa 
certainly severely tested in the present instance. It appears, then, that by applyb'g ANTISEPTIC SURGERY. 
527 
Co ft firmed in the clearest manner by the microscope and lie adds, “It 
aPpears, then, that by applying a ligature of animal tissue antiseptically 
Ul,c.)ri an artery, whether tightly or gently, we virtually surround it with 
a ri«g of 11 ving tissue and strengthen the vessel where we obstruct it.”1 
Mr. Fleming, who made a series of experiments to determine the 
Ranges accomplished in antiseptic ligatures, says:—“ The results2 of 
le9e experiments show that a gradual softening takes place from with- 
°ut in, the catgut breaking down and becoming infiltrated with cells, 
Plobably leucocytes; . . . next, the pultaceous mass into which it 
, as been converted begins to metamorphose, and is soon permeated with 
■ °°d-channels and ultimately may be described as a cast of the catgut 
?n a kind of granulation tissue freely supplied with bloodvessels which, 
ln Uiaiiy of my sections, were freely injected.” It is a well-established 
a°t that epithelial cells, far removed from the circulation and actually 
ead, placed in contact with a granulating surface, live again and multi- 
by 5 and there seems no reason why the cells of the fibrous tissue of the 
leeP should not also. Ivory pegs driven into bone become absorbed ; 
letals, glass, wood, and silk ligatures may remain in the tissues for an 
'minited time without exciting irritation, inflammation, or suppuration. 
Ihe question as to the special value of carbolized catgut remains open 
I,'Ce the facts above stated of wood, metal, silk, glass, etc., are well 
established. Prof. Paul F. Eve, of Fashville, Term., informs me that for 
sfture of animal tissue antiseptically upon an artery, whether tightly or gently, we virtually 
rround it with a ring of living tissue, and strengthen the vessel where we obstruct it. The 
'Seen, therefore, may now tie an arterial trunk in its continuity close to a large branch, 
tic abk'e against secondary hemorrhage and deep-seated suppuration, provided always 
tj at ae has so studied the principles of the antiseptic system, and so carefully considered 
fed eta‘k °f the mode of dressing best adapted to the particular case in hand, that he can 
-e* Certain of avoiding putrefaction in the wound. For my own part, I should now, 
out hesitation, undertake ligature of the innominate, believing that it would prove a 
Ba(e Procedure. 
r°l- Lister, in the Discussion which followed the reading of this paper, objected to 
am' POB it ion in which he had been placed in reference to the organization of the ligature 
*. t.loptically applied, and the following explanation was subsequently made by the author: 
cor'18 Ue *° Tf°b Lister, due to the Surgical Section, and due to myself that I should 
annp am'sstatteen'ent °f the position of Prof. Lister in regard to ligatures antiseptically 
atit' bi® Report on Aptiseptic Surgery, in the part relating to the use of the 
■gvifPtfc ligature, the following passage occurs: Prof. Lister says,‘Ample as was the 
fafleilce afforded to the naked eye of the organization of these ligatures, it was satis- 
‘lt bad it confirmed in the clearest manner by the microscope,’ . . . and again, 
aPPears, then, that by applying a ligature of animal tissue antiseptically upon an 
st e'L whether tightly or gently, we virtually surround it with a ring of living tissue and 
aad'b", en the vessel where we obstruct it.’ 'These are the precise words of the report, 
by r ,le precise words of an article On Ligature of Arteries on the Antiseptic System, 
Pub|F*Ph Lister, Esq., F.R.S., Professor of Surgery in the University of Glasgow, as 
y-;ut , la the London Lancet for April 3, 1869. page 451, and copied into Rraith- 
kenoin ?etl’osPecL vol; Iviii., 1869, pp. 139, 140. So far, it would appear that in the 
Suao- on.-Antiseptic Surgery I was entirely correct in my quotation of Prof. Lister’s lan- 
be e\as k appeared in print; but Prof. Lister having stated in the Surgical Section that 
acce t i*1- a<lvocated the theory of the revitalization of the antiseptic ligature, I must 
cnib? as correct, and modify my report accordingly. The quotation 
by pa°pS bfit two sentences of an elaborate article, a careful reading of which, prompted 
°f tli' ster s disclaimer, permits me to conclude that the expression, ‘ the organization 
are r?S° ,?atures,’ is not intended to convey the thought that the tissues of the ligature 
the evilalized, but that a living tissue takes the place of the absorbed ligature ; and that 
the ]p.PresBa)n’ *a ring of living tissue,’ does not refer to a revitalization of the tissues of 
bed >Faiure’ but to a new tissue occupying the former site of the catgut, as if cast in its 
Flerr!?16 Lehavior of Carbolized Catgut inserted among Living Tissues; by Vm, J, 
Lancet, May, 1876. 528 
HODGEX, 
forty years he has been in the habit of using the sinews of the deer f°r 
ligating vessels. He says: “I have never used carbolized spray or lig'a' 
tures. The tendons of the deer, dried and torn into shreds and rolled 
into ligatures, are what I employ. They are absorbed, and I have never 
seen a knot made in tying a vessel. I have occasionally used them a3 
sutures, but generally apply silk for this purpose.” Dr, Eve’s experience 
with the tendons of the deer leaves us free to conclude that the carbolized 
oil and water with which Prof. Lister’s catgut is prepared has no special 
value in preventing suppuration or hastening absorption. 
The following propositions are sustained by our present knowledge 
the subject of Antiseptic Surgery : 
I. Putrefaction may and does occur in the solids and liquids of the 
body both with and without the direct contact of germs borne in the a 1 
or water. In sustaining this proposition, I need only call attention to 
the innumerable abscesses containing fetid pus that may occupy any sito 
within the human body, sites so remote from all the mucous and cuta- 
neous surfaces that neither air nor water as such can reach them. 
11. Putrefaction of the solids and liquids of an open wound may 111 
many cases be prevented by not permitting the contact of living germ 9 
with the surface, or by destroying their vitality after contact with P- 
The experiments made by Prof. Tyndall are so conclusive that to deny 
their force and completeness seems irrational. If were negative, °r 
if they were few, a question might arise, but being positive and almost 
innumerable, there seems no reasonable doubt of the correctness of hi3 
conclusions. In his admirable series of experiments he allowed the float' 
ing particles to settle from the air until it was optically pure, and found 
that infusions placed in this pure air did not undergo putrefaction, and 
that living organisms were not produced. There are many agents by 
which the vitality of septic germs may be destroyed; and their contact 
with the cut surfaces is sufficient to destroy the vitality of such germs as 
may be present at the moment. While it is exceedingly difficult in the 
case of an open wound to prevent the contact of septic germs that peJ' 
\ade the atmosphere, it may generally be accomplished for a brief period- 
And while there are many substances that efficiently destroy the vitality 
of septic germs, the profusion in which they exist renders it necessary 
that the applications for their destruction shall be so precisely made, a»d 
so frequently renewed, that it will in practice rarely be accomplished. 
111. It is possible that the living solids and liquids of the body may be 
so altered that they shall not furnish the conditions necessary to put1’6' 
faction. Polli’s experiments with the sulphites afford evidence ot the 
truth of this proposition. For he found that the bodies of dogs fed with 
the sulphites did not decompose, and that urine passed during the adm*11' 
istration of sulphites did not putrefy. 
IY. Practically, the conditions to be met in preventing putrefaction 
are so difficult, that in many cases it is impossible to comply with them? 
yet even partial success is eminently worthy of our best efforts. W 
the experiments made by Prof. Tyndall, in which he determined the preS' 
ence of germinal protoplasm in the air, it appears that several days 0 
absolute quiet are necessary for the complete settling of the germs so 
that the air becomes free from them. These particles of living matte 
are so infinitely minute1 that they are utterly beyond the reach of tn 
1 Spontaneous Generation Controversy, by Rev. W. H. Dallinger ; Monthly Microscopic 3, 
Journal, vols. x. and xiii. See Popular Science Monthly. ANTISEPTIC SURGERY. 
529 
and can only be made visible by a condensed beam of light. 
v‘j, lnSer and Drysdale have shown that, while the life of the monad 
j • n°t resist a temperature of 140°, the germs that Prof. Tyndall recog- 
s , W by his electric beam are capable of germinating after having been 
0 dec ted to a temperature of 300°. In view, then, of these facts, and the 
oj.e established by Pasteur, that putrefaction occurs only in the presence 
living germs, and that Prof. Fischer has uniformly found bacteria 
'<er antiseptic dressings so ingeniously devised as those of Prof. Lister, 
c 'bust conclude that germs cannot be prevented from coming in con- 
c| with wounds. While this is true, the rapidity of putrefactive 
‘anges may be diminished, the absorption of septic matters limited, and 
10 eliminative functions stimulated so that septicaemia may not occur. 
Jn conclusion: Putrefaction does not occur in the absence of living 
this fact was established by Pasteur and is supported by 
Tl c * • 
re germinal matter active in putrefactive changes is found abundantly 
lb air and water; most conclusive evidence of this fact is furnished by 
‘rp®xPeriments of Tyndall and Edndfleisch. 
lT) Lbe germinal matter resists exposure to a temperature of 800°, while 
e >llads cease to manifest vital phenomena after exposure to 140° ; the 
n of Ballinger and Drysdale are presented to sustain this 
h°sition< 
js induced by the presence of the products of putrefaction 
• blood ; the precise element which causes by its presence septicaemia 
18 "ot determined. . , 
str l'°^essw)nal experience teaches, and the experience of Billroth demon- 
y la^es, that absorption of putrefactive products does not occur with suf- 
c>ent rapidity from a granulating surface to produce blood-poisoning, 
to ) l\ce’ bi the early stages of the healing of injuries, septicaemia is more 
bi tf ten red than after granulations have been formed; and the danger 
f * bis period is heightened by the presence of dead and decomposing 
clgiQents of original tissue. 
0 may simply strain out the catalytic germs, as cotton-wool; 
. estroy the germs, as carbolic acid, salicylic acid, the salts of copper, 
ftiercury, etc. 
Uii n^SePtics may destroy the products of putrefaction, as iodine, bro- 
chlorine, and permanganate of potassium*, etc. 
Hot U^Septics may alter the putrescible matters so that putrefaction can- 
a occnr, as sulphurous acid, etc.; or antiseptics may alter the tissues of 
surface so that, though septic matters are present, they may 
be absorbed, as perchloride of iron, etc. 
face le-l aPbi removal of septic matter from contact with an absorbing sur- 
T,Wlll prevent absorption, as is done by the water-bath. 
me difficulty encountered by experimenters in preventing the develop- 
n .°b infusoria in vegetable and animal infusions, teaches, and the 
in<r!]ence °b surgeons confirms, the impossibility of invariably prevent- 
careF n of germs to putrescible substances, either in the most 
hod i constructed reservoirs or on the free surface ot the human 
1 T 
I)rs. BrT iln<?ebted to Drs. Evers and Boutwell for translations from the German, and to 
rny om:fPere and Lebeau for translations from the French. I must also acknowledge 
able f°r the use of the Army Medical Library, at Washington, and of the valu- 
ation of the College of Physicians of Philadelphia. 530 
HODGEN, 
Discussion on Dr. Hodgen’s Paper. 
After the reading of the preceding paper, Dr. Addinell Hewson, of Philad6/' 
phia, said :—I have been, for many years interested in the subject of Antiseptlo 
Surgery, and have tried almost every substance which has been introduced I®l 
the purpose of destroying germs. 1 have relied principally of late upon 
as I am satisfied that dryness is the most essential element in any dressing' 
As Prof. Hodgen has said, water produces germs rapidly, and it is impossible t° 
prevent this even with powerful antiseptic agents. 1 have therefore, during o*®. 
past year, at the Pennsylvania Hospital, absolutely prohibited the washing0 
any wound during its entire treatment, in addition to dry dressings, it is impol' 
tant to remember that there are other necessary conditions for rapid healing’ 
and I have not used a ligature in the Pennsylvania Hospital for ten yeal'3’ 
employing always either acupressure or torsion, and thereby avoiding foreigll 
bodies in the wound. I also enjoin quietude of the parts, with infreqn®11 
changes of dressings; I have also tried the effect of color, by covering wound 
with blue paper, to exclude all but the actinic rays. For six months I hav° 
tried salicylic acid, sprinkling it freely upon the wound, and covering the latte1 
with cotton-wool and then with blue paper. I never wash wounds nor distun 
the dressing save to remove the outer layers when they are soiled. The sab' 
cylic acid produces no pain, but acts as a sedative, so much so that at 
thought it was narcotic, but I subsequently found this to be an error. I 11111 
seldom obliged to give morphia, but, to satisfy the patient, have tried hyp0' 
dermic injections of a fluidrachm of cold water, a remedy which I have als° 
found successful in relieving sciatica. I have partially superseded earth bj 
salicylic acid, but have not abandoned the former, save when the prejudice3 
of patients or nurses have thrown obstacles in the way of its successful olll' 
ployment. 
Dr. J. H. Pooley, of Columbus, Ohio, said;—l have come to consider 01lt' 
bolic acid as important in surgery as instruments themselves. I have kno"'11 
large ragged wounds to heal under its application without one drop of pus. 
have found the most efficacious form to be one part of carbolic acid to seven 0 
olive oil, which is less offensive than linseed oil. I always make the appbl'11' 
tion with a brush, carrying the oil well down into every portion of the woun11 
then applying lint saturated with the same mixture, and retaining all witn ; 
bandage. This should be repeated every twenty-four hours, brushing the 01 
in thorough!} 7, and removing all sloughs. I have recently seen an extensG 
crush of the soft tissues of the foot heal, without discharge, in three week3 
under this dressing, while under ordinary circumstances the cure would bav _ 
occupied two or three months. It must be added that, while carbolic acid 101 
a time assists the healing process, yet after a certain period it seems positi'’ 
to retard cicatrization, pointing to the possibility that this acid has the sai°° 
repressing power upon granulations that it has upon germs. I have had b° 
little experience with salicylic acid, but in one case in which I used it upon 1111 
immense mass of granulations situated over the region of the liver, and I1’011 
which had been discharged a large number of gall stones, the dusting ol 1 1 
surface occasioned severe pain, an opposite effect to that described by 1 l' 
Hewson, who has stated that the application is painless. . f 
Dr. Hewson said :—ln amputations, when I close the wound with a coven°» 
of powdered salicylic acid and cotton-wool, there is no pain; but the salll 
dressing in open wounds does give pain. I should add that I always c|°s 
the wound, not with adhesive plaster, but with strips of gauze and collod'01b 
which is less irritating and favors primary union,besides giving the advantag 
of a visible wound, and preventing the direct contact of the salicylic acid 0 
earth. 
Dr. William Cannief, of Toronto, Canada, said:—lt is, I believe, very gellC 
rally acknowledged that the air is inhabited by various forms of germß"" ANTISEPTIC SURGERY. 
531 
’ganisms possessing different degrees of vitality; but it remains a question 
tether putrefaction is due to the operation of these microscopic organisms. 
1 • Hodgen’s first proposition states that “Putrefaction may and does occur 
solids and liquids of the body, both with and without the direct contact 
1 germs found in the air or water.” Well, if that is the case, I submit that 
te doctrine urged by Prof. Lister is undermined. 
Hodgen said:—l did not intend to convey the meaning that germs are 
°t present in all cases of putrefaction. The organisms may be introduced to 
part through the blood. 
l’* Canniff said :—Then what is the use of applying to a wound or open 
scess means to form a barrier to the ingress of germs ? If organisms can 
.i‘ the S3?stem through the lungs, or any other mucous surface, and find 
le,r way to a certain part to work mischief, it is entirely futile to adopt any 
Mocedure to prevent their action. I should like to ask the advocates of the 
ei‘te theory if the}' hold that organic matter can never putrefy without the 
Iteration of air germs ? Because if it ever does, it would be difficult in any 
case of putrefaction to show that this was not a simple chemical change 
1 the elements composing the dead animal matter. It is a received doctrine 
at the bod}r is made up of an infinite number of cells, or molecules, each of 
>teh possesses a distinct individual life. They have a moment of birth, and a 
Jl llod of growth and development, of maturity, of decline, and of death ; and 
tiling- their period of life they, like the whole body, are subject to disease, and 
Regeneration ; they may be feeble, or possessed of vigorous vitality. They 
j e. a^s° individually and in number liable to injury. Take a contused wound; 
v lt teay be found a number of cells crushed to death; others are injured in 
j.ail°Us degrees, some of which will or may under favorable circumstances 
ecover and be completely or partially restored to their normal vitality. Which 
perish and which shall be restored, has to be determined by nature. 
le Iffie of demarcation has to be established ; and the cells deprived of life 
equestrated. This is a work of time, and is accomplished by natural laws. I 
11« able to see in what way the presence of germs can affect this procedure. 
s a Portion of tissue is crushed to death, beneath it is carried out the work of 
J 'ptestration ; and this is attended with chemical changes in the dead organic 
tetter, it is asking a good deal to expect ns to believe that this is due to air 
ste'rus. 
j. own experience is such that I find it impossible to entertain the doc- 
ute °f germ putrefaction. I will mention three cases in my own practice: 
Vy lv'an of over sixty had his leg crushed by a wagon heavily laden. There 
, c. s a compound dislocation of the knee-joint, with fracture of the upper extre- 
a/? le tibia- The limb was placed in a proper position, the parts adjusted, 
u cold water dressing alone applied. The wound was freely and constantly 
'Posed to the air; and, although the weather was hot, the wound healed, and 
w'h. man recovered with perfect use of the joint and with no suppuration 
b Two men, injured at the same time by a railway accident, were 
Wllght *ut° ie Toronto General Hospital. One had contused wounds of the 
otT vvater dressing was employed; and he made a rapid recovery. The 
VVo*°r tean, in a bed beside the first, had severe contusions of the leg, but no 
The skin was unbroken. In a number of days it was found that sup- 
had taken place. The abscess was opened,and forth came putrefying 
Now here the putrefaction must have taken place without the presence of 
n*118’ 01 e*se they had been exceedingly active in finding their way through 
i’eo UC°US sulTace and by the blood to the part. I may say that the practice 
flG by. Prof. Lister has not been adopted in the Toronto Hospital; his 
atu* ' 6*s n°t as vet acted upon ; and 1 feel safe in saying that the success 
that''o'’0'’ ie treatment of wounds in that Institution is not exceeded by 
vvhi .i'11 ai °tber. Of course, in hospitals and other places, the organisms 
liCe° ex'ist in the air are often depraved; they take a low form of degraded 
’ aiut the result is an impure air which will more or less affect open tissue ; 532 
HODGEX, 
but lam referring to ordinary air. I have in hundreds of cases seen 
wounds,many in connection with plastic operations, in which healing by primary 
adhesion has taken place, and yet in which no care has been taken to keep 
away supposed germs. Often the wound is allowed to remain open for some 
time, until all oozing of blood has ceased. Now how are we to account l°x 
these results, if the air is everywhere peopled by organisms bent on working 
destruction whenever a solution of continuity takes place on the surface of the 
body ? 
In speaking of the treatment pursued in the Toronto Hospital, I do 
intend to convey the impression that the agents called antiseptics are not used- 
They are constantly employed for purifying tissue, not with the view 
destroying or preventing the action of air germs, but to arrest or prevent putre- 
fying decomposition due to chemical changes. In conclusion, I would say that* 
1 believe that everything, almost, depends upon cleanliness in the management 
of wounds; and 1 believe that the success which has been obtained by those who 
practise according to Prof. Lister’s theoi’y, is greatly due to the cleanliness 
which that practice secures. Next to cleanliness, 1 think that the maintenance 
of rest is valuable ; physical and physiological rest. Rest after the evacuation 
of an abscess will often secure an early adhesion of the walls of the collapsed 
sac. Pressure again is an important element in the treatment of wounds so 
as to press away fluid in the part, and to. prevent feeble circulation or stagna- 
tion of blood in the tissues which have to supply the reparative material. And 
lastly, attention must be given to the constitution and to the surroundings oI 
the patient. Is it not to be feared that the particular treatment advised by 
Prof. Lister tends to divert the attention of the surgeon from these essentia1 
points ? 
Dr. F, H. Hamilton, of New York, said:—ln common with all the other 
members of the surgical section, I feel a great interest in what you, Mr. Presi- 
dent, will have to say on the subject of antiseptics in surgery. The medical 
men of this country are familiar with your labors in this direction. They 
know with how much zeal and intelligence yon have prosecuted your inquiries? 
and I may add for myself, personally, that I have never seen a medical gentle- 
man who had enjoyed the privilege of witnessing your practice in your own 
wards, who was not delighted with the results. Nevertheless, a large propol' 
tion of American surgeons seem not to have adopted the practice; whether 
from a lack of confidence or for other reasons, I cannot say. We are happ} ’ 
therefore, that you have this opportunity to address us at this time, and we 
hope sincerely that you will be able to remove such doubts and practical didl' 
unities as remain in our way. Indeed we would be glad to have you convince 
us that your method is the best. 
It seems necessary to remind the Section, however, that there are in tin® 
country and abroad other methods of treating open wounds, for which then 
advocates claim exceptional and extraordinary results. Recently our atten- 
tion has been called by a paper read before the American Medical Association 
1 think at St. Louis, to wdiat is called the “open-air treatment,” in which n° 
dressings whatever are employed, but the wound is left open to the air, the 
discharges being permitted to drop into proper receptacles, or to dry up°n 
the surface. My friend, Prof. Moore, of Rochester, called my attention to n 
case of amputation at the shoulder-joint treated in this manner in one of 
surgical wards, which was closing rapidly and with very little suppuration- 
At the Bellevue Hospital this method has been employed recently, in quite 
number of major amputations, and with remarkable success. It must be notice1 
that the open-air treatment is the exact opposite of Prof. Lister’s antiseptic 
method, yet there are not a few who claim for it equally good results wit 
those obtained by Prof. Lister. A few years since I was appointed operating? 
surgeon to the St. Francis’s Hospital, a hospital of several hundred beds, 111 
the city of New York, where I found Dr. Rose and the other gentlemen (a/ 
.of whom were German, and thoroughly educated) employing warm water i ANTISEPTIC SURGERY. 
533 
ile treatment of nearly all surgical accidents. The same plan was pursued 
these gentlemen, under ray observation, after I became connected with the 
capital, and, I must say, with most extraordinary results. No ointments nor 
I, washes were used to my knowledge, unless as a rare exception, but 
tr° Wai'm water dressings were applied to all open sores, whether simply 
aumatic or specific, in the form of either baths or fomentations. Under this 
eatnient, pyaemia, septicaemia, erysipelas and gangrene were almost unknown, 
Cept as these originated outside of the hospital and before admission to the 
ai(’s* That is to say, under the warm-water treatment the origin or develop- 
JJt’ of these conditions was almost unknown. 
4he same plan has been adopted to a certain extent by myself and some of 
colleagues in the Bellevue Hospital, and several of the gentlemen, including 
l°C Gouley, who I believe.is present, have attested its excellence, if not its 
Periority. My largest and most satisfactory experience, however, has been 
while occupying the position of Surgeon-in-Chief of the New York 
Hospitals. The results have been given to the profession in a couple 
I Papers, one of which was published in the Richmond and Louisville Medical 
°ui‘nal, in 1874, and the other in the Medical Record of New York, during 
; c same year; but the most complete essay upon the subject was published, 
p by my former pupil, Dr. Frederick E. Hyde, of New York, in the 
u®alo Medical Journal, and subsequently in pamphlet form. 
4here are yet other plans for the treatment of wounds and other surgical 
ClHents, for which their advocates have made special claims, all of which 
„ ay be considered as contending with the method advocated b}r Prof. Lister, 
consideration, if not for preference. 
.. 4t may not be possible for this body to decide now between the merits of 
>ese several methods, but we shall listen with great interest to what the 
1 sting,)jshed gentleman from Edinburgh shall say upon this subject. 
c|. r. J. A. Grant, of Ottawa, said:—For many years we used cold-water 
j l°ssings at the Ottavva Hospital, with great success, yet failed to obtain 
exults equal to those secured by Prof. Lister. 1 therefore made a visit to 
j '“burgh, and was fully convinced of the superiority of the antiseptic method. 
s particularly attracted by the extreme care and cleanliness which charac- 
eijzed all of Prof. Lister’s operations. 
R- A, Kinloch, of Charleston, said:—While I am willing to accord to 
n e antiseptic system, carried out in the various ways which have been sug- 
gested, all or much that has been claimed for it, I think that rest is an important 
°torin the treatment of wounds, which is too much overlooked, and to which 
cl, Pei’haps be attributed much of the good claimed for certain kinds of 
ai efS.ln.£* I'he valne of immobility is recognized in the treatment of fractures 
*d joint diseases, but it is equally important in dealing with lesions of the 
parts. The benefits said to have been derived from the use of warm 
jj,a. er5 may be in part due to the quietude of the limb within the box in which 
in-'8 during the course of treatment. The cotton dressing serves ad- 
ably the purpose oLsecuring apposition and immobility of the wounded 
be^Ue’ many of the forms of antiseptic dressing are similarly effective, 
cause the dressing is but seldom disturbed. The dirt dressing of Dr. Hew- 
keU 111 g°°d ill the same way; it moderately compresses, supports, and 
*P*at rest the injured structures. Even the plan now carried out at Belle- 
q^e Hospital, of exposing wounds to the air, may act in the same manner. 
ql® Parts are secured in their proper situation, and not handled ; a crust forms 
le surface, and serves still further to protect and insure rest to the parts, 
pr r'- OHN T. Carpenter, of Pottsville, said:—l enjoyed the opportunity of 
a-ctising antiseptic surgery on a somewhat extended scale, many years before 
fovtoliginati°n the germ theory or of the use of carbolic acid. It was my 
aroUUe’ '-n as Medical Director of the U. S. Army Hospitals in and 
jj Ul Cincinnati, to supervise the treatment of a large number of cases of 
ospital Gangrene. Recognizing the extraordinary virulence of this septic 534 
HODGEN, ANTISEPTIC SURGERY. 
disease, and yet believing its constitutional symptoms to be exclusively the 
result of local infection, 1 directed the employment of an antiseptic local treat- 
ment, which met with most gratifying success. The hospital surgeons were 
directed to remove, as thoroughly as possible, the whole of the diseased tissues 
with the knife; to bathe the wound with freshly generated chlorine gas (use< 
as chlorine water) ; to pack the then purified raw surfaces with lint saturated 
in creasote ; and to trust to free ventilation, good food, and tonic treatment, 
for the rest. Of more than a hundred cases of hospital gangrene thus faith' 
fully treated, I recall now but two which proved fatal, one from erosion ot 
large branch of the femoral artery, the other from thrombosis with enormous 
heart-clot. Here then was made a decided attempt, in treating a putrefactive 
disease: (1) to remove the poisoned tissues; (2) to disinfect those which 
could not be removed, and (3) to occupy the wound with a protective dressing 
as a means of preventing any re-inoculation by a poison which we all recog- 
nized as existing in the atmosphere of the wards. Here were recognized at 
that early date the principles of causation and of treatment which have oub 
recently been thoroughly expanded and perfectly carried out. I may a(l< 
that creasote was the only chemical agent known at that time which coun 
substitute or replace our present carbolic acid, and which would produce results 
at all similar. 
Dr. Frederic Hyde, of Cortland Village, N. Y., said :—ln according va|lie 
to any form of topical treatment, whether antiseptic or not, the true conditm11 
of the part, both at the time of and often anterior to the occurrence of tl'e 
injury, should be taken into account. Whether the conditions existing 
before the wound or injury was received were strictly physiological, or mf>'e 
or less pathological, will materially influence the results of any and all f°l>nlS 
of local treatment, and whatever importance and value may belong to °lie 
mode or another, we shall observe in the results that the rapidity or tardiness 
of repair, and the degree of recovery, will depend much upon the state of tbe 
patient at the time the injury was received. 
Dr. 34. F. Weir, of New York, said:—Perfect cleanliness is important in W 
treatment of wounds. By using cotton waste instead of sponges, by the e)U 
ployment of the douche for washing wounds, and by paying great attention t° 
the cleansing of bedding, etc., we have been able to almost banish septic»einlC 
diseases from the Roosevelt Hospital, We use both carbolic and salicylic ad » 
but not for the purpose of excluding germs from wounds. 
On motion, the discussion of Dr. Hodgen’s paper was adjourned, and the 
President, Professor Lister, was requested to address the Section the neN 
day upon the subject of Antiseptic Surgery. 535 
ANTISEPTIC SURGERY. 
REPORT of remarks made before the surgical section, during 
THE ADJOURNED DISCUSSION ON DR. HODGEN’S PAPER. 
BY 
JOSEPH LISTER, F.R.S., 
PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF EDINBURGH. 
(PRESIDENT OF THE SECTION.) 
Having been requested to address the Section on the subject of Anti- 
Surgery, I will reply to some of the objections which have from 
tune to time been raised against this plan of treatment. 
. The first objection is, that it is “too much trouble.” I grant that it 
Is somewhat troublesome, and yet I believe that the trouble is more 
imaginary than real, and is one of the necessary results of a want of 
I'm proper apparatus and appliances, together with inexperience as to 
jheir use. There is always trouble with any operation until one has 
learned the minutiae of the various steps. But even supposing that it 
does require a little more attention at the time of the operation, I think 
Hat when the infrequency of dressing, and the shortening of the period 
jd cure, are taken into consideration, it will be seen that the labor per- 
formed is far less than when ordinary means are employed. Again, it 
18 worth some trouble to be able to seal up an amputation, an exsection, 
m’ a large wound, with the absolute certainty that no evil effects will 
follow. 
The second objection is, that “ other modes of treatment give good 
rosultg.” I grant that they give good results, but not the best attain- 
able. Without strict antiseptic treatment, it is impossible to freely lay 
°l’en a knee-joint, with the certainty that no danger will follow ; or to 
foke out a wedge-shaped piece from either femur, as I have recently 
done, and yet to feel that such a produced compound fracture is per- 
fectly safe, and without risk. And then we must consider the progress 
. the wound. The blood becomes organized under the dressings, and 
cicatrization occurs without one drop of pus, and almost without granu- 
Jtions, so that, when we take away the superficial blood-crust, a clean 
BlV'face is found beneath. This I venture to say never could be done 
Without antiseptic treatment. Again, to be able to open a chronic ab- 
-Bcess of the spine, without fear of irritative fever, or pyaemia, requires 
16 strictly antiseptic plan. And in acute abscess, it is pleasant to feel 
Eat after the procedure of opening and pressing out the accumulated 
material, not one drop more will form. Again, in the ligature of a large 
artery near a great branch, it is a great relief to know that rapid healing 
'V1 1 oot*ur, and that the danger of hemorrhage will be avoided. None of 
mse things can be done without risk, unless putrefactive changes are 
strictly prevented. 
I must object to the definition of Antiseptic Surgery, given by Prof, 
fodgen, as that includes the disinfection of water-closets, etc. I pre- 536 
LISTER, 
fer to use the term “ antiseptic system,” and construe this as meaning 
“ the dealing with surgical cases in such a way as to prevent the intro- 
duction of putrefactive influences into wounds.” 
Another objection which has been made, is that “putrefaction may be 
due to germs introduced from within;” but this is an objection easily 
met. Every simple fracture disproves it, for in every fracture we have 
a most serious wound, even although it is not visible to the eye—bones 
and soft tissues are all mutilated to a greater or less degree—and if paf' 
tial destruction and mere feebleness of tissue would cause putrefaction, 
then we should have it occurring in every injury of this kind. 
Another point raised by Dr. Ilodgen, is that, when serious results 
occur after the opening of an abscess, they are caused not so much by 
putrefactive changes as by injury to the pyogenic membrane and conse- 
quent absorption. With all due deference, I would say that a pyogenic 
membrane is a much better absorbing surface than a mass of granula- 
tions. It is well known that large granulating surfaces, which are dis- 
charging so profusely as to taint with their horrible odor a whole 
hospital, yet are not sufficiently absorbent to injure the system to any 
perceptible degree. 
Opening of such abscesses antiseptically, will certainly prevent putre- 
factive changes and a relaxed condition of the pyogenic membrane, and 
thus prevent constitutional disturbance. As to the cause of this dis- 
turbance, when the antiseptic system is not used, I would only say that 
in a chronic abscess the pyogenic membrane is not in the condition of n 
granulating surface. In acute abscesses it may be, but in chronic cavi- 
ties we sometimes have no secretion of pus until after the abscess is 
opened. This is sometimes seen in cases of diseased bone, in which 
clear liquid is all that can be drawn off, and pus is not secreted until 
subsequently. In proportion to the chronicity of an abscess does ds 
pyogenic membrane partake of the characteristics, not of a granulating' 
surface, but of cicatricial tissue with the epidermis stripped oft', and m 
this latter state it is vastly more likely to absorb. The bad symptom8 
usually appear within the first few days, while the membrane is in tinß 
condition, and patients sometimes die within twenty-four hours after the 
opening of the abscess, in which time the membrane certainly cannot 
have assumed the condition of a granulating surface. Pus may not forlll 
until the third day, while the irritative fever is usually observed earli61’ 
than this. The danger at first is from this irritative fever; afterwards, 
when the pyogenic membrane is in the condition of an open sore, from 
hectic. 
[Prof. Lister then gave a practical demonstration of the application of the antiseptlo 
system upon the person of a patient, and spoke of the different forms of carbolic acid.] 
At first I used the German creasote, which is very offensive from the 
krealic acid which it contains, I now used the purest acid I can procure* 
which is absolute phenol, and I have found that its solubility and wan 
of otfensiveness are in direct proportion to its purity. Calvert’s carbon0 
acid requires twenty parts of water to dissolve it, this only sixteen. n' 
other advantage is that a solution in which there are no undissolve 
particles is far less irritating than one in which the little portions of pmo 
acid are brought into direct contact either with the wound or the sm 
geon’s hand. Pure carbolic acid is used most satisfactorily in water, am 
for detergent purposes it has no equal. It is exceedingly penetrating, a3 
evidenced by its action on India-rubber, and when used in the proportion 0 ANTISEPTIC SURGERY. 
537 
1 to 20, will most effectually purify every portion of the epidermis, while 
instruments soaked in the same solution are rendered thoroughly antisep- 
tic, For the purposes of atomization, its volatility is an advantage, and 
although I most heartily wish that I could dispense with the spray, yet 
Ido not see how it can be accomplished. Thiersch, of Leipsic, substituted 
salicylic acid for a time, but he has now returned to carbolic acid. 
[Prof. Lister then showed a Spray Producer, manufactured by J. Gardner, of Edinburgh, 
■"’hich, by a modification of the French plan of having one tube and wick within another, 
"Was so arranged that alcohol was volatilized, and then this vapor burned, thus securing a 
Very large flame and insuring a rapid stream from the boiler.] 
When the pressure is sufficiently great, the atomization will he so tine 
that there will be scarcely any perceptible wetting of the surgeon’s linen, 
and when thus minutely divided the carbolic acid is much less irritating 
to the wound. The large size of the stream is also of great advantage in 
giving a larger area for work. The surgeon should always see the 
spray, and then he will be certain that it is in the right place. When 
assistants are scarce, the atomizer can be placed upon a table and made 
to play upon the part. 
The skin being throughly cleansed, the instruments soaked, the hands 
hashed,.finger-nails brushed, and sponges prepared, the incision is com- 
menced; and from this time until the completion of the dressing, if the 
surgeon’s hands or an instrument are passed beyond the area of spray, 
they must not be again brought near the wound until they have been 
dipped in the antiseptic solution. It is the close attention to these minute 
details that renders this system so absolutely certain and safe in its results. 
tJarbolized catgut ligatures are always used, both ends being cut-off*. 
-Before closing the wound, a purified Chassaignac’s drainage-tube is intro- 
duced, if needed, when the dressing can be applied with the perfect 
assurance that, every organism having been thus far excluded, none can 
euter the wound, and healing without suppuration will occur. 
The gauze employed is simply loose, open, cheap, cotton-cloth, impreg- 
nated with carbolic acid, one part; paraffine, five parts-; and common resin, 
®even parts, thoroughly spread over the surface when hot, and put under 
heavy pressure in a stout wooden box. The paraffine prevents stickiness, 
the resin makes an excellent vehicle. In dressing a fresh wound it 
18 best to protect the raw edges by a small piece of thin oiled silk, 
covered with copal varnish, in order to prevent any injurious effect from 
the direct contact of the carbolic acid, and to allow the blood clot more 
easily to organize. If this is done, a wound need not be opened for a week, 
Jl>t it will otherwise require earlier dressing. The next substance to be 
‘Applied is a layer of gauze, soaked in fresh carbolic solution, since the 
(:'y gauze might contain organisms from accumulated dust, and in its 
JVT state not be able to destroy them. Over this is placed half a dozen 
hicknesses of the same material, loosely wrapped around, the spray 
Meanwhile playing continuously upon the part. Then is applied a layer 
°t Mackintosh cloth, and over all is wrapped a loose bandage made of the 
sarne earbolized gauze torn into strips. The wound may now be left with 
ll reeling of absolute security, and without any anxiety, for a week, or 
hntil the discharge begins to soak through, when the outer dressings 
|TIay he raised under the spray, and fresh ones applied. The deep dress- 
ngs peed not be disturbed for weeks, if necessary. For changing the 
r lessings, in private practice, I carry a small atomizer which can be packed 
11 a box in the pocket. In wounds too large to be covered by the spray 538 
LISTER, 
from this instrument, one side can be dressed at a time. One or two dress- 
ings are all that are usually required. 
I have found resin a most excellent vehicle for the carbolic acid, as it 
holds the latter with extreme tenacity, while at the same time it has no 
affinity for the discharges, allowing them to pass through for a long time 
without extracting the virtues of the acid. I have found also that the 
energy of a drug depends not alone upon its quantity, but upon the 
affinity of its vehicle, so that 1 to 5 of resin is no more pungent than 1 to 
20 of oil, or 1 to 100 of water. 
It may be thought that all this caution in dressing is unnecessary and 
troublesome, and it would be so if one had to do all this and then failed 
to secure a good result, but when these minutiae are heeded bad results 
will not occur ; wounds will heal so rapidly and kindly that one will 
soon come to find that it is not the most but the least troublesome mode 
of dressing, when he takes the course of the case into account. Many 
doubtless fall short of these good results simply because they neglect the 
precautions mentioned, and then they blame the system for their failure. 
I have been making strenuous efforts to improve the catgut ligature, 
and believe that I have at last obtained the desired result. Old ligature 
is far preferable to new, and yet the knots will sometimes loosen. I have 
seen a case of Caesarean section progress admirably until the stitches in 
the uterus gave way, and then death speedily followed. The old liga- 
ture is harder and does not absorb as readily as the new, but I have 
found that gut which is reliable when tested with warm water, will yet 
loosen under the action of the liquor sanguinis. The ligature must not 
be made too hard, or it will be too stiff for tying, and will even act as a 
foreign body as much as silk does, and yet it must be so hard that after 
soaking in serum for weeks it will still hold firmly. I have tried many 
substances; chromic acid will harden the gut, but when the latter is 
soaked in serum it is as unsatisfactory as before. Glycerine gives a 
ligature which will knot well, but is still too hard. I have at last made 
a mixture of carbolic acid, glycerine, chromic acid, spirit of wine, and 
water, which I think will prove the very thing required. The ligature 
which I show has been soaked a month in serum, and yet the knots 
are perfectly firm. 
The germ theory of putrefaction is the foundation of the whole system 
of antiseptic surgery, and, if this theory is a fact, it is a fact of facts that 
the antiseptic system means the exclusion of all putrefactive organisms. 
Burdon Sanderson a few years ago established a fact when he showed 
that water developed bacteria. When Pasteur’s solution, with suga1’ 
and amraoniacal solutions, was boiled and exposed to the air, various 
forms of fungi were found, but no bacteria ; but if one drop of undis- 
tilled water was added then these latter appeared. Again, when a 
wineglass was tilled with cooled Pasteur’s solution, bacteria were found 
in the contents; but these were attributed not to air dust but to adhering 
water upon the glass. If it were true that water alone was the carrier 
of these germs, it would be of no use to employ the spray; it worm 
only be necessary to cleanse the hands and instruments. Formerly? 
when I used the carbolized putty, I have seen a joint which had been 
laid open do admirably until the blood clot at the wound was pujk 
away, when upon the next day the whole articulation would be m a 
state of putrefaction. I should like to know how this could occur savo 
from air dust. ANTISEPTIC SURGERY. 
[Prof. Lister then showed a glass stand, cup, and cover, which he had used for his ex- 
periments. The cast-iron box in which they were heated to 300° F., in order to destroy 
all living organisms, was fitted with a cover, in the groove in the lid of which was placed 
cotton, in order to filter the air which would otherwise pass uninterrupted through the 
crevice during the cooling process.] 
If a liquid free from organisms is introduced into such a prepared 
glass, it will remain without fermentation until it dries up. This proves 
that if a liquid be freed from living organisms, putrefaction will not 
occur. The lid may be raised for a moment, and some of the liquid sc- 
oured for experimentation, yet no dust will enter during the short space of 
time required for this manoeuvre. If instead of Pasteur’s solution we use 
hoiled milk, and remove the cover for fifteen minutes, then bacteria will 
appear. Milk is more favorable for the development of different kinds 
°f bacteria than Pasteur’s solution. We may have these organisms 
without putrefactive changes, and I have found them in milk treated 
as above described for days without any smell or putrefaction ; but if we 
let in air or water, at once the liquid will putrefy. This would indicate 
that there are bacteria of several kinds, just as there are great numbers 
torulse which cause alcoholic fermentation. Boiled milk is not prone 
to sour, but if we introduce one drop of sweet milk, we almost immedi- 
ately find bacteria. 
Again, suppose that we try how such organisms behave in boiled urine. 
It may be objected that the boiling will prevent decomposition of the 
Ul’ine, but it is possible to obtain pure urine which has never been exposed 
1° the influences of the air, and in which there is therefore no need of 
boiling to destroy any germs, unless those germs existed in the bladder. 
It may be set down as a rule that living tissues prevent the development 
°t bacteria in their immediate vicinity. This is instanced in the puncture 
°f an oedematous limb, where the liquor sanguinis which does not ooze 
away never putrefies, while if it were situated in meshes of cotton in- 
stead of connective tissue it would certainly do so, showing that the 
jiving structures prevent this process. Again, take the instance of heal- 
lng under a scab ; here is an underlying layer of liquor sanguinis, yet 
fermentation never occurs. Hence we might infer that the raucous 
membrane of the urethra would also exercise a forbidding effect upon 
the development of these germs, since, although the acts of micturition 
ai'e infrequent, no organisms are ever found beyond the meatus, even 
Vyben the glans and prepuce are abundantly supplied with them. 
. For experimentation, let the penis be thoroughly washed with a solu- 
tmn of carbolic acid, I to 40, which will produce no irritation; then, 
taking a flask which has been removed from the “ heating box” before 
described, gently lift the cover, and let the patient micturate into the 
dask. One will then have pure, uncontaminated, unboiled urine, which 
}VIH keep for a year, even although it contains vesical mucus. When it 
18 wished to obtain some of the contents of this flask, it is only necessary 
to remove the cap, slip over the mouth one-half of a rubber ball, which 
bas been steeped in carbolic acid, and through a hole in this any amount 
Can be poured, the little drop remaining at the orifice acting as a valve. 
Into one of these glasses of unboiled, pure urine, put one drop of boiled 
milk. The first day, nothing; the second, a dimness and milkiness; 
ai'd now, if we look, we will find long, spiral forms of bacteria. Inocu- 
ate a second glass of urine with one drop of this liquid; and now the 
acteria, having become accustomed to the liquid, will cause it to become 
lied with germs within a few hours. Transfer a drop from the second 540 
LISTER, 
glass into Pasteur’s solution ; again we have bacteria, but of different 
forms. The former were motionless; these are quite active. Now inocu- 
late a glass of boiled milk, and large, moving germs are soon seen. One 
drop of this last will produce lactic acid fermentation almost imme- 
diately. If we believe that torulse are the cause of alcoholic fermenta- 
tion, d fortiori we must believe that the bacteria lactis are the cause ot 
lactic acid fermentation. 
In regard to the inferences to be drawn from these experiments in 
regard to the healing of wounds, I would ask why the effused lymph, in 
the operation for harelip, does not putrefy ? I believe that the explana- 
tion is to be found in the fact that this lymph lies between two healthy 
living surfaces, which prevent the development of organisms just as does 
the urethral mucous membrane. I believe that we should even go fur- 
ther, and say that blood-clot should also be regarded as tissue. I made 
an experiment several years ago, which consisted in laying bare the jugu- 
lar vein of an ox, just struck down, applying two ligatures, and cutting 
away the vein beyond each, thus obtaining a receptacle of living tissue 
containing blood. This vein could be kept for hours without any change 
taking place in its contents. I then drew out the blood into a flask, 
and covered it with gutta-percha to prevent evaporation and dust; for 
twenty-four hours the blood still remained fluid, save where it was in 
contact with the glass, but the instant that the glass was stirred, coagu- 
lation took place. 
The formation of clots in aneurismal sacs may be explained by this 
experiment; as long as the wall remains smooth and uninjured, clotting 
does not occur; but when the sac is injured, or free circulation inter- 
fered with, then coagulation takes place. If the blood-clot in wounds 
does not receive injury, it will organize, and should be accounted as 
tissue. In this blood-clot are many consituents—fibrin, white corpuscles, 
etc. These leucocytes act just as the connective-tissue corpuscles, and 
prevent fermentation, and the explanation of the organization of blood- 
clots, when not disturbed, can thus be explained. Putrefactive changes 
may be introduced into the clot, and yet putrefaction not occur—a cir- 
cumstance which can be best accounted for by the fact that the clot acts 
as a living tissue, and thus prevents putrefaction, just as does the urethral 
raucous membrane before mentioned. There are undoubtedly often deep 
blood-clots in the tissues when acupressure is used after amputations; 
and yet these fail to putrefy, but become organized. This may occur 
under any form of treatment, hut by employing the antiseptic system 
such a result is rendered exceedingly probable. 
As regards the question of constitutional treatment which has been 
raised, I would say that, with strict antiseptic precautions, the wound is 
placed in a condition similar to that of a simple fracture, in which the 
injured parts are free from the dangers of atmospheric exposure, and the 
surgeon has far less need to attend so closely to the patient’s constitu- 
tional condition, as the cases will almost always progress favorably. 
The statement that cell-forms have been found beneath antiseptic 
dressings, must be received with caution. I have recently met a gentle- 
man who was with liancke, in Halle, when he found, as he supposed, 
these organisms beneath antiseptic coverings ; and when this gentleman 
pointed out to me the bacteria which he called putrefactive, I at once 
recognized them as of the non-putrefactive variety; and the gentleman 
was forced to admit that they differed from those found in decomposing 
masses. ANTISEPTIC SURGERY. 
541 
As regards bacteria found in abscesses when the skin is not broken, 
an(i in which Dr. Hod gen stated that the forms came from within, I 
the instances are very rare, although I acknowledge that such 
cases do occur. Again, it does not follow that every foul-smelling ab- 
scess is putrefactive. In ischio-rectal abscesses there is usually a stinking 
edor, even although no communication has been established with the 
,o'vel. My treatment for this class of cases has been not to poultice 
them, for that would surely make a true fistula, but, after thoroughly 
disinfecting the skin, to la}' them freely open under the spray. I then 
cover them with lint soaked in carbolized oil, and over the mass place a 
1-bandage, which can be drawn aside at each act of defecation, I never 
lnject them, nor use a drainage tube. Under this treatment they soon 
heal without either suppuration or odor; and I have never failed to 
secure this result save in one case, in which the house-surgeon, on the 
hrst day, failed to change the dressings under the spray. 
In regard to salicylic acid, I think its action is chemical, and that it is 
specially useful in destroying those odors which are not the result of 
putrefactive change. That it has this chemical property is proved by 
the fact that, when mixed with amygdaline and emulsine, it prevents the 
formation of hydrocyanic acid. Mixed with mustard, also, it prevents 
the evolution of the volatile oil. I have thought that the action of sali- 
cylic acid is very similar upon living tissues. Other classes of cases for 
xvhich this agent is especially suitable, are compound fractures, which do 
getter if kept closed for weeks, and yet are liable to become offensive 
before the expiration of that time, and chronic abscesses connected with 
diseased vertebrae, when the skin is excoriated and ulcerated. In such 
Cases I simply smear the under surface of the carbolized gauze with the 
powder of salicylic acid, and then have allowed a single covering to 
leuiain for six Aveeks without either odor or irritation. 
Discussion on Mr. Lister’s Address. 
_ I-pon the conclusion of Prof. Lister’s remarks, Dr. W. H. Van Buren, of 
ew York, said:—l would ask how far the antiseptic treatment is applicable 
o° a certain class of operations, as, for instance, those for the relief of stran- 
gulated hernia; and how far it is safe to throw the carbolized spray upon the 
Peritoneum in ovariotomy and laparotomy? Absorption has occurred in such 
cases, as evidenced by the production of hsematuria, and other symptoms of 
Carbolic acid poisoning. 
Lister said;— Upon this point I can speak from experience, as I have 
lepeatedly operated for strangulated hernia under the spray, and, in one case 
° abdominal wound, a cloth soaked in the carbolic solution lay upon the 
exposed intestines for several hours without producing any irritation. As for 
e'ariotomy, I am informed that Mr. Keith now uses the spray in all his ope- 
ations, and also that Niissbaum attributes his great success in this class of 
l*ases fo the use of the antiseptic system. I myself think that the danger to 
*e apprehended is not so much from peritonitis as from the toxic effects of 
i le acid. In one case, in which a large ovarian tumor had been removed and 
ernorrhage occurred, I did not open the wound, but simply applied a large 
aii)olized sponge, with pressure, and although a large amount of clotted 
J ood remained in the peritoneal cavity, yet no inflammation resulted. I have 
b^c*1 a ew cases °f danger from the toxic effects of carbolic acid, the symptoms 
cing weakness, failure of appetite, sometimes vomiting, and the urine very 
Uc 1 darkened. These effects have seldom occurred since I have ceased the 542 
LISTER, 
use of the antiseptic putty, and I believe that they will only he found where 
there is a peculiar idiosyncrasy. 
Salicylic acid I consider inferior to carbolic acid as a detergent, yet, in those 
cases in which a deep dressing is to be left on for weeks, and in which the 
odor is apt to become very offensive, I have used it with great advantage. 
This odor is particularly disagreeable in dressings applied to the feet, axilla, 
or perineum, and is not due to putrefaction or to the presence of organisms. 
Dr. T. E. Satterthwaite, of New York, said:—The vegetable germ theory 
seems to be regarded by some as an essential foundation for the antiseptic 
system of surgery. 
The hour being late, I merely desire to point out a few facts which, in my 
opinion, militate against the theory, as far as it claims that a certain class of 
minute living organisms of a vegetable character is essential to disease-pro- 
cesses. Pasteur has, of late, considerably modified his ideas, so far as to 
acknowledge that alcoholic fermentation may- be initiated without the presence 
of certain minute living vegetable organisms, in other words, torulse or allied 
forms, whatever their name. A statement to this effect was made at the 
recent discussion on the Germ Theory in London. Le Chartier and Bellamy 
have observed that, in some modified forms of alcoholic fermentation, such 
minute organisms may at first be absent, though later they make their appear- 
ance. Again, Hiller has inoculated eggs with bacteria, and no putrefaction 
has ensued. Some French observers also have found no organisms present in 
putrefaction. 
These facts are stated to show merely that it is questionable whether alco- 
holic fermentation and putrefaction are due solely to certain minute living 
vegetable organisms, to the growth and multiplication of which these processes 
are due. 
The early views of Pasteur have met with opposition, notably from Liebig, 
Stahl, and others of the German school, and views of a somewhat similar 
nature are still maintained now by those who oppose the “germ theory.” As 
for the changes which it has been stated take place in one and the same bac- 
terial body, under differing circumstances, I think that this is an important 
and interesting fact, and one that has not as yet received sufficient recognition* 
But it is an argument that is exceedingly valuable to those who do not 
believe in the vegetable germ theory. It helps to explain a fact that has led 
to a great deal of confusion, viz., that the different organisms alleged to be 
found in different diseases may owe their differing form not to the disease, 
necessarily, but rather to the peculiar menstruum in which they happen to be* 
With regard to the experiment recited by Mr. Lister, in which urine was 
passed into a glass vessel that contained air, but no floating particles, where 
the fluid continued to resist ammoniacal decomposition until, the air being 
admitted, it was seen to contain particles, I would say that the presence of 
these particles does not necessarily indicate that they are bacteria; in fact, the 
experiments of Blackley, in England, and of Wyman and others, have shown 
that the air contains numerous particles beside bacteria, such as the pollen of 
grasses, epithelial scales, and what is known as granular matter, whatever that 
may happen to be in any given case; and we have a right, in view of certain 
other experiments, such as the production of putrefaction without bacteria, to 
believe that some of these particles—not bacteria—may have occasioned the 
change. 
The same statement applies to Prof. Tyndall’s experiments, in which he 
passed the beam of the electric light through a box fitted with windows, where 
the box contained matter easily susceptible of putrefactive change. When the 
electric beam showed that the inclosed air contained floating motes, then the 
fluids soon commenced to putrefy, but when the beam showed that the pal" 
tides were no longer in the air, the tubes might be introduced and exposed to 
the air, and yet would remain unchanged indefinitely. Now it is implied by 
Prof. Tyndall that the presence of particles is synonymous with the presence ANTISEPTIC SURGERY. 
°f bacteria, which is certainly an assumption, as the electric beam does not 
show that these particles are bacteria in distinction from other particles. 
Experiments with vacuum tubes in relation to putrid matters, if performed 
11li delicacy, tend to show that the fluid of such infusions, although virulent 
ln so far as inoculation is concerned, may still remain clear or transparent for 
Un mdefinite time, without the formation of bacteria. 
In some experiments made with salicylic acid and putrid matter intimately 
ln'xed, infection took place in animals I inoculated, when the quantity of sali- 
ne acid was sufficient to prevent the development of bacteria in organic 
"ifusions. These are simply a few of the points maintained by those who 
the vegetable germ theory as generally accepted. In my paper read 
!n the Section on Sanitary Science, these and other facts are stated at more 
length. 
-Mi’. Lister said:—l am of the opinion that Pasteur has not materially 
Modified his views. The penicilium glaucum, without air, produces a degree 
alcoholic fermentation; there are also certain forms, which when grown 
Under water have thick filaments, with loose joints, and which closely resemble 
.ol’ulae; but, if in oxygen, the growth is much more rapid, and the similitude 
ls less marked. Pasteur made an experiment with grapes kept in an atmos- 
phere of carbonic acid, and although they showed evident signs of ferraenta- 
t'on, yet Pasteur attributed this process to the natural change in the vegetable 
Cebs of the fruit itself, and not to organisms. 
I have made numerous experiments to determine the question as to whether 
le cause of fermentation is a chemical or a vital one; also whether this is in 
Solution in water, or in suspension. I can hardly believe that living things are 
soiuble, and yet if they are only in suspension, by taking minute enough drops, 
'Ve ought to avoid them. I have tried as small a quantity as of a drop of 
Putrefying liquid, introduced by means of a syringe into different solutions, 
have found that no matter how small the quantity used, yet under favor- 
lng circumstances, bacteria are developed. I would mention as a point worthy 
Jd note, that I have discovered that bacteria are killed by the reduction of 
cmperature to a degi’ee still considerably above the freezing point. 
Er. Satterthwaite said :—ln regard to the modification of Pasteur’s views 
1 stated had taken place, the instances referred to by Prof. Lister illus- 
,ate the point which lam desirous of making. 
Ei certain of these instances, as in the well-known experiment where grapes 
'vci'e suspended in an atmosphere of carbonic acid, Pasteur admits1 that fer- 
mentation took place without the intervention of certain minute organisms, by 
llch is doubtless meant the }mast plant or other allied organisms. The fer- 
ment was, in this case, Pasteur said, the tissue elements of the fruit, the vege- 
d J‘e cells, rather than the minute organisms known as fungi, torulse, etc. I 
<\ 111 7 ,0 23 ' , ' 
j.1 aware that Pasteur claims that this admission does not necessarily affect 
1,8 doctrine, hut I must st ill maintain that Pasteur’s view, as generally under- 
. °°d, is considerably modified, to use no stronger expression. The ferment is 
n. Eds case stated to be the substance of the fruit, rather than a minute 
jllei‘oscopic organism ranked among the cryptogams. This is the only point 
am desirous of making in this matter, and the object of introducing it is 
.°k 80 much because fermentation and putrefaction have to do with the discus- 
‘,on, as because the connection between minute living organisms and these 
Processes is brought forward as good a priori evidence of a similar relation 
listing between other minute organisms, such as bacteria and disease-processes, 
j, 11 rcference to Liebig and others of the German school who have opposed 
asteiir, ] did not allude to them as expressing distinct statements as to the 
a llre of the' fermentative agent, for these views varied as the discussion on 
508^ Medecine, Mar. 2, 1875, No. 9, p. 255; Lancet, April 10, 1875, p. 544 
LISTER, ANTISEPTIC SURGERY. 
these topics went on, but rather as showing that there have been and still are1 
those who believe that these changes are not dependent on the growth and 
multiplication of such living organisms as have been described. 
In reference to the nature of disease-poisons, it does not necessarily follow 
that because they may not be bacteria, they may not be molecular; indeed, it 
is my present conviction that this is the case in a certain number of instances, 
as filtration experiments appear to show. The most virulent fluids with which 
I have experimented have never produced lesions when they have been passed 
through porous cla}7. 
Mr. Lister said:—Pasteur has shown that if the grape is bruised, and then 
placed in the atmosphere of carbolic acid,fermentation no longer takes place; 
implying that only living tissues undergo this change. I have tried the experi- 
ment of passing solutions through pores so fine as to arrest bacteria, but X 
have found that albumen is also stopped, and it may be that chemical substances 
in solution are also prevented from passing ; consequently the experiment proves 
nothing save that the cause of fermentation has been prevented from passing. 
1 Handworterb. d. r. und a. Cliimie, 1848, S. 232; Annalen der Chim. u. Pharm., 153, S. 
1, 6, 146. Bastian, Researches illustrative of the Physico-Chemical Theory of Fermenta- 
tion ; Proceedings of the Royal Society, No. 172, 1876. 545 
THE TREATMENT OF ANEURISM. 
BY 
W. H. VAN BUBEN, A.M., M.D., 
PROFESSOR OF THE PRINCIPLES AND PRACTICE OF SURGERY IN THE BELLEVUE HOSPITAL 
MEDICAL COLLEGE, NEW YORK. 
In seeking for information concerning the medical and surgical treat- 
ment of aneurism, we find by far the most ample experience in the records 
°* English surgery. Breschet, in his well-known memoir on aneurism, 
Umlished in Paris in 1832, frankly admits that the pathology of this dis- 
euse had received more attention in England than in France, because of 
greater frequency in that country.1 The greater frequency of aneu- 
>sni in the British Islands than elsewhere still exists; and, unless we 
accept the suggestion that it is the result of the more general use of beer 
spirits in those countries, I must follow Breschet in ignoring its 
aUse. Although our own country has been singularly prominent in the 
o*dness and success of operations upon the great arteries for aneurism, 
the disease is not so frequent here as in England, and at the same 
lnie spirit-drinking is very common. On the continent of Europe, where 
Ile consumption of spirits is less general, aneurism is comparatively rare. 
u connection with the etiology of the disease it is to be remarked that 
,v ? Weight of opinion in favor of syphilis as a cause of aneurism is notice- 
tloly less than formerly. 
inill H*e very able lectures on the treatment of aneurism delivered in 
p ‘2, 1873, and 1874, by Mr. Timothy Holmes, as Professor of Surgical 
. in the Royal College of Surgeons of London, he states that, in 
ejecting his materials, he addressed letters to more than thirty hospital 
“Urgeons throughout Great Britain and Ireland, and that he received notes 
Bo less than three hundred and thirty-seven cases of aneurism, in reply, 
overing ten years of practice. Mr. Holmes complains, moreover, that 
• e pathological museums of London alone are so overstocked with mate- 
j-la, that it is difficult to master their contents, whilst the bulk o± pub- 
•j.8 Je(l matter outruns the best efforts of any one inquirer to keep up with 
i ’ kueh recent and ample supply of material bearing on our subject 
.caves little scope for further research, and the evident ability shown in 
8 collation and digestion gives these lectures great value. Since Guth- 
lectured on this subject from the same chair more than forty years 
‘ &°5 We have had nothing more judicial and authoritative. I shall, of 
tt,BslUb draw largely from them in this report.2 
am • Purel7 medical treatment of aneurism, more especially of internal 
eurisrn, has risen into greater importance within the past ten years. 
r‘ t’°lliffe Tufnell, of Dublin, has fairly and ably demonstrated the posi- 
21 e!n°ires de I’Acad&nie de Medecine de Paris, t- iii. 
treat 18 l)e regretted that Mr. Holmes’s eighteen lectures “on the medical and surgical 
of aneurism in its various forms” are only accessible in the pages of the journals 
PWhnl Ihoy were reported at the time, without any copies of the drawings, or tables, or 
profe' • ICa,l PreParations by which they were illustrated. They are too valuable to the 
ession not to be reproduced in a more permanent form., 
35 546 
VAN BUREN, 
live value of absolute repose in the horizontal position, conjoined with/*' 
greatly restricted diet, omitting entirely the frequent bleedings which 
had brought the so-called treatment of Valsalva into disfavor. Mr. Tut' 
nell’s successful results certainly justify the systematic enforcement o* 
his method, especially in cases of thoracic and abdominal aneurism, which 
we are too much in the habit of regarding as incurable. “The method 
o # # o # _ 
I advocate,” says Mr. Tufnell, “is the imitation of nature’s cure; the pr°' 
duction artificially of that consolidation which in isolated cases has from 
time to time occurred spontaneously.” The recumbent position is the 
secret of cure, but it must be steadily maintained. It places the same check 
upon the circulation in internal aneurism which in external cases is pro' 
duced by mechanical appliances. Three months of horizontal position, 
with eight ounces of solid food and six ounces of fluid as daily allowance, 
were the measures with which he cured Doyle, a hackney coachman m 
thirty-five, with an abdominal aneurism as large as an orange.1 Tufnell s 
method is legitimately derived from the principle so ably illustrated by 
the Irish surgeons when they established the value of compression as a 
remedy, the principle originally demonstrated by Hunter, that to p1’0' 
duce coagulation in an aneurisrnal sac it is only necessary to slow its cm' 
rent of blood, not to arrest it entirely; and, in the judgment of tbe 
writer it is destined hereafter to play a prominent part in the therape11' 
tics of aneurism. 
The aid of drugs has been also invoked in the medical treatment 0 
aneurism for the purpose of slowing the action of the heart and favoring 
coagulation; digitaline and ergotine have been used by Albertini ; all( 
Langenbeck has made trial of ergot in subcutaneous injection. Acetate 
of lead has also been used internally. I have met with little evidence 
in their favor. A case of orbital aneurism is reported by Dr. Holmes,0 
Chicago, which got well after six weeks’ use of tincture of veratrum 
viride in doses of five minims, with a fluidrachm of extract of ergot, sug' 
gested by the late Professor Brainard.2 
In a recently published work Dr. Balfour brings forward further evi- 
dences of the value of potassium iodide in causing solidification of intei- 
nal aneurism.3 This remedy has been tested by the profession, and theic 
are favorable reports of it.4 In many instances, however, the recumbcn 
position and restricted diet have been employed at the same time with 
the iodide. In aneurism in a syphilitic subject its use would be iiml 
cated. Pretty certainly the iodide in such a case would increase the 
number of the red globules of the blood, as Keyes has observed to be the 
case under the use of small doses of mercury, and, possibly, also, its fibi1' 
nating power.5 Until we gain more accurate knowledge of the cause3 
c 
1 The Successful Treatment of Internal Aneurism by Consolidation of the Contents o 
the Sac. By Jolliflfe Tufnell, F.R.0.5.1., etc., President of the Royal College of Surgeol 
.of Ireland, etc.; 2d edition, London, 1875. 
2 Amer. Journ. of Med. Sciences, July, 1864. 
3 Clinical Lectures on Diseases of Heart and Aorta ; London, 1876. f ,jie 
4 See case of .cure of aortic aneurism in a woman of thirty-five, attributed to doses or 
iodide of twelve to fifteen grains three times a day for several months, by Dr. T. M. Matthe' 
■of Texas, in Amer. Journ. Med. Sci. for January, 1875, and others. Mr. Annandale, 
Edinburgh, from “ repeated observation,” bears testimony “ to the value of the iodide 
relieving the symptoms.and promoting coagulation in this disease.” Brit. Med. Journ-, 
80, 1875, p. 550. Plood 
5 On the Effect of Small Doses of Mercury in modifying the number of the Red B 
Corpuscles in Syphilis, a study.of Blood-counting with the llematimbtre; by E. L. E-el ’ 
M.D., etc.; New York, 1876. TREATMENT OF ANEURISM. 
547 
modify the quality or quantity of its fibrin, the mode of action of 
(u'ucrs in favoring coagulation of the blood must remain obscure. 
-Lhe ligature,as applied by Hunter, maintains its character in a general 
Way as the most prompt and certain of the surgical remedies for aneu- 
llSnL and, when not employed in the first instance, it is always held in 
Reserve as a final resort in all cases to which it is applicable; but safer 
raethods of cure are constantly being sought for in order to escape the 
< augers which are still inseparable from the use of the ligature, viz., 
‘cniorrhage, gangrene, and inflammation of the aneurismal sac. 
/-he ligature of carbolized catgut prepared by Professor Lister’s method 
°fiers the best promise, at this time, as a preventive of secondary hernor- 
l rlaSe- Bickersteth, of Liverpool,1 Pemberton, of Birmingham, Heath, 
‘Plunder and Holmes, of London, besides Professor Lister himself, cer- 
am of his colleagues of the Royal Infirmary of Edinburgh, and others, 
)ave recorded evidence that the carbolized catgut ligature is competent 
? c°nstrict an artery for a sufficient time to bring about the consolida- 
tion of an aneurism without causing ulceration of its coats. After this 
. ufy has been accomplished the substance of the ligature then softens 
lnto a mass which is, as it seems, capable of serving as a nidus for cell- 
|r°wth, and, having excited no suppuration whatever, the catgut becomes 
identified with the surrounding tissues.2 Thus, after such a liga- 
/re has been applied, both of its ends may be cut oft' and the wound 
ci°sed as for quick union. This latter result is more likely to be 
stained,according to Professor Lister, when the operation is done under 
Cui’bolized spray, and the wound dressed according to the antiseptic 
Method. The Edinburgh surgeon expresses his readiness to ligate the 
artery by this method, believing confidently that the vessel 
be obliterated with greatly diminished risk of suppuration and 
deration,and with increased chances of rapid consolidation of the 
s A double surety would be thus obtained against secondary 
leinorrhage. 
If is proper to state, however, that some instances have been recorded 
Introductory Address on Recent Progress in Surgery, delivered at the Liverpool 
2 *ca>l Institution, Liverpool, 1871, p. 20. 
P PObservations on the Ligature of Arteries on the Antiseptic System, by Joseph Lister, 
■ -S., etc., Lancet, April 3, 1869, p. 451. More recently, Professor Lister’s statements 
i\jV®. been confirmed by Mr. Fleming, Lecturer on Physiology in the Glasgow School of 
j e<gc*ne, in a very conclusive series of experiments on dogs and rabbits, reported in the 
th° t 011 fjancel> May 27,1876, p. 771. Mr. P. says : The results of these experiments show 
in<t a £ra(lual softening takes place from without in, the catgut breaking down and becom- 
/'filtrated with cells, probably leucocytes. This part of the process takes from five days 
at ° twenty, varying with the specimen of catgut, the tissue amongst which it is situ- 
]k e ’ atl<l the age and vitality of the animal. Next the pultaceous mass into which it has 
(,jfu converted, begins to metamorphose, and is soon permeated with blood channels, and 
su lr/ately may be described as a cast of the catgut, in a kind of granulation tissue freely 
IT led with bloodvessels, which in many of my sections are very fully injected. 
t„- y then, we admit these conclusions, we can easily account for the different results ob- 
T)o-'eC 'T the use of catgut in different hands. We see that it is in reality merely a tern- 
bgature, because when in the softened stage we cannot consider it to have any con- 
stucting effect. 
sior Vl6ther’ then, this temporary condition lasts long enough to produce embolic occlu- 
,' ?' the vessels, depends upon the sample of catgut and the vitality of the patient, 
nial v!' conclusion, my experiments seem to demonstrate that an aseptic, dead, foreign, ani- 
aiid , raa'T un<ler appropriate conditions become, by a process of softening, absorption, 
oro-. le.'(lePos'tion, changed into or replaced by a living, vascular, and comparatively highly 
Bam zed, animal structure.” 
olmes’s Lectures on the Treatment of Aneurism, ut supra, Lancet, June, 1872. 548 
VAN SUREN", 
in which the catgut ligature has become prematurely soft, and pulsation 
has returned in the aneurism ; and in which, when the wound has not 
united, secondary hemorrhage has occurred.1 The answer has been made 
that in these cases of failure the catgut may not have been well prepared, 
and that the necessary details of the antiseptic method were possibly 
neglected.2 
Meanwhile, those who, like Mr. Maunder, lack confidence in the cat- 
gut ligature, have reverted to the use of carbolized silk, which was em- 
ployed by Professor Lister before he adopted the catgut; and it has been 
found in several reported cases to answer the same purpose. There P* 
no danger that the carbolized silk ligature will give way, but Lister bad 
reason to suspect that it might provoke suppuration, and therefore pre- 
ferred the catgut.3 
The problem is to discover a mode of preparing catgut ligatures so that 
they shall possess first the right amount of strength and durability when 
exposed to soakage in. the tissues, and at the same time that their very 
desirable quality of disappearing by blending with the tissues shall not 
be impaired. Professor Lister has just announced to us that he has rea- 
son to believe that he has succeeded in solving this problem, which has 
cost him so much labor. By this event surgery will have secured a great 
triumph over the danger of secondary hemorrhage after ligature >of the 
great arteries for aneurism. 
The employment of pressure upon an artery previous to its ligature has 
been heretofore regarded as a means of averting the danger of gangrene, 
O m On c p, « 
which, according to Norris, causes 12.2 per cent, of all the deaths attei 
ligature of large arteries for aneurism.4 As early as 1820, Todd, 01 
Dublin, had practised compression as a preparatory course prior to ope- 
ration “in order that mortification of the limb might be prevented by 
allowing some progress to be made in establishing the collateral circu- 
1 My late colleague, Dr. Krackowizer, used a carbolized catgut ligature upon the primi- 
tive iliac artery for aneurism at the German Hospital, New York, and pulsation return® 
in the tumor within twenty-four hours, rendering it necessary to reopen the wound and appo 
another ligature. Similar cases are recorded by Dr. E. Watson, of Glasgow, in the Glas- 
gow Med. Journ., May, 1870, p. 340 ; by Professor Spence, of Edinburgh, in the Lancet, Jun® 
5, 1869 ; by Mr. Holden, in St. Bartholomew’s Hosp. Reports, vol. viii. p. 187; by Mr. H- L- 
Browne, Lancet, May 6, 1876; and by Mr. Maunder, in Surgery of the Arteries, London, 
1875, p. 147, where the results of ten cases of “ antiseptic” ligature are detailed, some o 
which are favorable, and others the reverse. 
2 It is only fair and just to Professor Lister that when the remedy he has proposed B 
under judgment, the conditions under which he employs it, and on the strength of which n® 
recommends it, should be strictly complied with. i 
3 Careful microscopic examination of the tissues around a loop of prepared silk which ha 
successfully obliterated an artery, after rapid healing of the wound, in one of the lower anl 
mals, has shown as a rule the persistent presence of portions of the substance of the si v’ 
which have been found in several instances surrounded by granulation tissue in process o 
organization along with some pus corpuscles, proving that silk does not become entire 
blended with the tissues, and does not so readily lose its identity as the properly prepai® 
catgut. Lister, ut supra. 
In a recently published clinical lecture at the Royal Infirmary, Glasgow, Dr. Eben M a 
son describes a patient in whom he had tied both external iliacs for inguinal aneurism at a 
interval of nine months. Both operations were done under carbolic spray, carbolized si 
ligatures applied, and then cut off. The wounds healed well, and the ligatures were 
heard of. Dr. W. gives evidence for his belief that they became encapsulated. He pr® el 
them to catgut, which, for reasons derived from his own experience, he considers less sa 
than silk. Lancet, Aug. 12, 1876, p. 213. 
4 Contributions to Practical Surgery, Philadelphia, 1873. In one hundred and eigh 
eight cases of ligature of large arteries for aneurism, gangrene occurred in thirty-one, an 
was the cause,of death in twenty-three. TREATMENT OF ANEURISM. 
549 
ation.-i This idea has been effectively disputed recently, by Mr. Holmes, 
\ controverting certain conclusions arrived at by Mr. Jonathan Hut- 
c‘ unson, asserts that the larger experience contained in his (Holmes’s) 
‘chected table of hospital cases leads to precisely the opposite conclusion, 
v,z-j ithat the mortality from ligature, after compression has failed, is It) per 
ceiu. greater than when the Hunterian operation has been performed at once? 
Mr. Clement Walter tied the external iliac, at St. George’s Hospital, 
o|' inguinal aneurism, after six weeks’ trial of pressure, both distal and 
lu’°ximal, as -well as flexion, without avail, and the patient died in four 
8 with incipient gangrene.3 It is well known, also, that pressure, espe- 
cudly if intermittent, or irregularly applied, is liable to provoke inflam- 
mation of the sac ; and that it is possible, in rare instances, for pressure 
seu, alone, to occasion gangrene, as in a case recently reported by Hr. 
, scar H. Allis, of Philadelphia.4 These facts should teach us, when it 
18 decided to try compression, to use all possible means to command 
pimupt success, and, these failing, not to prolong unavailing efforts. 
Ice prestige acquired for the Hunterian operation by the brilliant 
Recesses of Astley Cooper, Abernethy, Travers, Mott, and others, caused 
16 Pgature to be regarded, during the first half of this century, as the 
®ftiedy above all others for all forms of aneurism, wherever its applica- 
,l.on Was possible; and it continued to be so regarded, in spite of its really 
11 mortality, until the feasibility of a safer cure by compression was 
Established by the Dublin surgeons. After it became an established fact 
‘iat the disease was safely curable by compression, numerous other 
prices were proposed to attain the same end to the exclusion of the 
’gature, and of compression also; some of greater, others of less promise, 
)llt mainly of a bloodless and safer character. These methods, after a 
ew remarks on compression, I propose to enumerate. 
Meanwhile, it seems to me profitable to ask ourselves how far English 
d . American surgeons may have carried a partiality for Hunter’s ope- 
latl°n to excess, and tied arteries for aneurism in cases in which other 
.!'ethods might have offered a better chance for life ? That this has been 
e case in some degree we have the authority of Syme, of Edinburgh, 
mdoubtedly one of the greatest operators of his day. Towards the 
? °Se> of his life, this surgeon formally raised the question as to the 
applicability of Hunter’s operation to axillary and iliac aneurisms, after 
paving advocated it, as he states, for thirty years. After a series of 
Perations upon the greater arteries, unequalled in brilliancy and success, 
ple felt himself justified in asserting that “ aneurisms of the popliteal, 
Jfmoral, and carotid arteries alone are proper subjects for ligature by the 
lmterian method,” and that all other aneurisms are more safely treated 
in - tactical Remarks on the Treatment of Aneurism by Compression, with plates of 
qum mrents’ etc., by Jolliffe Tufnell, M.R.1.A., etc. etc., Dublin, 1851, p. 24. Tufnell here 
the GS Add, who adds, “at the same time not altogether without hope that by diminishing 
the °Urrent °f blood in the trunk of the artery so as to favor coagulation of the blood in 
the C’ a Pure without operation might be effected.” This is interesting as showing that 
2 y3, °f cure by compression was still fairly in view at this early period, 
had i e°^ure ivM part i., 3d series, Lancet, July, 1874. The probability of this conclusion 
ifii’i een already demonstrated by Dr. J. Ashhurst, Jr., in his System of Surgery, Phila., 
a1’ P-543. 3 
4 H George’s Hospital Reports, vol. vi., 1871-72. 
a g 11 a robust colored man of 50, with a recent popliteal aneurism, a cure was effected on 
leo- o°n(| a^enipt at compression in thirteen hours. Gangrene appeared in the foot and 
one 6 next day, and the patient died in eight days. Dr. Allis states that he has found 
0 her case of gangrene after pressure. Trans. Path. Soc., Phila., 1874, vol. iv. p. 117. 550 
VAX BUEEN, 
by the old operation of laying1 open the sac.1 After careful study of hi 9 
very interesting cases, it is difficult to refuse a large share of assent to 
Syme’s conclusions. Even if we cannot admit his premises, which have 
been shown to be untenable by Holmes and Henry Lee, and refuse to 
return formally to the “old operation,” preferring to trust to the medica 
treatment of Tufnell, or to the promises held out by galvano-puncture, 
coagulating injections, the manipulation of Fergusson, distal ligature 111 
one of its new applications, or even to some form of compression—whicn 
Syme, through what Holmes calls a “strange prejudice,” so singularly 
undervalued—nevertheless, the terrible mortality of the Hunterian ope- 
ration in subclavian, axillary, and iliac aneurisms demonstrates clean} 
that the Edinburgh surgeon was right in raising the question of 
applicability to these cases. “ The Hunterian operation on the inomiuata, 
says Holmes, “and upon the first part of the subclavian, gives twenty- 
eight cases, in only one of which did the patient survive, and then aft®£ 
repeated attacks of hemorrhage—a ghastly record of death and blood. 
The ligature of the second and third parts of the subclavian for aneurisni 
is also very unpromising ; Mr. Poland gives us twenty-one cases, 01 
which only nine recovered.3 In consequence of the pushing up of 
clavicle by the growing tumor, ligature of the subclavian in its thn’c 
portion for aneurism is often difficult, sometimes impossible, and aLva} 9 
dangerous. Hupuytren abandoned it on one occasion, after persevering1 
for an hour and a half, asserting that it was the most difficult operation 
he had ever undertaken ; and Liston punctured the aneurisraal sac 111 
carrying his ligature around the vessel, and lost his patient.4 On the 
other hand, in two cases of rapidly advancing axillary aneurism, Syllie 
limited himself to dividing the tissues at the root of the neck so as fo 
permit a finger to be introduced to compress the artery against the firs 
rib, and then he laid open the tumor in the axilla and tied the vessel y9 
it entered and again as it left the sac, and in both instances saved hi 9 
patient. In two cases of axillary aneurism of a still more desperate cha- 
racter, he succeeded in saving the patients by amputation at the shouldc1- 
joint after the ligature had failed ; and Mr. Spence adopted the same 
mode of procedure, at least with temporary advantage, in a case of 9tll)' 
clavian aneurism.5 
How, granting that Syme has demonstrated that laying open y1'1 
aneurism is a safer and more certain mode of cure than the Hunterian 
ligature in these localites and others similarly situated, where pressure can 
be momentarily effected between the tumor and the heart, does not tin9 
success also prove that it is feasible to attempt a cure, perhaps at a_n 
earlier period, by galvano-puncture, or coagulating injections?—for it 19 
in cases in which the circulation can be thus suspended that these u°ve 
and ingenious remedies offer the best prospect of successful application- 
1 On the Treatment of Axillary Aneurism, Med.-Chir. Trans., vol. xliii. p. 142. See a s 
another paper in vol. xlv. of the same Transactions. 
2 This includes thirteen cases of ligation of the innominata, and fifteen of the subclavia 
Holmes, ut supra, Lect. iv., part ii., Ist series, 1872. , ,g> 
3 Statistics of Subclavian Aneurism, by Alfred Poland, Guy’s Hospital Reports, v 0 
xv., xvi., xvii. . \ 
4 Surgeon Otis, of the U. S. Army (in Medical and Surgical History of the R-ebelnp /’ 
gives 76 per cent, of deaths for ligature of the subclavian outside of the scaleni, 
for hemorrhage or traumatic aneurisms after gunshot wounds, however. In my table 
eighty-six cases of the same operation for all causes, the deaths were nearly 40 per ce 
Contributions to Practical Surgery, Phila. 1865, p. 194. 
5 See Mr. Poland’s paper in Med.-Chir. Trans., vol. lii. p. 277. TREATMENT OF ANEURISM. 
551 
s In thirty-two cases of ligature of the primitive iliac, tabulated by Dr. 
Smith, of New York, the operation was done for aneurism in 
ueen, in which ten died, and one only, Mott’s patient,1 was permanently 
Whatever value, therefore, may be ultimately assigned to the ope- 
!atl°n of Hunter elsewhere in the arterial system, it seems clear that, 
ln these localities at least, it has proved neither safe nor reliable, and 
Cannot be so regarded in future. 
lor gluteal aneurism, the Hunterian operation is equally unpromising, 
ftolmes, who studied this subject thoroughly two years ago, succeeded 
collecting but twelve cases in which the disease was considered spon- 
atteous, and for which the internal or common iliac had been ligated ; 
0l these five, or nearly half, died.3 On the other hand, there were twenty- 
-olle cases in which the affection was pretty certainly traumatic; in two 
0 these the Hunterian operation was done—one of them the case of Dr. 
thgelow, of Boston—and both ended fatally. To these I can add an 
Unpublished case I witnessed in the Bellevue Hospital, New York, some 
3 cars ago, in which ligature of the internal iliac was undertaken, but 
• Patient died within a few days, as was supposed, from wound of the 
hiac vein. There are several other cases on record in which the same 
cause of death is noted, showing the difficulties which attend the ligature 
this vessel. 
In summing up his conclusions concerning gluteal aneurism, Holmes 
hardly shows his usual surgical acumen. He says: “ The old operation 
by laying open the sac and tying the vessel, is a desperate business, and in 
Mate of the really considerable amount of success which has attended it, 
1)0 prudent surgeon could contemplate it without repugnance,” Now, if 
success of the old operation in gluteal aneurism has been “ really 
considerable,” as could bfe readily shown if time permitted, is not this 
conclusion rather sentimental than surgical ? The affection is undoubt- 
edly, in the great majority of cases, traumatic in its origin, and the 
treatment demanded is that of a wounded artery, whenever practicable. 
. Dne succeeded by laj-ing open the sac, following the lead of John Bell 
111 his famous case of the leech catcher. Mr. Bickersteth, of Liverpool, 
and others, have been also successful in a similar mode of procedure. 
Ihe source of fatal delay in quite a number of cases has been the fear of 
Uncontrollable hemorrhage, and lack of power to command it. This 
I>lsk, in the hands of a less confident and skilful operator than Syme, is 
a great drawback, and it is certainly very desirable to find some safe 
of commanding the circulation in this locality. Lister’s aortic 
?\anip, as used by Syme in the case in which he successful!}' attacked an 
d'ac aneurism by the old operation, is not free from danger of crushing 
intestines and causing congestion of the kidneys, as proved by Mr. 
Bryant’s fatal case at St. Bartholomew’s.4 
I have a suggestion to offer which seems to me feasible and effective, 
Phila. Journ. Med. and Phys. Sciences, vol. xiv. p. 176. 
Amer. Journ. Med. Sciences, July, 1860. 
Lectures, ut supra, June, 1874. 
this was an attempt to cure an aneurism of the aorta very near the diaphragm by 
means of distal pressure. Holmes’s Lectures, ut supra. 
Mr. (Jeo. Pollock, in trying the rapid pressure treatment with Lister’s compressor upon 
aorta with chloroform for two hours and ten minutes, and again with ether for an hour 
atm a quarter, was obliged to desist on account of faintness on each occasion. The attempt 
M’as also followed by haematuria which lasted for several days. He did not succeed. 
1-ans. Clin. Soc. Loudon, vol. vii, 1874. 552 
VAX BIT BEN, 
and which I shall put in practice if I encounter one of these rare cases. 
In explorations of the rectum, after stretching the sphincter ani, where 
several fingers or the whole hand, after the suggestion of Simon, of Hei- 
delberg, have been introduced into the bowel, I have been struck with 
the facility with which the great arteries of the pelvic cavity could be 
felt by the fingers, and compressed against its bony walls; and I alll 
confident that either the external or internal iliac or their common trunk 
could be thus easily commanded long enough to render it a safe opera- 
tion to lay open a gluteal aneurism and secure the artery involved, d 
external to the pelvis. All that is necessary is a reliable assistant with 
a small hand, who is somewhat familiar with the manoeuvre.1 
If, possibly, a gluteal aneurism should take its origin within the pe*' 
vis, emerging through the sciatic opening, this fact might be also ascer- 
tained by rectal examination, as already advised by Holmes; and at the 
same time, carrying the exploration a little further, the feasibility 01 
commanding the circulation through the tumor by digital pressure from 
the rectum could be determined. In this latter event, to attempt a cure 
by distal ligature would involve less risk to life than the operation oi 
tying the internal or primitive iliac. 
I would therefore venture the conclusion, in view of the uncertainty 
of diagnosis of gluteal aneurism and its generally slow progress, together 
with the great probability of its traumatic origin and the ascertained 
difficulty and risk to life of the Hunterian operation, that its employ' 
ment, in this variety of aneurism, is of doubtful propriety. 
Ligature of the external iliac for inguinal and femoral aneurism, 111 
ninety-seven cases collected by Horris, gave twenty-six deaths, or a mor- 
tality of about twenty-seven per cent., a comparatively good result, and 
equal to that attained by compression ; so that judging from mortality 
alone, there is little choice in these localities between the two methods. 
According to Holmes’s table of cases, the same general conclusion win 
apply to popliteal aneurism. 
Owing to the number and size of the branches given off by the com- 
mon femoral artery, relapse of aneurism has occurred quite frequently 
the groin after obliteration of the external iliac artery, whether by h»a' 
ture or compression, and this is an argument in favor of the old operation 
in this locality. It is certainly to be preferred in cases of relapse, and 
after the failure of flexion, to ligature of the primitive iliac, as Mr* 
Annandale, of Edinburgh, decided in a case which he has treated suc- 
cessfully within the year by laying open the sac.2 
The distal application of the ligature for the cure of aneurism, as pi*o' 
posed originally by Brasdor, and executed successfully half a century 
later by Wardrop, after having been for a long period regarded with 
distrust, is again finding favor. In the well known case of Lambert, h 
produced a cure of an aneurism confined to the root of the primitive 
carotid.3 At the suggestion of Dr. Cockle, of London, Mr. Christophei 
Heath, in a case of aneurism of the arch of the aorta involving the origin 
of the left carotid, recently ligated the latter vessel, and the operation 
1 I have since learned that this idea had already been conceived and placed on record J 
Dr. Frank Woodbury, Resident Physician at the Pennsylvania Hospital. Am. J°ulll- 
- Sciences, Jan. 1874, p. 131, g 
2 Double femoral aneurism treated with success by rapid compression ; return of 00 
aneurism; ligature of external iliac, unsuccessful; cure by laying open the sac. Lance , 
April 22, 1876, p. 297. 
3 Wardrop, on Aneurism, London, 1825, p. 36. TREATMENT OF ANEURISM. 
553 
•'as fallowed by shrinking of the aneurismal tumor and decided benefit 
1 belief of symptoms.1 Mr. Annandale, of Edinburgh, tied the right 
l 0^1(i in a case of aortic aneurism, in March, 1875, and, as I recently 
tll’ned from him, his patient is still living, and the disease is apparently 
arrested.2 
j. having failed in four cases of subclavian aneurism, the distal 
has at last been crowned with success in the hands of Prof. 
o|and, of San Francisco, California. In January, 1874, a miner pre- 
• . ed himself with an aneurism as large as his fist, extending from the 
'ter border of the left sterno-mastoid to the anterior border of the tra- 
ieziug. Two ligatures were applied to the third portion of the subcla- 
ari 5 they came away on the twentieth day. Pulsation in the tumor 
1 as Perceptibly lessened immediately after the ligature, and gradually 
greased up to the sixth week from the date of the operation, after 
'|efi no pulsation or bruit could be discovered.3 
|. a innominate aneurism there are instances enough on record in which 
has followed the obliteration of one or both of the branches of 
18 great trunk to warrant Holmes’s conclusion that “there are some 
of this disease in which the distal operation is not only allowable, 
’P imperative.” Although there are only three cures reputed certain 
y le cases of Fearn, Evans, and Morrison), of the forty-three he has col- 
®cted of distal ligature for supposed innominate aneurism, yet the 
‘'vorable consequences of the operation recognized in studying the indi- 
th’ al Cases leave a far more favorable impression on the mind than 
y I|s are statement would convey. In several of the unsuccessful cases, 
y 1 exarnple, decided relief to dyspnoea, and to other symptoms, followed 
feature of the carotid. 
yll fact, in a case in which operative interference is decided on, our 
I jcsent experience points to ligature of the right carotid in the first 
the most judicious course; and to the subsequent consideration 
le question of tying the subclavian, and at what part of its course. 
Any tendency to spontaneous obstruction of either branch of the in- 
()tßiuata should be most carefully sought for, as this “would be a first 
Jlci Srand step towards a cure of the disease.”4 Since Holmes wrote, 
jPe double simultaneous ligature, which has never yet succeeded, has 
done on a Hottentot in South Africa by Mr. Frederic Ensor; the 
8- . Burvived more than two months, and- died from bursting of the 
wT' 111 another case by my colleague Dr. P. F. Weir, of Hew York, 
10se patient did not survive so long.6 
hit n- Cockle, “Med. Soc. Proceedings,” vol. i. p. 5, and Heath, “On the Treatment of 
2 *1 "oracle Aneurism by Distal Ligature.” 
a PpCsh Med. Journ., Oct. 30. 1875. The patient was a man of sixty-two. 
< o ostern Lancet, July, 1874. Abstract in Amer. Journ. Med. Sci., Oct. 1874. 
by ulSery of the Arteries. Lettsomian Lectures of the Medical Society ot London, 1875, 
t0 J‘ 41 • launder, Surgeon to the London Hospital, p. 25. He refers in this connection 
p_ jY .striking case of Dr. Herbert Davies, in the London Hospital Reports, 1864, vol. i. 
A 111 wliich the subclavian and its branches were already occluded, so that ligature 
sTe carotid wrould have completed the cure, 
s j anoet, Feb. 6, 1875. 
proipHff most interesting case, published within a few days, of an aneurism of the aorta 
Dr s I'I,® hie root of the neck on the right side and simulating innominate aneurism, 
rirrht . °l' the Brooklyn City Hospital, Brooklyn, New York, obliterated the 
li».lt ar°tid by his invaginating “ constrictor,” and forty-eight hours later applied a silk 
ismal 10 uPon the third portion of the right subclavian. Immediate shrinking of the aneur- 
the s. Umor nnd relief to symptoms followed each of the operations; but inflammation of 
ac> taking its origin at the subclavian ligature, with subsequent hemorrhage from this 554 
VAN BUEEN, 
If the promise offered by the carbolized catgut ligature of Lister, °r 
by the methods of Howard or Speir, be fulfilled, we shall be Justified in 
applying these to the subclavian in the first part of its course. Wh®11 
this can be accomplished successfully, the distal treatment of aneurism 
of the innominata and also of the aortic arch—in certain cases—will l>e 
established as a more hopeful resource to which the sufferer from these 
form in able affections will be entitled, hereafter, when milder menu3 
have failed. 
It will be more profitable, perhaps, in connection with the distal treat- 
ment of subclavian aneurism, to refer to the recent case in whi ell Prof- 
Warren Stone, of Hew Orleans, succeeded in curing a traumatic aneur- 
ism involving the second division of that artery by distal pressure appl'e(l 
by the fingers upon its third portion where it crosses the first rib. 
interest will justify a glance at the details of this unique case, for it u()t 
only illustrates further the value of the distal treatment of aneurisnyhy 
ligature, but also that of compression. A healthy man of twenty-fA® 
was wounded, in April, 1874, by a pistol ball which entered immediate!} 
above the left clavicle, near its inner extremity, and passed downward3 
and backwards, lodging under the skin at the posterior margin of th® 
scapula. There was great pain, and partial paralysis of the arms, shoe- 
ing lesion of the brachial plexus of nerves, but only a trifling amount ol 
hemorrhage. At the end of six weeks an aneurismal tumor the size 01 
an egg had formed at the cicatrix of the wound, and was steadily in' 
creasing. It was attributed to a bruise of the artery at the summit m 
its convexity. Digital compression by a relay of competent assistant3 
was begun on the 15th of June, 1874, and continued for thirty-nme 
hours, when the skin began to suffer, and the patient was exhausted- 
The tumor was reduced to one half its original size, was much harder* 
and feebler in its pulsations. It continued to diminish and to gi’°'v| 
harder from month to month. About the middle of March, 1875, il‘ 
pulsation had disappeared, and up to the present date it has not returned- 
The tumor is now as hard as a marble, and quite as small.1 
This is the only recorded case I have been able to find in which & 
subclavian aneurism has been cured by distal pressure. 
Since the Dublin surgeons re-introduced compression as a remedy f()I 
aneurism, and established its value on a permanent basis, it has steadily 
point, produced a fatal result in the fifth week. At the post-mortem examination 
aneurismal tumor, which sprang from the aortic arch by a narrow opening, was found fid® 
entirely by a “solid mass of coagulated fibrin.” The “constrictor” had obliterated tn 
carotid successfully, and the wound had closed perfectly by quick union. See Archives 0 
Clinical Surgery, New York, Sept. 1876, p. 96. j 
1 A case of traumatic aneurism of the left subclavian artery treated successfully by dis|a 
compression, by Warren Stone, M.D., Professor of Surgical Anatomy, Charity Hospd® 
Med. Coll., New Orleans, from the New Orleans Medical and Surgical Journal, July, 18' ‘ 
In a private note, under date of May. 1876, Dr. Stone kindly adds the following details 
the published case : “ I examined the patient a few weeks ago in company with my friell 
Dr. Choppin. We found a mere remnant of the tumor, with not a particle of pulsation 1 
it. But there was evidence that blood had found its way through the main trunk of f1 
artery (probably by way of the subscapularis), for, by pressing it against the first n » 
radial pulsation was arrested, as on the other side of the body.” Dr. Stone also adds tul3 
interesting fact, since published by Dr. S.: “In Dr. Smyth’s successful case of ligature 
the innominata—which was also traumatic in its origin—notwithstanding all direct curre'1 
was cut off”, as well as the distal flow through the carotid and vertebral, the sac evcntua ; 
filled again (taking ten years it is true), suppurated, bled, and caused the patient’s dea 
Post-mortem examination showed that it was principally supplied by the subscapula 
branch of the axillary.” TREATMENT OF ANEURISM. 
555 
dvaneed in the favor of the profession, and has attained new methods and 
Wider range of application. At first the process was slow, intermittent, 
|amfa], accomplished only by mechanical contrivances, and uncertain in 
s results. ]STow, thanks to our countryman, Knight, of Kew Haven, 
1 "d to the Italian surgeon, Yanzetti, who have taught us the advantage of 
accurate compression by the fingers, and thanks also to the American 
1 scovery of ancesthetics, we are often able to cure aneurism by compres- 
lon in a few hours. The method has been extended from the femoral, 
0 which it was at first confined, to the largest arteries ; where the liga- 
I dre has failed, it has succeeded ; an aneurism of the abdominal aorta has 
. eeu cured in five hours by compression applied to that vessel; another 
1,1 ten and a half hours; and an iliac aneurism in five hours of aortic 
—all under anaesthetic influence.1 The fatal case of Mr. 
tyant, of St. Bartholomew’s, of rapid aortic compression, in which the 
Patient died of peritonitis,2 and a similar case of Mr. Maunder, at the 
°ndon Hospital, in which death occurred suddenly at the fourth hour, 
apparently from the effects of chloroform,3 warn us as to the direction 
_n whjch dan ger lies, nevertheless, Mr. Holt has cured an abdominal 
tlneurism at the Westminster Hospital, London, after fifty-two hours’ 
Pressure under chloroform.4 
■At first employed only indirectly upon the artery between the aneurism 
‘llc* the heart, compression has also been applied with advantage directly 
0 *be aneurisraal tumor, as in a successful case of subclavian aneurism, 
by Mr. Poland,5 and another of femoral aneurism, cured by Hr. 
Uckminster Brown, of Boston.6 In a solitary instance a subclavian 
|Vleurism has been cured by digital compression applied to the artery on 
' distal aspect of the tumor—the case of Prof. Stone, already cited ; 
n<L in not a few instances, both indirect and direct pressure have been 
lsyd conjointly in the same case. 
Perhaps the most remarkable cure of subclavian aneurism by pressure, 
case published last year by Hr. Tiffin Sinks, of Leavenworth, Kansas, 
pistol ball at close range perforated and comminuted the clavicle, 
j > according to the best judgment of the surgeon, entirely divided the 
Flavian artery at the commencement of its third portion. The pro- 
se discharge of arterial blood which the surgeon, who was present, saw 
clung up in a column of three-eighths of an inch in diameter to the 
Perpendicular height of an inch, caused profound and death-like syn- 
, Pe 5 but the patient, a robust man of fort}r-six, unexpectedly rallied, 
pll(* bad no return of bleeding. The cylindrical opening through the 
f°ne, with its projecting spiculse, seemed to have fixed the clot which 
med during the syncope so firmly that it acted like a stopper, and the 
“suit was the formation of a circumscribed aneurism at the seat of 
''Jury. Although the pleural cavity slowly filled afterwards in conse- 
jfUence of internal leakage, showing that it also had been opened by the 
u let, this ceased after a few days, and the pleural effusion was slowly 
Pr An account of a case of aneurism of the abdominal aorta, which was cured by com- 
the ll°n artei7 immediately above the tumor; by Wm. Murray, M.D., etc., Phys. to 
Vo] lsPensary, Newcastle-on-Tyue, and Lecturer on Physiology, etc., Med. Chir. Trans., 
sor X V}'1' r- Yoxon cured a case in ten and a half hours, using Lister’s aortic compres- 
Cllr,bIU er chloroform. Med. Chir. Trans., vol. lv., 1872. Mr. Claudius G. Wheelhouse 
h0 an aneurism of the external iliac by Lister’s instrument applied to the aorta, in five 
a funder ether. Trans. Clin. Soc., vol. vii., 1874. 
4 rp,olmes’s Lectures, ut supra. 3 Surgery of the Arteries, ut supra, p. 11. 
6 , 'ans, Clin. Soc., vol. vii. p. SG. 5 Med. Chir. Trans., vol. lii. p. 277. 
■Boston Med. and Surg. Journ., Oct. 21, 1875. 556 
VAN BUEEN, 
absorbed. The compound fracture went on to consolidate, and, strangely 
enough, the external wound closed entirely without any suppuration? 
which is ascribed to the fact that no compresses or plugs were at any 
time applied to it. Eventually a time came when diminution of the 
general swelling allowed pressure to be applied to the artery just at the 
outer border of the scalenus, by which the pulsation of the aneurisni 
could be controlled. By the judicious use, at first of intermittent and 
later of permanent pressure at this point, conjoined with temporary 
pressure by a mass of lead modelled from a plaster cast of the parts, ap' 
plied to the tumor itself, all swelling and bruit finally disappeared, s0 
that at the end of three months the patient was able to take a trip f° 
New York on business.1 
In the form of acupressure—by needles, or by metallic wire, what Br* 
Pirrie, of Aberdeen, styles “ metallic pressure, removable at pleasure gp 
this remedy of systematic pressure has been subjected to various modifi- 
cations for the purpose of curing aneurism. In one form it has been ap' 
plied successfully as a wire compress to the carotid, and again, to the 
femoral, by Mr. Bix, of Hull, England.2 Mr. George 11. Porter, of Dublhfi 
laid bare the innominata, and compressed it by an instrument of wii’6 
resembling a miniature lithotrite, hoping to obliterate the calibre of the 
artery without dividing its coats ; but they ulcerated under the chafi11# 
and pressure, and the patient bled to death. I have seen the preparation 
from this case, and also the instrument. With the latter in a modified 
form, Mr. Robert Perssti White, of the Meath Hospital, has since cured- 
an inguinal aneurism by compressing the external iliac.3 Mr. W. Stokes, 
of the Richmond Hospital, has also applied Mr. Porter’s instrument, as 
perfected by himself, to the abdominal aorta so effectually as to stop ac- 
curately the current of blood through that great vessel without injury 
to its coats, but the patient perished from shock and incipient peritonitis- 
Mr. Bickersteth, of Liverpool, has also failed in an attempt to obliterate 
the innominata by means of an apparatus of lead wire and caoutchouc. 
The so-styled “ constricting ligature” of our countryman, Hr. B. Howard, 
in which a loop of silver wire is applied around, an artery so loosed7 aS 
not to cut tlirough its coats, may also be regarded as a variety of “ dl®' 
tallic compression.” It is not removable at will, for the wound is closed 
over it as for quick union, with the belief—founded on experiment—that 
the little loop will be tolerated by the tissues, and become encysted, and 
that the inclosed vessel, which is not so tightly constricted as to cause ul- 
ceration of its coats, will nevertheless become permanently obliterated. 
1 Medical Herald, Leavenworth, Kansas, Aug. 1875, p. 15. 
2 Two cases of aneurism, one of the carotid, and one of the femoral artery, treated J 
the wire compress, by J. Dix, M.R.0.5., etc. etc., in Brit. Med. Journ., August 28, I®4 / 
Mr. Dix cuts down upon the artery, and introduces a strand of flexible iron wire benea 
it in the usual way by the aneurism needles. Each end of the ware is then threaded to a 
ordinary needle, and brought out through the tissues by the side of, but clear of, the woiui , 
which is then closed entirely as for healing by first intention. A piece of cork is the 
placed between the two points of emergence of the wire, and pressed down firmly upon t 
artery, and over this cork the wire is tightly twisted until the circulation is stopped. A 
the end of six or seven days the wire is withdrawn. , . 
3 Dublin Medical Press, November 24,1875, p. 428. In this case, the artery is stated 
have been compressed one hundred and sixty-two hours, and yet there was no ulceration no 
hemorrhage. 
4 Dublin Quarterly Journ. Med. Sci., August, 1869. 
5 Holmes’s Lectures, ut supra. e 
6 An Essay on the treatment of Aneurism by a new method, with experiments upon 
closure of arteries. By Benj. Howard, M.D., late Prof, of Clinical Surgery, etc., fi° 
Transactions of Amer. Med. Association, 1870. TREATMENT OF ANEURISM. 
557 
r- S. Fleet Speir, of Hew York, has also devised an ingenious artery 
which can be applied upon the continuity of an artery, so as 
0 divide the middle and inner coats, and then to invaginate the external 
°f the artery within the tube of the constricting instrument to a 
Efficient extent to roll up the two inner arterial tunics into an impass- 
. e barrier equally efficient with that produced by the method of tor- 
_ After this, the instrument is withdrawn, and the wound closed, 
bis ingenious device has been successfully applied to the carotid three 
]lTles, to the femoral and the brachial, each, once ;in each instance it has 
obliteration of the artery, and, as Dr. Speir informs me, has in 
°br cases caused a cure of aneurism.1 
, the whole, the results of compression by metallic wire have not 
~een very satisfactory in any of its modes of application, so that, at the 
llnie he wrote, Mr. Holmes felt justified in asserting that, for his part, 
vbether Mr. Lister be right or no in saying that, with the carbolized 
£atgut ligature properly applied, the ligature of the innominata will be 
°Und a safe proceeding, he, Holmes, would much prefer tying that vessel 
?n fhis method to making any attempt at acupressure.2 But, although 
alludes to a case in which he used a wire ligature successfully, Mr. 
f°lmes does not mention B. Howard’s method.3 In my judgment, we 
Cannot afford to ignore this method of employing silver wire, for, in 
Case the carbolized catgut ligature should in the end prove unreliable, it 
86ems to me that Howard’s suggestion, and the invaginating constrictor 
. Speir, hold out the best remaining promise of occluding an artery 
Without dividing its coats. 
. b>ut the most interesting case of metallic compression has occurred 
lnce the date of Holmes’s lecture: it is that in which Mr. Arthur Fer- 
p|son McGill, of Leeds, succeeded in consolidating an aneurism of the 
subclavian artery by means of a pair of ordinary artery forceps 
applied to its first division for ten hours. Unfortunately, in consequence 
, the anomalous position of the vessel, the pleura was wounded, and 
U’ough this accident he lost his patient.4 In this case the efficacy of 
Vo] 'Ge rch- Clin. Surg., ut supra, pp. 96, 106, and 115; also New York Med. Journ., 
(11 * Xv-> 1872, p. 175, “Successful application of Dr. Speir’s artery-constrictor,” by Dr. 
i.rpjs- A. Hart; New York Med. Record, March 1, 1873, p. 102, and March 15, 1873, 
2 bf artery-constrictor, with cases, by Dr. Speir.” 
3 Dolmes’s Lectures, etc., ut supra. 
tyjti °^mes says of this case, in which he tied the femoral artery for popliteal aneurism 
'vit)1 S^Ver wire, that it was “ thoroughly satisfactory,” the wound healing, though not 
bepl 0 suppuration, in less than a fortnight. Nothing was seen of the ligature; and he 
hav'^'68 at k “buried itself in the tissues of the vessel, and in all probability without 
H*? divided the continuity of the latter;” Lect. iii., Part i., Ist series, June, 1872. 
sPea^s °1 an experiment upon an ass, in which the carotid was obliterated and not 
4 'qd, and adds a caution about not tying the wire too lightly, lest it cause ulceration, 
to fib °ase kft subclavian aneurism, treated by temporary compression applied directly 
pT> artery in the first part of its course, with remarks; by Arthur Fergusson McGill, 
bon i ‘Y surgeon to the Leeds Public Dispensary, Med.-Chir. Trans., vol. Iviii. p. 338, 
dec/uu A woman of 35, with a left subclavian aneurism, had already been very 
0c ( edly benefited by four applications of galvanic needles, but she had resumed a laborious 
whAf0u and the tumor began to grow again, and the pain of the shoulder and arm 
the Ci* *Jeen relieved by the galvano-puncture returned. The tumor had extended above 
the ?AVicle into the neck, and was approaching the surface. She was too poor to spare 
hud |Une Tufnell’s medical treatment, and refused amputation of the shoulder, which 
had °een P10l)0Sed in consequence of its partial success in Mr. Spence’s case. Mr. McGill 
Co 'U) cnnfidence in the distal ligature without amputation, and makes no mention of distal 
t0 jj, less‘°n. He, therefore, proceeded to cut down upon the artery in the usual way, failed 
dig K in its usual place on following down the inner border of the scalenus anticus, but 
'ered it after a tedious search at the depth of his finger, “apparently through a layer 558 
VAN BUREN, 
rapid pressure by a metallic substance applied directly upon an artery 13 
indisputable, for the subclavian, in its first portion, was certainly oblite- 
rated without division of its coats, and, therefore, without danger ° 
subsequent hemorrhage; and it may be fairly assumed that the aneurisn1 
would have been permanently cured, but for the fatal wound of the 
pleura. ~ 
This brings us to consider the propriety of attempting the ligature o 
the left subclavian in the first part of its course. Holmes briefly passes 
it over as an operation not likely to be again undertaken on account o 
its great difficulty, the danger of wounding the pleura, and, perhaps? 
because Sir Astley Cooper once relinquished an attempt to tie this artery 
through fear of wounding the thoracic duct. But Rodgers accomplish 6 
the ligature of the artery at the Hew York Hospital safely, with01* 
wounding either thoracic duct or pleura. Unfortunately, his ligature 0 
silk cut through the walls of the artery, and his patient died in the thn’ 
week from secondary hemorrhage. McGill, hoping to obliterate the 
artery by employing metallic compression in place of the silken thread) 
and thus to surmount this danger, felt justified in repeating the opera' 
tion ; and he succeeded in his object of safely obliterating the artery a° 
avoiding the danger of hemorrhage; but, less fortunate than Rodgers, t°6 
anomalous position of the vessel led to the perforation of the pleura, aul 
this accident caused the death of his patient. 
How, is the danger of wounding the pleura in this operation so utisu*' 
mountable as to forbid its repetition ? This question must be answered) 
for if, in the future, it becomes certain that we may trust the carboliz6 
catgut ligature (or even Howard’s constricting loop of silver wire) f° 
safely obliterate an artery without dividing its coats, then the plßy 
incurred in laying bare the left subclavian would be the only remainnG 
obstacle to its successful ligature. I feel confident that others will undei- 
take this operation, under the lead of Rodgers, as McGill has done; ad 
as neither of these excellent surgeons had any trouble from the thoraui 
duct, we have only the danger of wounding the pleura to provide agai°s ’ 
and the other intrinsic difficulties of the operation. 
My late valued friend, Hr. Charles E. Isaacs, after Hr. Rodgers’s op°ra' 
tion in 1845, “ in order to improve our knowledge as to the relations ° 
the pleura to the parts at the root of the neck,” examined in a series 0 
years no less than one hundred dead bodies most carefully in refer®1160 
to this point of anatomy. He found that the pleura rises higher ab°ye 
the clavicle than is usually recognized by anatomists, averaging in 111 
100 cases nearly an inch and a half at its highest point, whilst in 2B_°a 
of the 100 it rose to two inches and upwards; and that both subclavian* 
within the scaleni muscles are in contact throughout their whole lengt 
with the pleurae. The reason why the pleura has not been more b6 
of pleura” which, in passing the needle around the vessel, was perforated. He then eflfeo , 
compression of the artery by means of a pair of ordinary torsion forceps, stopping encc 
ally all pulsation in the tumor, and closed the wound. Three hours later the pulse v 
130 ; respiration 44 ; and the air was rushing in and out through the wound as she 
but the artery was effectually compressed, and when, ten hours after its application, 
compressing forceps was withdrawn in consequence of the patient’s feeble condition, so 
the wound could be entirely closed, the tumor was solid and pulseless. She died on 
sixth day from intra-thoracic inflammation, just as death occurs from a perforating gj a 
wound. The pleura contained a pint of bloody serum. The aneurism was filled wi 
hard firm clot; in fact it was cured. “The artery had been compressed just before 
origin of the vertebral; it was patent, and in a perfectly healthy condition.” (p- 341.) TREATMENT OF ANEURISM. 
559 
fluently wounded in tying the right subclavian in its first division is, he 
in'ks, because the vessel is nearer the surface, and can usually be 
seen.l 
Now, the surgeon, as he approaches the first division of the left sub- 
avian from above and in front, as it rises almost perpendicularly from 
~le a°i'ta to arch over the dome of the pleura, unless he fully recognizes 
'e tacts brought out by Isaacs, and systematically pushes the serous 
.Membrane out of his way, just as we are compelled to raise the peritoneum 
IJ1 aPproaching the primitive iliac, must incur great risk of perforating 
,5 an accurate anatomist, keeping these relations of the pleura 
tl ''’ays in view, may, as Rodgers did, accomplish the operation safely. 
; bu cases where an aneurism is seated near a joint, so that its pulsation 
c'an be arrested by maintaining the limb in a flexed position, this simple 
eviee continues to be successfully employed, as another variety of com- 
pression, under the designation of “ the method by flexion,” or “ posi- 
lon* ’ It has been used most frequently at the knee-joint for popliteal 
aileurism, but Dr. Gordon Buck, at the Hew York Hospital, extended 
8 application to a case of inguinal aneurism which he cured by flexing 
.le fbigh upon the pelvis. This was a case of relapse, such as is liable 
u occur in this region, the aneurism having returned sixteen months 
, ter a cure by compression. Pressure upon the external iliac did not 
ail'est the returned pulsation; the vessel in fact had been obliterated. 
8 hgature, therefore, was out of the question, and the old operation 
s^e>ned to be the only alternative, as in the similar case of Mr. Annan- 
fjd e. already mentioned. Buck had observed, however, that extreme 
°xion of the thigh arrested the pulsation in the tumor, and he decided 
0 employ this method. In about a fortnight solidification was nearly 
f°mplete, and an entire cure shortly followed.2 In a case of femoral 
aneurism treated first by compression, without result, and finally by liga- 
Ure °t the external iliac, Dr. Gay, amongst other devices to arrest the 
peculation, tried flexion of the thigh upon the abdomen, which controlled 
completely ; but it was abandoned in six hours on account of the pain, 
be parts had become tender under the previous digital and instrumental 
y Isaacs, “on the extent of the pleura above the clavicle,” in Transactions of the New 
! * Academy of Medicine, vol. ii., part i., New York, 1857. Isaacs ascertained that in 
ri ", sulflects the pleura averaged 1.42 inches above the upper margin of the clavicle on the 
1 a,!1 and 1.23 on the left. It averaged higher in the male than in the female—l.s3 to 
g" - In 23 cases it rose to two inches and upwards above the clavicle, and there were only 
0r °i the 100 in which the pleura did not project above its superior margin. The sternal 
eternal aspect of the pleura of the right side extended across, even to the left of the 
of tllaU ne’ ln II cases, from half an inch to an inch and a quarter. A similar disposition 
her 'f IPrIs was never observed on the left side. The pleura rises higher in long-necked 
l>o P|e >ip bull-necked subjects the reverse is the case. In the 23 cases in which the pleura 
sitf6 V° incbes above the clavicle, 14 were on the right, son the left, and 4 only on both 
ar,es’ In these cases the subclavian was high in the neck, and in many of them this 
j.j ery in the third part of its course rested upon the pleura for a very considerable extent, 
of +] ’I Ihe symptoms of wound of pleura and collapse of lung in operations at the root 
Veil J 9 have not been falsely attributed, in some cases, to entrance of air into the 
case8' p Ikinhsen states that thoracic inflammation was the cause of death in 9 out of 22 
,n 01 extra-scalene ligature of the subsclavian arteries, and that it was not the pneu- 
per'la vv!lica so often follows great operations, but inflammation attacking the pleura and 
ai.(Ya£dium in preference to the substance of the lungs, looking as though the complication 
one p r°m causes essentially connected with the disease or operation. Isaacs thinks that 
exist lese causes is probably the unrecognized proximity ot the pleura, which he shows 
tlles S,lll one case out of every four. He also speaks ot “ the curious tact that the top of 
hyiral sac js no£ a]wayS dome-shaped, but sometimes forms cul-de-sacs extending 
2 U‘ fs> and sometimes laterally into the recesses at the root of the neck.” (p. 18.) 
Amer. Journ. Med. Sciences, January, 1870, p. 69. 560 
VAN BUREJST, 
pressure.1 In the case of a Japanese of 40, who was too fat for compl’®9' 
sion of the external iliac, and unwilling to submit to ligature, Dr. Stua1’ 
Eldridge, of Yokohama, succeeded in curing an inguinal aneurism 
this method. He devised an apparatus consisting of a jacket and thig’*l' 
sheath connected by copper wire, in which the thigh was kept flexed on 
the pelvis for tweut}' days, at the end of which time pulsation had pel' 
manently ceased. The patient was seen six months later, and there wa9 
no return of the disease.2 Dr, Edward T. Caswell, of Providence, E- k’ 
reports a case of double popliteal aneurism in which genuflexion shot 
of completely arresting the circulation cured both tumors. At the em 
of six weeks, during which time the man had resumed work, one ot t*1® 
tumors suddenly returned (evidently by rupture), and, after failing w'd11 
ordinary compression, it was necessary to tie the femoral. There wa9 
subsequent suppuration, and discharge of clots.3 In April of the saii]G 
year Dr. Montgomery cured a traumatic aneurism at the bend of the ai’lll 
by simple forced flexion of the forearm upon the arm for twenty-! 0111 
hours.4 , 
From these facts we may infer that this method is still in favor, a°c- 
certainly gaining in extent of application, for heretofore it has been col1' 
flned to aneurisms at the knee and elbow; and also that, when tried, 1 
should precede compression by ordinary means, which are liable to lea>° 
the parts tender. It is well to remember, also, that Theodore Maun°ir’ 
of Geneva, who reported the first case of cure by the method of flexip11’ 
in 1858, demonstrated that the position need not be forced or pain!lll’ 
but that, as in ordinary compression, a very moderate obstruction to tn 
circulation may effect a cure.5 
To conclude the subject of pressure, it is evident that digital comp)’63' 
sion is steadily gaining ground and taking the place, wherever it 13 
applicable, of pressure by means of mechanical appliances; and also tba 
the process known as “ rapid compression,” under anaesthetics and ano' 
dynes, is increasing in favor. 
Still, we must not forget that the old method by moderate and intel' 
mittent pressure has also from time to time effected striking cures, an 
i » U t | ~0 
these in localities—as, for example, upon the primitive carotid—wn°' 
it cannot be safely replaced by more permanent or rapid pressure. 
following cases of orbital aneurism are in point: that of Galezowsk>’ 
who cured a traumatic case in an adult female by digital compress)01 
applied to the carotid, for an hour or so every day at first, and afterwar) 
at longer intervals, for several months.6 In Scaramuzza’s case of kbo' 
pathic orbital aneurism a cure followed digital compression, employ® 
very cautiously on account of aortic disease, for not more than _hv 
minutes at a time, and afterwards for eighteen days, twenty or thbD 
minutes every day in five or six turns—the total period of compressl°11 
being only seven hours and twenty minutes.7 
I have noticed amongst hospital surgeons of experience a tendency 1 
allow intelligent patients to manage pressure for themselves, by mean 
of bags of shot, or of sand, or by a mass of lead modelled to the part, an 
gradually increased in weight. At St. Thomas’s Hospital, in London, 
saw a man in Mr. McCormac’s ward with a subclavio-axillary aneurisnn 
who was successfully controlling its pulsations by a buckskin bag of 8110 ’ 
1 Amer. Journ. Med. Sciences, January, 1875. 2 Ibid. r 
3 11' id., October, 1875, p. 444. 4 Ibid., April, 18 P- 
-5 L’Echo Mtklicale, Neufcbatel, Switzerland, September, 1858. r.,1 
6 Oazette des HSpitaux, 1871, p. 237. 7 Archives G6n6rales, 1858, t. xii. p- 1 TREATMENT OF ANEURISM. 
561 
0 which he had given a peculiar shape; and Prof. Tilanus, at the princi- 
hospital of Amsterdam, showed me a weight of three kilogrammes, 
y which, he said, several cases had been treated in this way. 
A time permitted, the subject of orbital aneurism might occupy us pro- 
ably. Mr. Piyington, of the London Hospital, has lately made a very 
study of this curious and obscure affection in connection with 
pase which he finally cured by ligature of the carotid.1 Dr. Morton, 
the Pennsylvania Hospital, by his unusually rich experience, has also 
(I<fed to our knowledge of this subject. His last published case illus- 
lates the great difficulty that often attends its diagnosis—already shown 
n He cases recorded by Bowman,2 and by Aubrey, of Hermes,3 in both of 
i .ch, with unmistakable symptoms of aneurism—such as pulsation, 
*Ult, and protrusion of the eyeball—no arterial lesion whatever was 
s°llnd after death. In Dr. Morton’s case, with all the characteristic 
fttiptoms of orbital aneurism, except pulsation in the protruded globe, 
fftffitorns sufficient to warrant the diagnosis of aneurism of the internal 
clf)tid in the cavernous sinus, and ligature of the carotid, no trace of 
neurisnial disease was found after death on the day following the opera- 
°n-4 It is to be noted that in each of these cases ligature of the carotid 
Deduced immediate relief of the symptoms. 
Mr. Holmes, as usual, discusses this subject ably in his lectures.5 In 
levv of the great uncertainty of diagnosis, and the possibility also of a 
pontaneous cure—such as took place in the cases recorded by France,6 
°Uard, of Berne,7 Erichsen,8 and I may add also a more recently reported 
ape of Mr. Jonathan Hutchinson,9 together with the admitted dangers 
the operation, he urges delay in resorting to ligature of the carotid. 
same time, whilst reasoning against it, Holmes speaks of the ope- 
ation in this affection, in his Surgery, as “ a most successful oneand 
t 18 noteworthy that the delay which he advised in Pivington’s case led 
A Riore loss of vision, and that the ligature was resorted to, of necessity,. 
m He end. 
c H a still more recent case of Dr. Greuning, of Hew York, diagnosti- 
J1 °d as aneurism of the internal carotid in the cavernous sinus, the 
perati°n was promptly and entirely successful.10 
AJr. Pivington arrives at the conclusion, derived from his very com- 
-1 Ge collection of cases, that “ ligature of the carotid is, beyond question, 
the st Vase Pulsating- Tumour of the Left Orbit consequent upon a fracture of the base of 
ride cure(l by ligature of the left common carotid subsequently to injection of perchlo- 
retn. | ir°n, after digital compression and other means of treatment had failed ; with 
orbi'tU ,vS> and an appendix containing a chronological r§sum6 of recorded cases of intra- 
aneurism. By Walter Rivington, etc. etc., Surgeon to the London Hospital. Read 
2 7, “> 1875, published in Med. Chirurg. Trans., vol. Iviii. p. 183. 
i Pnthalmic Hospital Reports, April, 1859. 3 Gazette des H&pitaux, 1864. 
s f\rtler; Journ. Med. Sci., April, 1876, p. 339. 
s Z,!3- ,cil-> June, 1873, 3d Lect., 2d series. 
7 pUy s Hospital Reports, 3d Series, vol. i., 1853, p. 58. 
8 gazette Mfedicale, 1866, p. 631. 
9 *cience and Art of Surgery. Phila., 1873, vol. ii. p. 108. 
the n ?0Uclle(l aneurism of the internal carotid as large as a bantam’s egg was found at 
Si'tTlor^em'tTl0r^em exaraination of a woman of forty, who had died of aneurism of the ab- 
of a . a°rta. Ten years before, Mr. Hutchinson had seen her with ptosis of the eyelid 
crania] yLion, paralysis of the ocular muscles, except the superior oblique, intra- 
aii(] , bruit, throbbing, and bad headaches. He had diagnosticated intra-cranial aneurism,. 
hgature of the carotid, but had been oveiTiiled, and spontaneous cure followed.. 
Med. Journ., April 17, 1875. 
rchives of Ophthalmology and Otology, vol. v. No. 1, p. 40- 
06 562 
VAN BUREN, 
the means most generally applicable to cases of intra-orbital aneurism1 
dependent on morbid states of the arteries.” His cases give forty-s'* 
instances of ligature of the carotid in forty-four cases (two being double)’ 
and six deaths.1 With such experience, ligature of the carotid in orbihd 
aneurism will continue to be employed, even though in some degi’ee 
empirically. 
I may record the fact that our countryman, Dr, McGill, of Maryland, 
was the first to tie both carotids in this disease.2 Erichsen places l)lS 
name second on his list of double ligatures of the carotid, for all causes- 
Dr. Foote, of Cincinnati, also tied both carotids at the same interval ofll 
month, arresting a traumatic orbital aneurism at the second ligature- 
It is proper to observe, in concluding my remarks under this head, that 
ligature of the primitive carotid for aneurism other than orbital, has proved 
a very fatal operation, mainly through embolism and interference with 
the blood-supply of the brain, probably less than half the cases on record 
having been successful.4 The evidences, therefore, in favor of compression 
of this vessel, collected by Mr. Holmes, carry great weight. Of his seven 
cases, five were cured; and in the two in which compression did not suc- 
ceed, the ligature also failed.5 
Galvano-puncture, as a method of treatment for aneurism, can hardly 
be said to be gaining rapidly in the confidence of the profession, perhap9 
mainly on account of the intrinsic difficulties "which attend the process, 
but, as has been truly said, it occupies at the present time a more pr°; 
raising position than did compression in the days of Guthrie, who du 
not hesitate to speak almost contemptuously of the pretensions of tb® 
latter. The promise held out by the relief of pain and the arrest of pul- 
sation, which so often follow an electrolytic operation, is not fulfill®® 
with certainty; for after a short interval the pulsation almost alwaG 
returns. This disappointing result seems to be due to the softness and 
friability of the resultant clot, which is broken and wasted away by tfie 
arterial current. We have learned, however, that this soft clot possessed 
1 Of these 44 cases, 25 were cured—one after subsequent injections (case of Brainard 
Chicago; Lancet, 1853, p. 162, vol, ii.), 7 received partial benefit, 5 were unsuccessiu ’ 
and 6 died. Two of these deaths were in patients over sixty years of age, and two othe 
(cases of Orftchett and Petrequin), in patients who survived several weeks, and died even 
ually from other causes, are not chargeable to the operation. 
2 In a letter to the late Dr. J. Kearney Rodgers, of New York, from Dr. Joshua J. Cohen- 
of Baltimore (in the N. Y. Med. and Phys. Journ., Sept. 1825, p. 576), it is stated that 
this case “ an ugly, confused mass protruded beyond the sockets of both eyes,” and 
increasing every day. The operations were done at an interval of about a month. ’ 
McG. found the effect of tying one carotid to be limited to one tumor, and ventured up 
the bold attempt (in which he had but one precedent, and probably was not aware of 
of arresting the progress of the other by tying the remaining carotid. Several months a 
the last operation the patient was doing well, and the tumors subsiding. At this ca 
date there were no recorded examples of successful ligature of the carotid for tumors abo 
the head except the cases of Travers (1809), and Dalryrnple (1812), in both of which . 
disease was supposed to be “ aneurism by anastomosis.” Doubtless Dr. McGill regar 
his case as of the.same nature. Cases of soft cancer protruding from both eyes, and doi 
well some months after ligature of both carotids, are not of probable occurrence, wU 
double aneurism has existed in several instances. _ j 
Since the above was written, I have seen a note from Dr. Charles McGill, of Richinoi ’ 
Ya.; dated June 9, 1876, in which he writes as follows: ** In 1823 my brother ligated g 
common carotids of a woman in Williamsport, Md., for vascular tumors of the orbits. ]0 
interval between the tying was about four weeks. The operation was successful, and 
■woman was still living and in good health in 1861, when 1 left the State of Maryland. 
3 Reported by Dr. B. Williams, in New York Med. Record, April, 1868, p. 75. 
4 Maunder, ut supra, p. 44, and Le Fort, Gazette Hebdomadaire, 1868, Nos. 28, 30, 
5 Op. cit., Lect. ii., second series, June, 1873. TREATMENT OF ANEURISM. 
563 
I'Gither noxious nor irritating qualities, so that the operation, which is 
d°ne under an anaesthetic, may be repeated indefinitely. 
'» e owe to Dr. John Duncan, of Edinburgh, the knowledge that in- 
arnrnation of the sac, the principal danger that attends the process, is 
llQt to be feared if there is no cauterizing effect produced by the needles, 
tlci that this can be certainly avoided if they are effectually insulated 
a coating of vulcanite—a device introduced and perfected by Dr. 
raserand himself. “ I have never met with the slightest reaction,” says 
uncan, “ when using insulated needles; and in one case I continued 
uperation for two hours and ten minutes.”1 
his being the case, the eschars and fatal hemorrhages, and inflamraa- 
aoll and suppuration of the sac, which complicated some of the earlier 
cuses of galvano-puncture, can be now surely escaped, and we have only 
uncertainty of the result to contend against.2 
• plan of operating which experience seems to point out as the best, 
|s to insert both the positive and negative needles, thoroughly insulated 
•f uieans of vulcanite, into the sac; to employ a battery of large electro- 
motor force; to prolong the operation so that the sac may be occupied as 
■ as possible by clot; and, finally, to repeat the application as soon as 
llnProvement shall have distinctly ceased. 
1 orhaps the best idea of the value of the electrolytic treatment can be 
Sot trom Holmes’s abstract of the cases of Ciniselli, of Cremona, who has 
eruployed it more largely than any other surgeon. In these, twelve in 
11 uruber, there were two relapses after many months of good health, one 
which was permantly cured by repetition of the operation, and three 
other cases in which a cure had been maintained for still longer periods 
dt the time of the report. Of the eight cases which were not benefited, in 
one was death caused by the direct action of the electricity, and no 
Jj!rm seems to have followed its use in the others.3 Abeille cured a case 
?. subclavian aneurism in a woman, having kept a weight of one 
w‘°gramme upon the tumor for ten hours after the application of the 
~ le great point in favor of this method is that it may be applied to 
oracic and abdominal aneurisms where other surgical remedies are 
Powerless, in combination, for example, with Tufnell’s medical treatment. 
•11 thoracic aneurism, both Ciniselli and Duncan have certainly succeeded 
I 1 averting imminent death from hemorrhage where the tumor was 
ready projecting beyond the ribs.5 In abdominal aneurism no success 
been as yet attained. In Keyes’s case the manoeuvre was accomplished 
a ev> but without apparent result beyond relief of pain.6 In Dell’ 
Infi ecturea on Electrolysis, by John Duncan, M.D., etc., Assistant Surgeon to the Royal 
P e1?!117’ Edinburgh, Lecturer on Surgery, etc.; British Medical Journal, June 28, 1876, 
and ie case Potrequin (Journal de Chirurgie de Malgaigne, t. iv. p. 246, 1840), 
De a*°ther case in Broca (sur les An6vrysmes, etc., Paris, 1856, p. 342), in which the 
law _ e.s> Un were applied seven times in one week for an aneurism under the 
ten ’ ,re was 110 consolidation, but inflammation and suppuration followed, with secondary 
tn lori’nage, necessitating ligature of the carotid, and free opening of the sac, and other 
to stop the bleeding, 
and ■ * ,!s ProPer to note that Ciniselli’s mode of operating is probably more liable to irritate 
4 111 tame the sac than when insulation by vulcanite is employed, 
s rcllives Generates, t. xx. p. 49, 1849. 
e octures, etc., ut supra, 
olev eW Mod. Journ., December, 1871, p. 569. Keyes demonstrated, however, that 
frot.eik poodles could be passed through several layers of peritoneum and convey the current 
wA :“lrty-two cells (of a Stohrer’s battery) without causing inflammation. His needles 
o msulated by vulcanite. 564 
YAN BUHEN, 
Acqua’s case the aneurism burst during the struggles of the patient 
under chloroform, and he died on the table.1 McGill reported a case oi 
subclavian aneurism as greatly benefited after four operations, manipu' 
lation having been also employed conjointly with electrolysis after the 
last application. But relapse took place, and nine months later the 
woman was subjected to the operation on the left subclavian already 
reported.2 
As to galvano-puncture in external aneurisms, Ciniselli cured a poph' 
teal case in 1846—the second recorded example of success by electrolyte 
treatment, Petrequin, of Lyons, having cured a small aneurism of the 
temporal artery the year before. 
Broca, in external aneurisms, recommends direct moderate pressure to 
be applied immediately after the withdrawal of the needles, with the 
view of its effect upon the tumor in the way of malaxation, or manipu^ll' 
tion, as it wasemployed, in fact, in Abeille’s successful case of subclavia11 
aneurism ; and this seems to me an excellent practical suggestion. All 
Esmarch’s bandage for example would really offer the best means oi 
effecting distal pressure (which in the leg and forearm is not easy to ac' 
complish) during the operation, and, if it were afterwards carried op- 
wards over the whole limb including the tumor, it might materially 
assist in preventing the liability to washing away of the clot. 
Dr. Duncan says, in his summary of conclusions, that “ in external 
aneurisms electrolysis should be tried, if compression be not available, 01 
have failed; and it is to be preferred to the ligature—at least of the in- 
nominate and iliac arteries.” 
In his address on Surgery before the British Medical Association, in 
August, 1875, Prof. Spence, of the University of Edinburgh, stated that 
his colleague Dr. Duncan had had successful results in treating large 
cirsoid aneurisms by electrolysis. There is additional evidence on this 
point in Dr. Duncan’s lecture since published.3 It is also very generally 
conceded that for most forms of aneurism by anastomosis, and erectn6 
tumors, electrolytic treatment offers, at the present time, greater advan- 
tages than any method of treatment in use. 
Manipulation, one of the bloodless methods of treating aneurism, wP'1 
which the name of Sir William Fergusson is principally connected, 
has not yet achieved credit for the success which it seems to proml3® 
and to deserve. According to Holmes, this method has been practised 
in five cases of subclavian aneurism, and in two of aneurism ot x® 
lower extremity, “ with clear evidence of cure in two, and a g°®° 
advance towards cure in another,” and no certain proof of injury to H® 
sac, which is the great danger of the proceeding, fn any case.5 Thl3 
surgeon has proved by carefully studied preparations and cases tha 
1 Gazetta Medica Italiana, Lombardia, No. 28, 1870, p. 217. 
2 My colleague Dr. Sands, with the aid of Dr. Guleke, attempted to arrest the prog 
of a traumatic subclavian aneurism in a young man of nineteen, at the N. Y. Hospital- 
March, 1869. He made four electrolytic operations of fifteen minutes each, follow 
Ciniselli’s method mainly. The tumor became momentarily firmer, but it continued 
enlarge, and finally burst. (Thesis of Dr. Allan McLane Hamilton, New York, 1870.) 
3 British Med. Journ., August, 1875, p. 189. In the same Journal, June 10, 1876, F 
715, Dr. D. says: “ There are four recorded cases in which electrolysis has been used 1 
cirsoid aneurism, and in three the disease has been cured. In a case in which Synie 
dined to operate, six applications of the battery effected a cure.” 
4 Med.-Ohir. Trans., vol. xl. e 
5 Op. cit. Lect. v. Part i., Ist series, 1872. I do not think that Dr. Lidell’s successful ca 
is among these. TREATMENT OF ANEURISM. 
565 
1 of clot in the distal end of the artery as it leaves an aneu- 
riSlnal sac is naturally (not always necessarily) followed by obliteration, 
flO1*6 or less complete, of the sac. The curative effect of the distal liga- 
Pre is thus explained, and also that of the method we call manipula- 
-1.0.0n* By the latter proceeding a portion of clot is intentionally and by 
Vlolence detached from the internal wall of the aneurismal sac, and 
Pushed by the fingers, or carried by the current, into its distal outlet, so 
as 1° plug it like an embolus. A large proportion of the cases in which 
clueurism is said to undergo spontaneous cure are doubtless brought 
(iJ°ut in this manner, and Sir William Fergusson has wisely recognized 
-Nature’s lead in proposing it as a remedy. 
. I think that many cases reach their final cure in this manner after the 
Uiterference of art, in which the real methodus medendi is not recognized, 
01 is referred to some other cause. Take, for example, the cases collected 
T Mr. Tufnell, at page 89 et seq. of his excellent “ Practical Remarks 
°;j Treatment of Aneurism by Compression,” published in 1851, in 
tvbich, after a certain amount of contraction and hardening of the 
unior, this treatment seemed powerless to arrest pulsation entirely, and 
, Je patients, as the disease had ceased to increase, were sent about their 
usiness. In every such instance in which the patient was followed up, 
a hual cure was found to have taken place, and it had always occurred 
uU(lenly and after some unusual effort, when a new, painful sensation 
'v°uld be felt in the tumor, and presently all pulsation would be found 
0 have ceased. Here, I take it, a fragment of clot had become detached 
aiM plugged the distal outlet of the half-cured aneurism. 
-Phis method of cure is only applicable to aneurisms in which a certain 
aittount of clot has already formed, and of which the walls present, as 
MC no evidence of thinning or softening, so as to endanger rupture by 
landliug. Dr. Bontecou, of Troy, recently tied the external iliac in a 
Case °f inguinal aneurism, which had been ruptured by the manipulation 
° a professional rubber, undertaken for the relief of pain.l A prominent 
)edical man of Dublin caused the rupture of an abdominal aneurism in 
18 own person. He had known of its existence for ten years, and it had 
pdergone partial cure. The object of his manipulation was to convince 
lls attendants that it was a mass of hardened feces, for, when he grasped 
le tumor and drew it away from the spine, its pulsations were arrested. 
, portly after they had retired to consult, he was found dying from 
Ar*na-1 llemorrliage.2 These examples teach us the necessity of caution. 
Manipulation of an aneurism of the innominata or of the primitive 
.arotid might occasion cerebral embolism, and inflammation of the sac 
always a possibly contingency. 
j apparently spontaneous cure of subclavian aneurism recorded by the 
a e J. Mason Warren, of Boston, the violence previously inflicted upon 
(p6 tumors was the real means of cure, by causing fragmentation and 
i lal impaction of organized coagula.3 And this is also the most pro- 
vable explanation of the success of Staff-Surgeon Reid in the interesting 
of popliteal aneurism in which, after failure of compression by ordi- 
aiy Methods, he effected a cure in fifty minutes by the application of 
v- Bsrnarch bandage.4 His patient subsequently died within the year of 
lseeral disease; and, in describing the condition in which he found the 
s ?evv York Med. Journ., 1876, p. 281. 
Urgical Observations, etc., Boston, 18(37, p. 424, 
2 Holmes, ut supra. 
4 Lancet, Sept. 25, 1875, 566 
VAN BUEEN, 
cured aneurism, Dr. Reid speaks of the manifest displacement of the 
fibrinated laminae which it contained, which laminae were probably dLie 
to the previous attempts at its cure by compression.l ~ 
I have been able to find no very recent cases in which the use 0 
coagulating injections has led to satisfactory results, except a case ascribe0 
to Plagge, of Darmstadt, who cured a traumatic aneurism, just belo'v 
Poupart’s ligament, by injection of extract of ergot, alcohol, and gly°e' 
rine, continued daily for three weeks, with an ice-bag applied to tne 
tumor in the intervals.2 The use of ergot is ascribed to Langenbedb 
and the absence of details detracts from the value of the case. In the 
case of Dr. Dutoit, of Berne, the cure of an aneurism supposed to be sub' 
clavian, in a man of 40, is attributed to fifteen injections of a solution 
of ergotin into the tissues immediately over and around the tumor, a 
intervals of two or three days. This caused diminution or shrinking 01 
the tumor, and subsequently indirect digital pressure was employed 
confirm the cure.3 
The danger of embolism, of which so many instances have followed the 
injection of erectile tumors by the perchloride of iron, has apparently 
inspired a fear of using this drug in the sac of an aneurism ; whilst bs 
known escharotic qualities, and the hardness and irritating nature of the 
magma of iron and blood-salts with coagulated albumen and blood-co*' 
o o , * i- 
puscles resulting from its use, have deterred surgeons from employing u’ 
through well-founded apprehension of inflammation in and around there- 
in the case of Lenoir, after a third injection which, like the previous 
ones, was apparently ineffectual, solidification of the tumor took \Mce 
unexpectedly, and inflammation forthwith developed itself in the sac, 
and resulted fatally.4 Here coagulating injections failed, but inflaming 
tion caused consolidation of the aneurism, and unhappily also the deaf*1 
of the patient. 
In cases where coagulation by the perchloride has succeeded, the rf" 
sultant mass takes on an almost calculous hardness, fails to be absorbed* 
and either becomes permanently encysted, or excites suppuration to se' 
cure its expulsion as a foreign body. 
The question is pertinent whether the tissues would tolerate any bettei 
a clot produced by the 'persulphate of iron.5 This substance, which is lIQ 
escharotic, has been used by the late Dr. Isaacs, of Hew York, and a|s° 
by Drs. Minor, Hutchison, and Enos, of Brooklyn, with success in v]' 
jecting varicose veins.6 In July of the present year, Dr. J. C. Hutchi' 
c 
1 Lancet, Aug. 5, 1876. Dr. Reid says in substance that the portion of the cavity 0 
the aneurism apposite its mouth was occupied by several layers of laminated fihlin’ 
Some of these were partially separated from the others and approximated towards tl6 
centre, the interspace thus caused being filled by an amorphous, softer, cheesy eoaguluin- 
-2 Amer. Journ. Med. Sci., April, 1874, from Loud. Med. Record. 
3 Langeubeck’s Archiv, Band. xii. No. 3. 
4 Broca, op. cit. . . 
5 Or subsulphate, as I believe it should be called. I mean the salt of iron which is 1 
basis of Monsel’s solution. 
6 I learn from Dr. James M. Minor, and also from Dr. Squibb, of Brooklyn, that in 
periments with this salt of iron they have been impressed with its great harmlessness, un 
even with its healing properties when in contact with the tissues. Dr. Minor has piiblis 
six cases in which it has been used successfully—one, a pulsating (erectile) tumor, and n 
cases of varicose veins. See American Medical Times, July Ist, 1860. He employ6ol 
Pravaz syringe, and a solution containing four parts of distilled water to one of the sa j 
which, he thinks now, was too strong, as Dr. Jos. C. Hutchison, of Brooklyn, since in‘°rn 
him that he has used it successfully in a solution of thirty to one, without exciting ulcer’ 
tion in any case. (Private communication of this date.) TREATMENT OF ANEURISM. 
567 
Son, at the Brooklyn (JST. Y.) Hospital, injected a large and increasing 
a'ieurism of the abdominal aorta in a sailor of thirty-two, three times, at 
mtervals of two or three days, with thirty minims of a solution containing 
about half a grain of this salt. Death followed within a fortnight with 
®}’mptoms of inflammation of the sac (i. e., local tenderness, increased 
temperature, 108°, frequent pmlse), and subsequent rupture. There was 
niuch stratified fibri ne in the sac, apparently recent. (From notes of 
Case as recorded by house surgeon.) 
Erainard, of Chicago, cured an orbital aneurism by injecting a solution 
?4 Rotate of iron, after ligature of the carotid had failed ; but destructive 
mflanunation followed.1 Bourget used the perchloi'ide successfully in 
seems to have been a cirsoid aneurism following injury, in a boy 
0l twelve, after failure by galvano-puncture.2 Desormeaux had similar 
success in an adult.3 Petrequin lost a case, but apparently from causes 
Unconnected with the injection. 
Embolism has not occurred in any of the cases of orbital aneurism 
mated by coagulating injections. 
. Eroca records his success in the injection of large vascular trunks of 
Cll’soid aneurism of the scalp, where accurate pressure could be made 
uP°n the vessel on either side of the portion injected.4 
Our best hope for the future success of the operation of Pravaz would 
Seem, at present, to depend upon the results of experiments with the 
Persulphate of iron, in solutions of different strength, in cases where ac- 
Clli'ate pressure can be made on both the cardiac and distal aspects of the 
aneurismal sac. 
. Closely allied to the use of coagulating injections as a remedy for aneu* 
rißm is the idea of inserting foreign material into its cavity in order to pro- 
mechanically, the deposit of fibrinous clot. The earlier attempts in 
Cbs direction, inaugurated by Moore, of Middlesex Hospital,5 London, 
yho employed fine iron wire,and whose example was followed byDomville 
and Murray, failed in each instance, because the wire produced inflam- 
mation of the sac—a result which was no doubt anticipated. Dr. Levis, 
°1 Philadelphia, ingeniously substituted an animal substance for the 
more rigid and irritating metallic wire, and inserted twenty-four feet 
111116 inches of horsehair through a fine needle canula into a subclavian 
aneurisrn, in a man of twenty-seven, at the Pennsylvania Hospital in 
Cotober, 1873. The tumor became hard, and the pulsation in it and in 
. 6 radial artery, ceased at once. The man died during the month from 
mternal hemorrhage, when it was discovered that the sac of the aneur- 
!sm had already ruptured previous to the operation, and that a part at 
,6ast of the walls of the cavity into which the horsehairs had been 
mserted was formed of lung tissue. Notwithstanding this untoward 
C(mdition, their presence had caused the formation of hard clot, and ob- 
structed the flow of blood into the axillary artery, solidifying the portion 
01 the tumor which projected above the clavicle, and causing entire 
cessation of the radial pulse. There were no evidences of inflammation 
Caused by the foreign body.6 
Pile conclusion can hardly be avoided, in this interesting case, that if 
1 Lancet, 1853, vol. ii. p. 162. 2 Gazette MSdicale, 1855, p. 772. 
3 Rivington’s paper, ut supra, p. 288. 
4 Bulletin de la Society de Ohirurgie de Paris, 1859. 
5 Med. Chir. T rans., vol. xlvii. 
6 Translations Pathological Soc. Phila., vol. v. p. 79, 1876. 568 
VAN BUEEN, 
there had been a true resisting sac to the aneurism, a cure would have 
followed. , 
This operation has been repeated by Mr. Bryant, of St. Bartholomew & 
Hospital, London, who introduced twenty feet—three hairs at a time—' 
into a rapidly-growing popliteal aneurism, “ with the effect of causing 
almost complete consolidation of the tumor. The man survived the ope- 
ration five days, dying from ulcerative endocarditis, a condition that 
existed before the operation.” This surgeon considers these results as 
quite sufficient to justify a repetition of the operation.1 
If we succeed in getting a preparation of catgut somewhat more per' 
manent than that now in use for ligatures, but still capable of blending 
ultimately with the tissues, the use of this substance would be still l®sS 
likely to provoke inflammation or suppuration. 
Finally, there is still a variety of aneurism to which experience has 
taught, us that the Hunterian operation is inapplicable; but the lesson is 
being learned slowly. I refer to the cases in which an abnormal opening 
has been formed between an artery and vein—what we call arterio-venous 
aneurism, a term properly used whether any tumor be present or not- 
This affection is almost invariably the result of a wound, and is charac- 
terized by an exaggerated and peculiar thrill2 often perceptible in the 
neighboring veins, and also by enlargement in calibre of the arteries 
involved, and thinning of their walls. 
The Hunterian ligature has been wrongly applied to the cure of tin 3 
affection, as is proved by the occurrence of gangrene or secondary hemor- 
rhage in all the cases in which it has been done in the lower extremity? 
and in some cases in the upper. Unfortunately it has had the sanction 
of Scarpa, Hodgson, Physick, and Liston. The rarity of its occurrence 
explains the delay in accumulating experience enough to reverse tin3 
authoritative endorsement. But on the other side we have Hupuytren, 
Breschet, Mott, and Norris; and, in addition, we have this great facL 
which experience has taught us, that this form of aneurism is not usually 
progressive, so as to threaten life and to justify the use of a remedy 
attended by risk. This is exemplified in a man of forty, whose case wa3 
recently reported to the Clinical Society of London by Mr. Hulke, of the 
Middlesex Hospital. Three years previously, in Missouri, a Derringer 
pistol had exploded as the man was putting it in his right hand t rowset’3 
pocket, and a bullet had traversed the thigh, wounding both vein and 
artery at a point about six inches below Poupart’s ligament. There was 
little bleeding at the time, and relief was ultimately sought some years 
afterwards because the limb was weak and painful, and its surface 
affected by eczema and ulcers. From the point of injury upwards, the 
femoral artery and vein were greatly dilated, and the risk in attempting 
1 The Practice of Surgery, etc.; London, 1876, vol. i. p. 435. 
2 N6laton has the credit of pointing out the fact that, whilst the murmur of an ordinary 
aneurism can he heard only after the systolic impulse, and is therefore interrupted, the pa' 
satory thrill of an arterio-venous aneurism is continuous. It is intensified by the systo 10 
impulse, but does not intermit. This circumstance should always arrest attention, as inch- 
oating the existence of venous communication. 1 have not verified the statement of syste- 
matic writers that, in varicose aneurism (*. e., where a distinct tumor has formed), the inter- 
rupted bruit resulting from the passage of the blood in and out of the aneurismal tun)1* 
can be heard distinct from the continuous thrill caused by the opening into the vein. *f1 
“ rasping bruit” is heard also in cirsoid aneurism, but everywhere equally ; whilst in artery- 
venous aneurism it is loudest at one spot, viz., near the point of communication. 1 ner. 
is also less forcible pulsation in the artery below the point of communication in mos 
instances where an artery opens directly into a vein; and a tendency to dilatation of arte' 
ries above. TREATMENT OF ANEURISM, 
569 
0 tie the former above and below the abnormal opening was considered 
/)0 great. Compression, direct and indirect, was patiently tried and 
°und useless, except in benefiting the eczema and ulcers. Ligature, as 
,<?r simple aneurism, was seriously thought of, but deferred. Meanwhile 
16 patient received so much relief by wearing an elastic laced stocking 
teaching from the foot to the groin, that he willingly accepted the advice 
0 content himself with this palliative treatment.1 
tn a recent case, and in a young subject, the probability of a perraa- 
eutly weakened limb would possibly justify' an operation as for a 
°|inded artery, as in the cases of Spence and Annandale, of Edinburgh, 
a,ln the use of an Esmarch’s bandage would greatly facilitate such a pro- 
ceeding. But in an old case, the number and size of the enlarged and 
°rtuous vessels all carrying arterial blood, the enfeebled vitality of the 
through habitually defective blood-supply, and the thinned walls 
° the arteries, unite to render all operative interference difficult, and, as 
egards gangrene and secondary hemorrhage, especially dangerous,2 as 
P°mted out by Breschet in 1838.3 
As long ago as 1848 I sought to aid in establishing this point of prac- 
lce- The late Valentine Mott tied the external iliac artery in a young 
t la.n from Alabama, for an arterio-venous aneurism in the same locality 
as tn the case just related, two years and a half after the gunshot wound 
$ which it had been caused. The patient had complained of lack of 
P°wer, and more or less pain in the limb, but mainly of the exaggerated 
Pulsation and continuous vibratory thrill over the course of the vessels, 
ydter the operation the limb fell into gangrene at once, and the patient 
J,led on the sixth day. I had an opportunity of dissecting the parts, and 
°Und two small aneurisraal tumors formed out of the adjacent tissues, 
Asides a direct communication between the femoral artery and vein. 
111 pressed by this grave reverse, I collected all the recorded cases within 
reach in which arterio-venous aneurism of the lower extremity had 
treated by ligature on the Hunterian plan, and found that gangrene, 
1 secondary hemorrhage, had occurred in all of them. In twelve cases, 
le eternal iliac was tied in five, and gangrene followed in all; the com- 
ma femoral in two, and gangrene followed in both ; the femoral artery in 
and gangrene occurred in two of these cases, and hemorrhage in all.4 
Morris deduced a similar result from the analysis of the 
ases ot Hunterian operation for arterio-venous aneurism in his tables of 
c° mpted cases of ligature of the femoral and external iliac arteries; and 
this result in connection with the clinical fact that arterio- 
ae"°us aneurism in most instances tends to lose its progressive character 
lit' ecome stationary—causing only inconvenience, and not danger to 
q e this excellent surgeon recorded his opinion that sound surgery con- 
emns a resort to operative measures in the treatment of such cases, “ so 
an' rrans- Clin. Soc. London, vol. viii., 1875, p. 175. Similar cases of arterio-venous 
to n!riSm lndefinite duration, without material progress, must have presented themselves 
tion ° SUrge°ns of experience. Norris quotes a case of Dupuytren’s of twelve years’ dura- 
and ’ -rn sPea^s another he saw in Velpeau’s wards in 1835, of twenty years’ standing ; 
paiif 1 „an°ther of “ long continuance, which inconvenienced though it did not distress the 
■? A - —Contributions to Practical Surgery, etc., Phila. 1873. 
vejn .r°f- Donald McLean, of Ann Arbor, dissected out and tied the popliteal artery and 
Co *n an old case of arterio-venous aneurism (traumatic) above and below the point of 
3 a,ucation, but lost his patient. (Private Communication, May 22, 1876.) 
4 kenioires de I’Academic de M6decine de Paris. 
fh(,n, ase.B °f inguinal aneurism, with remarks. New York Journal of Medicine, vol. ii. 
1 e'V series), 1848, p. 168. 570 
VAN BUREN, 
long as the infirmity can be made at all bearable by the use of coni' 
presses, laced bandages, and other like measures.”1 
I regret that my time will allow me to say nothing of traumM10 
aneurism, especially as there are several most creditable American case!’ 
by which its treatment might be illustrated, in which in the neck, pI)C. 
even behind the ramus of the lower jaw—that most dangerous ot 
localities for a deep punctured wound—the tumor has been laid open an 
the vessel successfully tied above and below the wound in its walls* 
may mention particularly the cases of Prof. Briggs, of Nashville, d®11' 
nessee,2 of Prof. Donald McLean, of Ann Arbor, Michigan,3 and also tn 
more recent case of Dr. Gr. E. Frothingharn of the same city.4 
I am conscious that I have already taxed your patience too long with 
these imperfect notes; and I am equally aware that the extent ot tn 
subject has precluded the possibility, in such limited space, of reasoning 
up to very clearly defined conclusions. The treatment of aneurism a 
the present day clearly does not consist, as thirty years ago, in a choi®®, 
between ligature and compression, but it involves judicial weighing 0 
the claims of many remedial measures, the number of which is ®oll' 
stantly increasing, and the selection of those which offer the best chance9 
of safe and certain cure; and, where the chances of cure are uncertai11’ 
dutyr requires us to try those remedies which give the best promise 0 
ameliorating symptoms and prolonging life. With the new methods ® 
treatment at our command—to alleviate, if not always to cure—l A 1 
venture to assert that, whilst some of the operations on the great arteri® 
sanctioned by distinguished names have failed to fulfil the hopes of then 
projectors—without any diminution, however, of the lustre of those 
names—Surgery is, nevertheless, richer in her aggregate resources; r 
there is no form of the disease which the well-trained surgeon of tj1 
present day can truly call incurable, or for which his art does not on® 
at least some hopeful resource. 
Finally, I would submit the following conclusions for the consider*1' 
tion of the Section : . , 
I. Tufnell’s treatment of aneurism by rest, position, and restricted di® 
offers a valuable resource in thoracic and abdominal aneurism. 
11. It should always be tried in innominate, subclavian, subclavj0' 
axillary, and iliac aneurisms, before resorting to measures attended V 
risk to life. 
111. For aneurisms of the subclavian and iliac arteries, the Hunteri*1*1 
operation, with our present means of preventing secondary hemorrhag®’ 
is not justifiable. , 
IV. For reasons formally set forth by Holmes and Henry Lee, the “P L 
operation” cannot properly be formally substituted for the Hunteria11 
operation in these cases, but should be held in reserve for special cases. 
V. It is the most safe and surgical resource in gluteal aneurism, if f 1 
circulation can be commanded by the hand in recto. 
VI. The mode of cure by embolism, aimed at in the method of mampll 
1 Contributions to Practical Surgery, Phila. 1873, p. 312. 
2 Nashville Medical and Surgical Journal, March, 1871. 
3 Peninsular Journal of Detroit. .^2, 
4 'this case, which Prof. Gross in Arner. Journ. of Medical Sciences, April, 1876, p- 
attributes to Prof. McLean, of the University of Michigan, I learn from this gentfeni > 
belongs to Dr. Frothingharn; Prof. McL. participated in it only as consulting surgeon- TREATMENT OF ANEURISM. 
571 
a^10ni is a not unfrequent explanation of what is called spontaneous 
cure of aneurism. 
* 11. The value of Esmarch’s bandage in the treatment of aneurism is 
Probably not fully estimated. 
-j- VIII. In view of the promising features presented by the eases of 
evis and Bryant, in which horse-hair was introduced into an aneuris- 
tumor, the repetition of this operation, or the substitution for the 
°rse-hair of Lister’s prepared catgut, or other animal substances, may 
e Properly tried. 
Discussion on Dr. Yan Buren’s Paper. 
After the reading of the preceding paper, Mr. Jollippe Tufnell, of Dublin, 
. 1(* •'—l have brought with me from Dublin a number of alcoholic specimens, 
°gether with photographs and drawings, which show some of the cures which 
ave occurred under the plan of treatment which I advocate in cases of internal 
eurism. In following out the idea of the cure of aneurism by compression, 
Uive found that it is not necessary to completely arrest the flow of blood 
the sac, but that a simple diminution of the force of the circulation 
8 that is required. I have also found that the object can be attained by 
euucing the force and frequency of the heart’s action, by placing the patient 
Pon his back and by regulating the diet in such a way as to secure nutrition, 
j yet produce a decided lowering of vitality. A moment’s calculation will 
IOT that if the number of pulsations be reduced from 86 to 56 in the minute, 
‘Sain will be secured of about 43,000 fewer pulsations in the day, a lessening 
*°rce which no one at first glance would fully realize. For the successful 
ari'ying out of this plan, certain conditions are necessary. Thus, (1) the 
neurism must be upon the anterior wall of the artery, as those upon the pos- 
Gl'°r wall are frequently of the dissecting variety ; (2) the sac must be entire, 
jll( (3) the blood must possess the proper fibrinating power. In those cases 
a which a hemorrhagic diathesis exists, and the patients bleed profusely from 
jjlv'al injuries, the method is of course inapplicable. The difference in the 
o°lc?e0°lc?e with which the blood is driven through the vessels is easily noticeable in 
ne s own person, if the test is made between the reclining and the erect 
°sture. I believe that the majority of cases of internal aneurism would 
ec°ver if the patients would be content to lie in bed for three months and 
u jmit to the restrictions of diet, etc., which I have recommended, 
j 11 the treatment of aneurisms in the lower limbs, I have succeeded in effect- 
§ cure bj' simply elevating the heel about six inches. 1 have, by this 
eor6 Produced consolidation of a popliteal aneurism the size of a hen’s 
111 twelve days, and the man is now doing full duty in the Royal Guards, 
j ,lave here alcoholic specimens of several aneurisms cured by the plan which 
t>i,lave proposed : one is an aneurism of the thoracic aorta, in which the sac is 
fo ecl with fibrinous layers; another, of the abdominal aorta, was cured in 
1 I c%s, but soon afterward a dissecting aneurism formed lower down upon 
j 6 essel, and bursting, caused death, the first tumor being entirely solidified. 
a,third, in which the internal iliac artery was affected, both the aneurismal 
e iiag and the degenerated artery became obliterated. 
le sPecimens referred to were then exhibited, and other cures were illustrated by 
urawingS-] J 
on ' ht” Pooley, of Columbus, Ohio, said:—An opportunity is offered by 
°t fit© recent advances of surgery for us again to consider the old ope- 
Th'101- layinS open an aneurismal sac and tying both ends of the artery. 
M.O,S,0,S, ;s fhe Esmarch bandage, which would not only act as a compressor, but 
u aiso give time to cut freely into the sac and leisurely hunt for the vessel 572 
VAN BUEEN, 
without fear of hemorrhage. In traumatic aneurisms, I believe that this 
the most promising form of treatment, as these are practically wound6 
arteries. 
Dr. Alfred C. Post, of New York,said;—Although the plan referred to by 
Dr. Pooley is undoubtedly a good one for aneurism of the traumatic variety* 
it would not be applicable to those of the idiopathic form. In the former cas6 
the walls of the vessel do not constitute the sac of the tumor, in the latter th 
vessel is diseased, and is likely to be in the same condition for some distant 
both above and below. In laying open the sac, in such a case, the artel.y 
itself would be opened and the ligature could not be, properly applied with111 
the sac. Even if the artery could be reached within the sac, this diseased con- 
dition of the coats would render secondary hemorrhage almost a matter ° 
course. 
Dr. George A. Otis, 11. S. Arnry, said;—l understood Prof. Van Bure11 
to refer to a case of ligation of the subclavian artery as a solitary examP16 
of shot-wound of the subclavian, in which the accident had not been I°' 
lowed by immediate death. The annals of surgery present other such cases? 
and several have been recently published. Prof. Billroth, in his Chirurgisc*1 
Briefe zur Schusswunden, has cited several cases in which he was able t° 
secure the right subclavian by ligature, after the above-mentioned injury?in 
the hospitals near Mannheim, in the Franco-Prussian War, 1870-71. I ha' 
endeavored to establish, in the fifth chapter of the Surgical History of t*l 
War of the Rebellion, that shot-wounds of the subclavian are not altogethe 
beyond the resources of art, and have adduced five cases reported by relink 
observers in which the fatal result after shot-injury of this vessel was delay 6 
for several days, the artery having been secured in two instances by ligature* 
In one of the cases, the left subclavian was transfixed by a splinter from tu 
shattered clavicle. I think that even in the presence of such supreme danger 
as is caused by an arterial lesion so near the heart, operative interference niaj' 
sometimes be essayed. 
Dr. John Ashhurst, Jr., of Philadelphia, said:—There is another set 0 
cases in which the “ old operation” may- be properly preferred to the HunteriaU 
method, and that is in certain cases in which the aneurism has Suddenly 
become diffused. No doubt when this accident occurs in a case of poplit6 
aneurism, amputation is the safest mode of treatment, but in a case of lento r 
aneurism, laying open the sac and tying both ends of the artery may be advau 
tageously substituted, as has been successfully done by Messrs. Birkett allt 
Cooper Forster, of Guy’s Hospital. Again, if an aneurism, in any localA/’ 
has ruptured externally, or has been accidentally opened through a mistake iu 
diagnosis, the “ old operation” may be the most available mode of treatnieu • 
Hemorrhage during the operation maybe prevented by using, as suggested hj 
Dr. Pooley, the Esmarch bandage, or, which I confess I think quite as g°0( ’ 
the ordinary tourniquet. In axillary aneurism, the subclavian artery may ” 
compressed over the first rib, through a preliminary incision, as advised jv 
Mr Syrae; and in iliac or inguinal aneurism, bleeding may be prevented D 
using the aortic compressor, for the introduction of which surgeons are s 
much indebted to our President, Professor Lister. 
I have lately had occasion to study the statistics of the operations of ty 
some of the larger arteries, and have been much impressed by the fact that a 
cases have accumulated the percentage of mortality has greatlyr increase • 
Thus, as regards the internal iliac artery, when the late Dr. George W. Non 
published his classical paper, there were known but six1 cases in which tu 
1 Dr. Norris erroneously attributed a seventh (fatal) case to the late Dr. J. Kearney I 
gers, of New York ; a mistake in which I confess to have followed him in my work 
the “Principles and Practice of Surgery,” in company with other systematic writers; 
which has only recently been corrected by the laborious research of Dr. Otis, in the seco 
volume of his Surgical History of the War. TREATMENT OF ANEURISM. 
573 
essel had been tied, and, of these six, four had ended in recovery ; but while 
whole number of recorded cases has since risen from six to twenty-five, the 
ecoveries have risen but from four to seven, so that the death-rate has in- 
from only thirty-three per cent, to seventy-two per cent. Similarly, 
.*• Norris collected sixteen cases of ligation of the common iliac artery, with 
recoveries and eight deaths, a mortality of fifty per cent.; while there 
le now recorded sixty-one cases, with only thirteen recoveries and forty-eight 
eatlis, a mortality of seventy-nine per cent. These figures, it seems to me, 
Peak very strongly in favor of bloodless methods of treatment, such as that 
. llch has been so beautifully illustrated to us to-day by the specimens shown 
y . Ir* Tufnell, and which I, for one, am quite ready to agree with him in 
d *ng the “ successful method of treating internal aneurisms.” 
o S. Fleet Speir, of Brooklyn, said:—l would invite the attention of the 
ection to the “ Artery Constrictor,” which I have devised, and for which I 
ann the advantage of effectiveness and safety. It consists of a mechani- 
arrangement for closing two jaws, one of which is curved so as to admit of 
s being passed beneath the artery, while the other forms a tongue, or male 
ac*e, and is forced down into a groove on the inner surface of the first. The 
'antage claimed for the groove is that it is so narrow as only to admit the 
yernal coat of the vessel along with the tongue, and that consequently the 
mdle and inner coats must give way, and then retract and curl up so as to 
j, 11 & the artery with its own contents, and favor speedy coagulation. In this 
the “ Constrictor” differs from Travers’s instrument. I have used the 
Artery Constrictor” successfully upon the femoral artery, in a case of popli- 
.. aneurism, and also upon the common carotid in a case of supposed dilata- 
. 011 of the innominate, in which, however, it was found that the aorta was 
v°lved. In this case 1 tied the subclavian and constricted the carotid. 
[Dr. Speir’s instrument was then exhibited.] 
President, Mr. Lister, of Edinburgh, said :—I can testify to the value 
Mr. Tufnell’s method in many instances. One case I particularly recall 
u°h occurred in the practice of Mr. Syme, in which a patient, in whom it was 
Imposed to tie the femoral artery for an aneurism of the popliteal, was placed 
at. )et\f°r a few days preparatory to the operation, and, although no particular 
\vi eilt'on was paid either to the lessening of the heart’s action or to diet, yet, 
j en be was brought to the operation table, the pulsation in the tumor was 
und to have entirely ceased. In regard to the distinction which has been 
rawn as relating to the traumatic or idiopathic nature of the affection, Ido 
ls° khink that this is a matter to be so much considered as the question which 
. 16 best and safest operation in the particular case, and the settlement of 
*ls Question will depend more upon the position of the aneurism than upon its 
In the case of popliteal aneurism, for instance, ligature of the femoral 
Co ■ VeiT apex of Scarpa’s triangle, as practised by Mr. Syme, is a very suc- 
but i- °Peration, whether the tumor be traumatic or idiopathic in its origin; 
ei, bgation of the brachial for an enlargement of the vessel at the bend of the 
o*l will probably fail to effect consolidation on account of the free anasto- 
t), ls in this part. This intermingling of vessels is sometimes so intimate 
occluding the brachial may not even destroy the radial pulse for one mo- 
ls P • la the arm, again, laying open the sac is attended with less danger than 
in 1 e.Sarne operation in other portions of the body. Other important elements 
ecidingupon the form of operation are: The character of the tumor, whether 
sho (ilna °r sacculated, and also the condition of the walls of the vessel. It 
tan- renQembered that the artery is just as likely to be diseased at a dis- 
ail Ce fr°m the tumor as in its immediate neighborhood, since the location of 
aneurism is usually the result of accident or some mechanical cause, 
tal, ,lollbl the Hunterian operation fail in aneurism at the elbow, I should cer- 
vL-7 the old operation. 
Ah regard to the aortic compressor, or abdominal tourniquet, I would say 574 
VAN BUREN,TREATMENT OF ANEURISM. 
that, although I formerly supposed it to be original with myself, I afterwards 
found that it had been previously used by Professor Joseph Pancoast, of Pbda' 
delphia, who is entitled to whatever credit pertains to its introduction. As 
the danger in the application of this tourniquet, referred to by Professor 5- 
Buren, 1 think that it is due to the misapplication of the instrument. Au 
inexperienced person, finding the artery beating below, may screw down the paC 
vigorously, while the difficulty really is that proper adjustment has not bee a 
effected. In such a case the intestine may easily suffer, but I guard agaiast 
this by always placing a sponge beneath the pad. 
I would like to say a word as to Mr.Holmes’s allusion to the late Mr. Symf 8 
advocacy of the ligature, as evidencing an “ unaccountable prejudice” in A 8 
favor. The fact is that Mr. Syme lost but one case of femoral ligation out o 
forty, and that one from pyaemia. His other unsuccessful case was one 
which avascular tumor, not properly an aneurism,was treated by ligation, bn 
proved fatal from hemorrhage. Mr. Syme always, cleaned the artery very 
thoroughly before applying his ligature, and he tied the femoral below the ape:S 
of Scarpa’s triangle, because, as he said, there are frequently very large 
branches given off from the femoral instead of from the profunda. 
Professor Yan Buren has said that one of the advantages of the antiseptlo 
ligation of arteries is the avoidance of secondary hemorrhage. This is tr«ei 
but there is also gained another important desideratum, namely, the dimin- 
ished danger of diffuse inflammation. In ligation of the subclavian, if the op 6' 
ration were done thoroughly antiseptically, it would make no great difference 
even if the pleura should be opened, for the danger is not from such a punc- 
ture, but from suppuration, and when this is avoided the operation becomes a 
far safer one. 
Dr. Ashhurst said:—l must say one word as to the history of the aortic 
compressor. I had the pleasure of being present when Professor Pancoas 
first used an abdominal tourniquet in amputation at the hip-joint (in 1859), an.( 
have myself since used, with satisfaction, the identical instrument, which i® 
still extant in Philadelphia, in hip-joint amputation. But with all due regar 
to national pride as American surgeons, I do not think that we can affol 
to let the modesty of our President, Professor Lister, deprive him of the credi 
which is justly due him in this matter. The instrument which was used Py 
Professor Pancoast was simply a large-sized S key’s tourniquet, and it is imo' 
rior to Professor Lister’s ingenious clamp, or compressor, being more difliclli 
of application, and of more complicated construction. Moreover, Professor Pa° 
coast’s use of the instrument wras hardly known out of Philadelphia, and cU 
not attract the attention of surgeons generally ; so that although as a matte 
of fact he undoubtedly preceded Professor Lister in the employment 0 
mechanical compression of the aorta, to the latter is as undoubtedly due tu 
credit of having perfected the mechanical means of effecting such compression 
and of bringing the method before the profession all over the world as a 
practical resource in surgery. , 
Mr. Tufnell said :—I would just mention that, many years ago, a simqal 
instrument was devised by Mr. L’Estrange, of Dublin, for the compression 
treatment of aneurism, and is still preserved in the museum of the Royal Lo 
lege of Surgeons of Ireland.1 
On motion, the conclusions of Dr. Yan Buren’s paper were adopted aS 
expressing the opinion of the Section. 
1 [lt may be added that in Mr. Birkett’s and Mr. Forster’s cases of diffused femoral an 
rism, treated by “ the old operation,” the aorta was compressed by a tourniquet “rec * 
mended by Dr. Humble, many years ago, for compressing the abdominal aorta in caseSeS. 
post-partum hemorrhage” (Trans. Clinical Society of London, vol. i. p. 38), so that the 
tion of actual priority in the use of an aortic compressor probably cannot be settle 
Editor.] 575 
the pathology and treatment of morbus coxarius. 
BY 
LEWIS A. SAYRE, M.D., 
I>R°PEssor op ORTHOPEDIC SURGERY AND OF FRACTURES AND DISLOCATIONS IN THE BELLEVUE 
HOSPITAL MEDICAL COLLEGE, NEW YORK, ETC. 
resident and Gentlemen:— 
I he time allotted me for discussing Morbus Coxarius, its causes, symp- 
85 and treatment, is so limited, that I can only briefly refer to the 
two, and for more minute information must refer you to my pub- 
j Med writings on this subject, where more definite and full information 
as been given ; and I shall occupy a portion of the time with a practical 
. Ration of the plan of treatment in each different stage of the disease, 
•ls Ming the best manner of conveying the largest amount of information 
11 the time that has been allotted to me. 
Morbus coxarius, or hip-disease, as it is generally called, is more fre- 
observed in childhood and early youth than at any other period 
- Me, although it may occur in the infant or the adult. It is generally, 
n°f always, the result of some direct injury to the joint involved, either 
y Ry a blow or concussion of the head of the femur against some portion 
* Me acetabulum, producing an extravasation of blood in the network of 
. essels underneath the articular cartilage of one of these parts, and ending 
11 caries and necrosis; (2) by some strain or overstretching of the joint, 
Pr°ducing rupture more or less complete of the ligamentum teres, and its 
fessels and nerves, thus interfering with the nutrition of the head of the 
®QiUr, and inducing necrosis; or(3) by excessive violence and over-exer- 
,lolb producing free perspiration and synovial secretion, which is sud- 
enly checked by an exposure to damp and cold, thus producing a syno- 
;is which not unfrequently ends in suppuration. 
Ehe young infant is protected by the watchful mother or the careful 
Urse- and the adult has generally sufficient prudence to protect him- 
V L Me reckdess, romping, healthy child indulges in wild sports 
MMout discretion, and slight injuries are unnoticed until serious con- 
fluences have resulted, and often until so long a time has elapsed 
e ween the receipt of the injury and the development of symptoms suf- 
fieut to attract attention, that the cause of the difficulty is entirely for- 
ten, and the constitutional effects of long-continued irritation and 
_ Ppuration are mistaken for the cause of the disease, instead of the 
re-sult 
Mntil within a very few years, every author taught that the disease 
as Necessarily connected with a strumous condition of the system, and 
st>- n°t ex^st without it, and that it was therefore necessarily of con- 
do j^° origin, and never occurred in the robust and healthy. This 
re c ritie I believe to be incorrect; in fact, by a careful examination of my 
I Rf’l(^ed notes of many hundreds of cases of morbus coxarius, I find that 
be M arger number occur in children of perfect health, and born of 
m a My ancestry, and the simple reason is that children of this class are 
°*o active and daring, and therefore more exposed to accidents and in- 576 
SAYRE, 
juries, than sickly strumous children who seldom have energy enough to 
expose themselves to any danger. But even the strumous constitution 
requires some local injury to the part itself, in order to develop the dis- 
ease, and therefore I am inclined to regard the disease as almost always? 
if not always, of traumatic origin. , 
Of course the sickly strumous child, having less recuperative power anc 
vital force to resist disease, will have it developed from a much less exciting 
cause than would be required to develop the same trouble in the healthy 
and robust; but even among the strumous I believe that, if sufficient 
care is taken in the investigation, the disease will nearly always be traced 
to some slight injury which was considered of so little importance as t° 
pass unnoticed at the time, and that months afterwards, when the seri- 
ous consequences of this slight injury have been fully developed in the 
well-recognized hip-disease, the universal belief in the doctrine of its con- 
stitutional origin has prevented the surgeon from examining for an) 
other cause. 
This has been the cause of the fatal error in the treatment of this dis- 
ease ; for, of course, as long as we believe that the disease depends upon 
constitutional taint, all our efforts will necessarily be directed towards 
correcting this constitutional poison or element. The result of all sued 
treatment has been either death, after many months or years of suffering 
and exhaustive suppuration, or else recovery with more or less deformity? 
and with imperfect motion, or anchylosis more or less complete. Whereas? 
belief in its traumatic origin (no matter what the constitutional con- 
dition may be) will direct our treatment to the part involved, and, it the 
disease is early detected and properly treated, will result in the vast 
majority of cases in recovery with perfect motion and without deformity* 
For convenience of description, I will divide the disease into three dis- 
tinct stages, as each represents a different pathological condition of the 
parts involved ; and, as the symptoms vary to a greater or less degree, so 
does the treatment applicable to each : 
I. The stage of irritation. 
11. The stage of effusion. 
111. The stage of rupture of the capsule, or perforation of the aceta- 
bulum. 
In the first stage, or the stage of irritation, before effusion has occurred 
within the joint, the symptoms are not well pronounced, and it often 
requires a very careful investigation in order to recognize the disease- 
Generally, the first thing noticed is that the child appears very slightly 
lame when he first gets out of bed in the morning, or when he first moves 
about after some hours of rest. This limping or halting gait is so sligp 
as hardly to be observed, and, after a few minutes of exercise, may <b9' 
appear altogether until the following day, or until after a few hours o 
rest, when it will again make its appearance on the first attempt at move- 
ment. The patient may sometimes complain of pain even in the early 
stage of the disease, but it is generally referred to the knee. Even in 
this early stage, however, if the child be properly examined, the disease 
can always be detected. 
By stripping the child naked, and standing him on a table or on the 
floor, with the back towards you, the first thing noticed will be that the 
child bears his entire weight upon one limb, the other being slight) 
bent at the knee and hip, with its natis lower and more flattened than 
on the opposite side, while the corresponding gluteo-femoral crease 1 MORBUS COXARIUS. 
577 
er than the other, is less distinct, and nearly obliterated at its outer 
Un?v If you now let the child walk around the room, he may not 
:mP at all, or not sufficiently to attract attention, in this early stage of 
e.; disease; but when you bring him back to the position as first de- 
ribed, and let him stand a moment or two, you will find that he inva- 
ady resumes the position of sustaining his whole weight upon the 
limb. (Fig. 1.) 
Fig. 1. 
Fig. 2. 
,0].1°n next lay the patient on his back upon a table, floor, or some other 
d 'i plane, covered only with a blanket, and lift his lower extremities 
1 fhe entire spine touches the plane (Fig. 2), and twist the pelvis one 
Pro •°rle °flier until a line drawn from one anterior superior spinous 
a f}88 of the ilium to the other will be crossed at right angles by 
the l6r ne rawn from the centre of the sternum over the umbilicus to 
.centre of the symphysis pubis. 
Uie (-• n spinal column touches the plane, and the two lines above 
are at right angles to each other, the spinal column is slightly 
no' ]• ter than normal; but it and the pelvis are at right angles, and, if 
llPo ISease exists within the hip-joint, the limbs can be brought down 
lattQth? plane, so that the popliteal spaces can be made to touch the 
]jft-er disturbing the relation of the lines described, and without 
fhe spinous processes from the plane. If you therefore hold the 
limb in your hand in such a manner as to keep the spinous 
othpC'SSeS 011 f^e P^ane while the other lines are at right angles with each 
tab]1 ’ U observe that the well limb can be pressed down to the 
can 80 that the popliteal space will touch. (Fig. 3.) The diseased limb 
Sp e pressed down nearly to this position, but, before the popliteal 
UiaP touc^les the plane, jmu will notice that the pelvis becomes tilted, 
het ln§ a curve in the lumbar vertebra, so that the hand can be passed 
cen the child’s back and the plane. (Fig. 4.) In flexing the limbs,. 
87 SAYRE, 
the well one can be completely flexed, so that the knee will touch 1 1 
thorax ; the diseased one cannot be flexed to this extent; and before f1 
knee touches the thorax the pelvis becomes lifted from the plane. A 
duction and external rotation may, possibly, at this early period, 
Fig. 8. 
Fig. 4. 
carried nearly to their normal extent without much pain, but adduct^1 
and internal rotation are much more limited. Pressing the head of 
femur into the acetabulum, by concussion at the knee or pressure °v 
the trochanter major, will give pain, providing the pressure is made 
that the head of the femur shall sweep around all portions of the acet‘l 
bulum, the pain being made manifest the moment the parts corne 1 
contact in which the disease exists. Extension, even though very shff1 ' 
in the proper direction, gives instant relief from pain, while pressu1 
causes it as instantly to return. , 
Atrophy of the muscles of the thigh, from tonic contraction caused m 
reflex irritation, will often be found even in the earliest stages of the d> 
ease, so that the measurement of the two limbs will often differ by fr(? 
one-eighth to one-fourth, or even half an inch. Rigidity of the musC Q 
is one of the earliest symptoms observed, and is always present until t1 
disease is entirely arrested. j 
If the disease be detected in this early stage, and properly treated? 
am satisfied, from an extensive experience, that the great majority 
cases will entirely recover, with perfect motion and without deform1 'J 
If the disease be not detected at this stage, and properly treated, it Vr^Q 
grosses until effusion takes place within the joint; and, in ordei 
accommodate this increasing effusion, the limb becomes more 
more abducted, and more everted, or outwardly rotated—to unfold, p° 
speak, the capsular ligament, thereby enabling it to accommodate 1 
to the increased amount of fluid within. . c. 
This is the second stage of the disease, or that of effusion. The £m 
tor muscles become more rigid and contracted under the influenc6 , 
reflex irritation ; constant -efforts are made to draw the thigh 
but without avail, as it is impossible for the limb to yield to their traC 
force, because the effusion within the capsule compels it to assume 
position above described. ' in£ 
This stage of the disease is attended by the most acute and 
pain, the slightest attempt at motion, concussion, or compression cam MORBUS COXARIUS. 
579 
16 most extreme torture; even the jarring of the bed, stamping upon 
16 floor, the slamming of a door, or anything that causes the least 
Movement of the bed upon which the little sufferer lies, may be followed 
} an increase of pain. At this period of the disease the attendant is 
lefluently awakened at night by a sharp, shrill, agonizing shriek. The 
’'arse runs to the child, and probably finds it asleep. She will have 
left the bed before the same thing occurs again; and this is often 
Repeated a number of times during a single night. The inflammation of 
,le joint produces reflex contraction of the muscles, thereby adding to 
16 pressure between the diseased surfaces of the bones, and promoting 
Resorption of the same, as also the peculiar deformity connected with 
. 118 disease. The muscles are kept in this state of constant contraction 
111 order to prevent any motion in the joint; but this incessant, constant, 
Remitting effort so exhausts the patient that finally he falls into a 
Rj*onient’s slumber, from sheer fatigue, when, the muscles being relaxed, 
Je limb changes its position, thereby producing motion in the joint, and 
causing such instantaneous pain that the muscles instantly give a 
spasmodic contraction, followed by the piercing scream to which I have 
Abided. 
Of course, at this period of the disease, it can hardly be mistaken for 
ny other, or misunderstood; but upon stripping the child, and examin- 
es him as I have directed that he should be examined in the first stage, 
will be found to present, both in the erect posture and in the recura- 
. e,b position, precisely the same appearances as in the first stage, only 
111 a more marked degree (Fig. 5), the chief differences being that the limb 
Fig. 5. 
.. 1 be more flexed, abducted, and everted, or rotated outward, and the 
th 11 .more fixed; in fact, any attempt to move the limb in this stage of 
le disease is futile, the entire pelvis rolling upon the opposite acetabu- 580 
SAYRE, 
lum as if the diseased joint were positively anchylosed, though the sup' 
posed anchylosis is only apparent, being wholly due to muscular rigidity- 
If the disease be not arrested at this stage, it goes on to ulceration ot 
the capsule and effusion of its contents into the cellular tissue of the thigh’ 
or else to perforation of the acetabulum and escape of the fluid into the 
pelvic cavity, pressing off the internal periosteum before it. 
At this point begins the third stage of the disease; and as soon as the 
capsule is ruptured, or the acetabulum perforated, and the contents ot 
the joint escape, either into the cellular tissue of the thigh, or into the 
pelvic cavity, the limb at once assumes an entirely different position, y 
now becomes adducted, inverted, and more straight at the knee; the pelvi3 
on the diseased side becomes raised (whereas in the first and second stag63’ 
it was lower than on the sound side); and the limb is shorter. rihe 
gluteo-femoral crease is higher than upon the opposite side, whereas, iu 
the previous stages it was lower, or entirely obliterated. (Fig. 6.) 
Fig. 6. 
If the rupture through the capsule is very large, so that the contend 
escape rapidly, this change in the position of the limb from that of th 6 
second to that of the third stage may take place in a single night ’ 
while if the opening is small and fissure-like, and the contents ooze on 
slowly, the change of form may not be completed for several days. F1 
some cases, even when the capsule has ruptured, or the acetabulum 
been perforated, the limb will remain in the position of the second stag6’ 
owing to adhesions which may have formed, or to the head of the bon6 
being locked in the opening through the acetabulum. The pain is greatly 
relieved upon this rupture of the capsule and escape of its contents, bn 
the disease has only advanced one stage further in its progress. 
It has been thought by many authors that, when this change tak63 
place, the head of the femur is absolute!}’ luxated from the acetabulum, an 
that this luxation is due alone to spontaneous muscular contraction. To6 MORBUS COXARIUS. 
581 
VfR811 change in the distortion, from flexion, abduction, and eversion, 
I 1 elongation, to shortening, inversion, and adduction, has caused this 
. 6lief in the occurrence of positive luxation, but in the sixty-three cases 
II I have exsected the hip-joint, I have never seen luxation upon 
(Pu orsum of the ilium except in one single instance, and in that the 
p was produced a few days before the operation by bending the 
) in the effort to remove the patient from the bed, and was therefore 
Ue to the carelessness of the nurse, and not to spontaneous muscular 
°utraction. The absorption of the head and neck of the femur, pro- 
| by constant pressure, diminishes its size, while the ilium being 
■ So pressed upon, becomes eroded and absorbed, thereby immensely 
the size of the acetabulum. (Fig. 7.) But while this inter- 
Fig. 7. 
P 1 absorption has been going on within the acetabulum, there has 
in^11 at the same time periostitis upon its upper and outer borders, caus- 
t formation of new osteophytes; and the capsular ligament, attached 
\v . lese new deposits, has thus been gradually pushed upward and back- 
; ■rc* °n the dorsum of the ilium, immensely increasing the size ot the 
retaining within its embrace what is left of the head and 
p] ° femur. It might therefore with propriety be called a dis- 
, acenient of the acetabulum, but not a luxation of the head of the thigh- 
bone. 
tin 1,18 may aPPear a ®maii point to cavil about, but accuracy in observa- 
c|-gn 18 essential for obtaining correct knowledge of the pathology ot any 
R ',?.ase, and unless our pathologv is correct, our treatment will be neces- 
agy empirical. 
pat- ie Pus or other fluid having now escaped from the_ capsule, the 
(j0 lent is greatly relieved from the pain, but the disease still progresses. 
pa^ant muscular contraction produces interstitial absorption of the 
Jj ‘ anfi neck of the femur, and of the acetabulum, and the pus, which 
ace ef.caPed into the cellular tissue, burrows in different directions, 
aps°1<'^ug to the position which the patient maintains, forming extensive 
o„Cereß.whicb finally make their way to the surface. These sometimes 
eit!*1 the trochanter, sometimes at a long distance from it, opening 
ler upon the outer or inner side of the thigh, or on both ; and even. 582 
SAYRE, 
as I have seen in cases in which the acetabulum has been perforated* 
making their way between the internal periosteum and the ilium, aIU 
forming openings above the pubis; so that the third stage of hip-diseas0 
may be accompanied with external fistulous openings in various diroo' 
tions, and with very great exhaustion from extensive suppuration. 
We are now prepared to study the treatment of morbus coxarius, which 
of course varies according to the stage in which we find the disease; ancl 
the reason that I have dwelt so particularly upon the diagnosis of the 
affection in its earlier stages, is because, as I have before stated, prop6l 
treatment at this time, in the great majority of cases, will be followed by 
perfectly satisfactory results. 
In the first stage of the disease, if the symptoms of inflammation be 
very acute, and pain and tenderness very great, absolute and perfect restoj 
the joint is most essentially requisite. In the hearty and robust patient? 
in vigorous health, leeches or cups, or some other form of local depletion’ 
may be necessary ; ice bags, surrounding the joint, often afford the great- 
est possible relief, while in other instances hot fomentations, the exac 
opposite, will give the greatest ease. There is no rule with which I 
acquainted, that will guide you in the application of heat and cold? 
except the feeling of the patient, and this can only be determined by a 
practical test. The remedy which gives the greatest relief, and is the 
most agreeable to the patient, is the one to employ. In addition to these 
local measures, extension (very slight, but continuous) in the line of w 
deformity, should be made by means of a weight and pulley, secured f° 
the limb by strips of adhesive plaster, and a roller. The adhesive strip 
should always extend above the knee, to avoid traction upon this articu- 
lation. The pulley should be attached in some manner to the bed, th 
foot of which should be elevated ten or twelve inches, so as to make th 
body act as a counter-extending force. (See Fig. 8.) 
Fig. 8. 
When the extension is first applied, the traction should be made 11 
the line of the deformity, and the direction should be changed by s‘°Vj 
degrees, day by day, until the limb is gradually brought into its natuiq 
position. It is sometimes necessary to apply a second extending P°yv?1’ 
at right angles to the limb, to remove the pressure of the head of t1 
femur against the inner surface of the acetabulum. This is readily do1 
by passing a handkerchief around the upper and inner part of the thig j 
securing in its outer loop a cord to which is attached a weight play11]» 
over a pulley at the side of the bed. . 
If the bowels are constipated, cathartics as a matter of course are m<- MORBUS COXAEIUS. 
583 
a|ecl; and all the secretions and functions of the body must he care- 
rV looked to and kept as nearly in a normal condition as possible, 
f his plan is to be pursued until the more acute symptoms have sub- 
(lecl ; but as the disease is chronic in its nature, time, as well as rest, is 
I Vefy important element in its treatment. And as long confinement in 
/ !s injurious to the general health, we must contrive some mechanical 
Pphance which will give the necessary amount of extension and counter- 
tenaion to relieve the joint from pressure, while at the same time it 
OWE it to have free motion, and permits the patient to take exercise 
II the open air. 
fn some cases, when the disease is very acute, and the child very small, 
is best effected by placing him in a wire cuirass (Fig. 9), which is a modi- 
Fig. 9. 
yy,1 10n of Bonnet’s “grand appareiland which will be found very useful. 
Ce§ en this instrument, or any other fixed apparatus, is employed, it is ne- 
t]J(fc}r7 that the patient should be taken from it very frequently; and all 
ftiii^°ln,t8 should be carefully moved, lest too long-continued rest may ter- 
arfldt? an°hylosis, not only of the joint diseased, but of all the other 
I’h ations thus permanently deprived of motion. lam aware that Dr, 
Liverpool, has denied this doctrine; but having seen the 
bio! ln a oumtjer of cases, I must be pardoned it I insist upon placing 
le confidence in my own personal observations than in the theories of 584 
SAYEE, 
any one. Perfect rest, too long continued, even of the diseased joint,13 
decidedly injurious, as there is danger of its resulting in anchylo9l.8 > 
hence the objection to plaster of Paris, or any other fixed apparatus,111 
the treatment of this affection. The disease is essentially within 
joint, the capsular ligament not being involved ; hence, all that is require 6 
is extension and counter-extension, just sufficient to prevent the disease*- 
surfaces from coming in contact; while at the same time motion is p6l' 
mitted, to keep the capsular ligament and other parts not involved in a 
healthy condition, by allowing the free use of this their natural stimuli3. 
If the child is large enough to run about, and the thigh sufficiently 
long to give attachment to the adhesive plasters, then the short sphrl 
(Fig. 10) is altogether preferable. I have used this splint for many 
Fig. 10. 
years, and having tried all others, I find it altogether the best wherever 
it can be applied, as it allows free flexion at the knee, and is, therefor6’ 
more comfortable in the sitting posture. If the patient is ten or twelv6 
years of age, and too heavy to bear the weight of the body upon tn 
instrument without breaking it, or if too much tension is produced up°n 
the skin by the adhesive plasters, then crutches will be necessary when 
the short instrument is used. If the child’s thigh is too short, and n 
is too small, to receive a sufficient amount of extension by the use 6 
the short splint, then the long splint, which I here show you (Fig* 
is much to be preferred, and with it, if properly applied, the patient w1 
be able to walk without the use of a crutch. 
The short splint and its various modifications, together with the 101H 
splint with its abducting joint and rotating screw, and their mode 0 
application, have already been so fully described (in my work on Fiseas 
of the Joints), that I shall barely refer to them here. . 
The short splint (Fig. 12) consists of a curved cross-bar, surmounting 
the crest of the ilium or entire pelvis, well padded on its inner surface, nn 
to its two extremities are fastened a perineal band or bands, for count6 
extension, and on its outer surface a ball-and-socket joint, from win 6 MORBUS COXARIUS. 
ans an iron rod or bar down the outer side of the thigh to within about 
inches of the lower end of the femur. This outer bar is divided into 
av° sections, one running within the other, and gauged or controlled by 
latchet and key, which can make it longer or shorter. At the lower 
Fig. 11. 
Fig. 12. 
xtreniity of this outer bar is a projecting branch going around to the 
atler surface of the thigh to receive the attachments of the plaster, here- 
j|er to be described. Both of the lower extremities terminate in 
yhudrical rollers, over which the tags of the plasters are attached to the 
VVP buckles placed at the lower ends of the instrument, 
fn applying the instrument, it is first necessary to have the adhesive 
raps to which it is to be fastened properly secured, and this is done as 
0 lows. When using the short splint, which is only worn during the 
night-extension is necessary, which is effected by means of weight 
P pulley: for this purpose a strip of adhesive plaster, to the lower end 
a stout piece of webbing is sewed, is placed on either side of the 
y>’ extending from the malleoli to above the knee, in order to avoid 
J*ti°n on the lateral ligaments of the knee-joint; this is secured by a 
ell-adjusted roller, leaving the pieces of webbing projecting for the 
0£ aebrnent of the extending force. (Fig. 13.) Next, for the application 
the instrument, triangular pieces of plaster, in which are cut several 
* 8 converging toward the apices of the pieces, are placed on both the 
t[l fl' inner side of the thigh, first measuring with the instrument so 
tags which have been sewed to the apices of the plasters will 
jja . 7 conform to the places of attachment upon its lower extremities. 
ti av;*g secured these with a roller, using care at the upper part of the 
to reverse each alternate strip of the plasters in carrying round the 586 
SAYRE, 
roller (Fig. 14), and with another turn taking in the other strips—braid- 
ing them in, basket-shaped—run the roller down the thigh again and sei'r* 
Fig. 13. 
Fig. 14. 
In applying the instrument, first buckle on the straps at the loWd 
extremity of the femur. Then pass the strap under the femur to the 
buckle at the outer side of the instrument for the purpose of keeping 
in place. We now pass the perineal band around the perineum, aim 
buckle it snugly, but not too tightly. We next insert the key into the 
ratchet, and make gradual extension, until the patient is made perfectly 
easy, and until compression can be made upon the femur against the 
acetabulum without pain. It is sometimes necessary to employ tw° 
perineal bands, and then the cross-piece at the top nearly surrounds the 
pelvis. 
If the disease has arrived at the second stage before we see it, and the 
effusion is very great, which will be indicated by the abduction, flexion 
and eversion of the limb—sometimes even fluctuation can be detected-'' 
the patient must be kept in bed and the extension applied to the liym 
exactly in the line of the distortion, which will be in the line of flexi°a 
and abduction. This line of extension is to be changed day by day, hy 
slight degrees, until the limb is brought as nearly as possible to the 
straight position. Blisters applied occasionally over the joint mW 
hasten the absorption of this effusion. Firm strapping with adhesive 
plaster around the joint and compression with a sponge and roller 
also be applied for the purpose of aiding absorption ; of course, extension 
being used before this compression is employed. It is barely possible 
that the effusion may be so great as to paralyze the absorbents, and that n° 
treatment will decrease the effusion. Under such circumstances aspn’a' 
tion of the joint is not only advisable, but the proper treatment, all MORBUS COXARIUS. 
587 
be immediately followed by a restoration of the joint to its natural 
Position. J J J 
ben the limb has been brought to nearly its normal position, then 
e treatment by the short or long splint, according to circumstances, is 
le same as in the first stage of the disease, the plasters beino- re-adjusted 
often as necessary. Good adhesive plaster (Maw’s, of London, I have 
°und to be the best), properly applied, will frequently remain in position 
. °m two to four months, seldom requiring removal oftener than once 
111 six weeks or two months. 
fl the disease has gone to the third stage, capsule ruptured, abscesses 
oi’nied and not yet opened, it is necessary to puncture these abscesses at 
i ai'ious points where they are nearest the surface to prevent the pus from 
Arrowing. The limb then being adducted, the extension, as a matter of 
must be exactly in the opposite direction from what it would have 
Jeen in the second stage of the disease, and the limb gradually abducted 
lnlil it is brought parallel with the other, when the splint, either long 
?r short, is requisite, to be modified by the abducting screw, which I have 
Jeeu in the habit of using for many years with great advantage. In 
I Unierous instances, even when the disease has progressed to this stage, 
ithe use of the splint the patient is enabled to improve the general 
leGth by out-door exercise, which frequently results in perfect recovery, 
hi some cases with a moderate degree of motion. The majority of 
le cases, however, that have arrived at this point before proper treat- 
r leut has been adopted, are apt to recover with more or less complete 
in fact, anchylosis should be considered in this stage of the 
ls®ase a very favorable termination. 
Ihe long splint (Fig. 11) which we sometimes have to use, differs from 
10 short one, in the following particulars:— 
, hn the first place, it extends the entire length of the limb, receiving 
le. Weight of the body at a cross-bar under the foot, and upon two 
l)eHneal straps which are attached to an iron girdle whidi very nearly 
the pelvis. Where the adduction is great and the joint fixed, 
will be necessary also to apply the abducting screw, and in some cases, 
oen the inversion is very great, a screw for the rotation of the foot 
illlward is also necessary. The long bar, reaching from the pelvis to the 
°ttom of the foot, is hollow, and has another bar running inside ot it 
u'''fished with a ratchet and key, by which we make extension, and 
Mfich is locked in the same way as in the short splint. The cross-bar 
‘l Ihe bottom of the instrument is covered with leather to keep it from 
aking a noise on the pavement while walking, and a strong leather 
r raP is passed beneath two iron rods above this latter for the purpose of 
Uckling on to the adhesive strap upon either side of the leg to make 
extension. 
Iu applying it you take two strips of strong moleskin adhesive plaster, 
10,11 two to four inches in width, according to the size the patient, 
i , entire length of the limb, the upper extremity of the plaster 
01llrt divided into strips for two or three inches. Strong webbing, an inch 
!. Av° in length, with buckles, is sewed fast to the lower extremities 
} the plasters. These plasters are then placed on either side ot the leg 
11 Such a manner as to leave the buckles a little above the ankle-joint, and 
eeUred by a snugly-adjusted roller, so applied as leave the tags with 
u°kles attached hanging loose, the roller being carried up over the knee, 
;u<! as far up the thigh as can be done with convenience, when the upper 
P't ends of the plasters are reversed and braided in with the roller as it SAYRE, 
turns clown the thigh, securing it smoothly. The stocking is next pulled- 
up on the foot, and holes cut on either side for the buckles to pass through* 
and the shoe then applied, and corresponding holes cut through it I°L 
the same purpose. 
The instrument is now placed on the outer side of the leg, with the 
cross-bar at the bottom brought in front of the heel of the shoe, and se- 
curely buckled to the tags above described. The pelvis-belt is next 
brought around the hips, and secured by the buckle upon the opposite 
side, and the perineal bands attached as firmly as need be. The knee-pad 
band is then slipped up or down until it is made to rest opposite the 
knee, where it is passed round the leg and buckled fast. Extension 
now made by the key upon the ratchet until free compression is borne 
without pain. The abducting screw is then to be used, and daily turned, 
for the purpose of abducting the limb. 
If the limb be strongly flexed, an additional power is applied at the 
posterior part of the instrument at the knee, running up the back of the 
thigh, and secured to the posterior portion of the pelvis-belt, and made 
tighter as occasion may require for the purpose of extending the lirnh* 
This latter strap should be always elastic, for the purpose of keeping 11 p 
a constant tractile force, and at the same time allowing of flexion when 
the patient wishes to sit down. A fixed or leather strap, as used by 
Taylor, prevents any motion whatever at the hip, and simply anchyloses 
the joint. 
By this means many cases that have gone to the third stage of the dis- 
ease may in the course of time recover, with tolerably good form and a 
moderate degree of motion, without any further operative procedure* 
(Fig. 15.) 
Fig. 15. 
If, however, notwithstanding your treatment, the disease progresses, 
and suppuration increases, the joint becoming more and more impaired? 
showing a case of progressive caries, we then have no remedy except ill 
exsection. MORBUS COXARIUS. 
589 
Nature’s only way of curing these cases after they have arrived at this 
?olnt is by the slow exfoliation of the carious bone, and, if this is limited 
111 ai*iount, she is often successful; but if involving the entire head and 
I es, the process is a very tedious one, and the patients often succumb 
et°re nature completes the cure; and even in the most favorable cases 
lealed by nature in this way, they have been left always with permanent 
'deformity and imperfect motion—in fact, with a very much less useful 
Unb than those which have been cured by exsection. I have now per- 
mitted this operation sixty-three times, and can, therefore, speak with 
positive assurance upon the subject. 
fhe operation is very simple, indeed, and in itself attended with 
a m°st no danger. The patient being anaesthetized and laid upon the 
side, an incision is made from a point midway between the crest of 
'le ilium and the top of the trochanter major, the knife carried firmly 
to the ilium, and drawn with a single sweep downward and out- 
over the posterior edge of the trochanter major, and then curved 
9l’Ward and inward, making a crescent-shaped incision of some four to 
inches in length, according to circumstances, and carried fairly down 
0 the bone in its entire extent. The wound is then held open with spa- 
11'as, and a narrow firm-bladed bistoury is carried around and close to 
be femur just above the trochanter minor, and at right angles to the 
Brst incision, dividing only the periosteum, but in both directions, as 
ar around the bone as can be reached, one-half or three-quarters of its 
Clrcuinference. By this circular division of the periosteum you avoid the 
ganger of tearing it off from the femur below the point where section is 
fo be made. If the first incision has not divided the periosteum com- 
pletely, then carry your knife again through the first incision from the 
toP of the trochanter major down to this cross-incision just described, 
Pressing it firmly through the periosteum down to the bone. The peri- 
°steal elevator is then placed in these two triangles, and the periosteum 
peeled off from the trochanter major, carrying with it necessarily the 
Muscular attachments to it. This can be very successfully done until 
)°u reach the digital fossa at the neck of the bone and behind the tro- 
|lauter major, where the blade of the knife will be necessary to divide 
le tendinous insertions of the rotator muscles. The capsule being freely 
opened, the head of the bone will now be easily lifted from the acetabu- 
m.n by strongly adducting the limb and depressing it, thereby tearing 
?. the internal portion of the bone from its lining periosteum, when the 
nger can be glided around the bone, and with a finger or chain saw it 
Biay readily be removed below the trochanter major. By this means the 
Periosteum will not be peeled off from the bone below the pointy of sec- 
lon with the saw, as is too often done by luxating the bone too forcibly. 
„ bf upon the first section it is found that the caries has extended still 
Ul’ther down the femur, you can very easily separate it from its perios- 
ea‘ Rttachments, and whatever amount of bone is necessary can be re- 
moved in the same manner with the saw. Under no circumstances 
' IQuld bone forceps be used in the section of so large a bone. The tro- 
-0 major should always be removed, even if it is not diseased, as 
.j her wise it would occlude the opening and prevent the escape of the 
and by peeling it from its periosteum, as I have before de- 
**ed. the attachments of the muscles are all left lor future use. 
W hen the head and neck have thus been removed, you have a fair 
Pportunity to explore the acetabulum, and to remove all the carious or 590 
SAYRE, 
necrosed bone by scraping and gouging. If the acetabulum be perforated* 
which I have frequently found to be the case, with a little care the 
necrosed bone can be chipped off down to the point at which the perm9' 
teum is attached. I have only in one instance found the internal permß' 
teum perforated. 
After washing the wound carefully with warm water, fill it with 
Peruvian balsam; a small plug of oakum should be inserted to the very 
bottom of the acetabulum, and left dependent from the wound. rlho 
upper and lower ends of the incision are then brought together b} 
stitches, and if necessary adhesive plaster, and the patient placed in a why 
cuirass (Fig. 9) with a window opposite the place of incision. As it lS 
of the greatest importance that this dressing should be done with caro? 
I will describe to you my mode of doing it. 
The cuirass being properly prepared and well padded, the patient 13 
laid in it so that the anus is opposite the opening, and free from all/ 
possibility of obstruction. The well leg is the first one to be dressed* 
By making it perfectly straight and screwing up the foot-rest until it Is 
brought firmly against the heel of the patient, having a pad between 
the foot and the iron rest to absorb the perspiration, the instep is then 
well padded with cotton ora blanket, and a roller is carried firmly round 
it and the foot-rest, running up over the limb; but before going ovei 
the knee a piece of pasteboard, or leather, or several pieces of folded 
paper, are placed over the leg, knee, and thigh, and the roller carried 
firmly over this extemporized splint for the purpose of preventing the 
slightest bending of the knee, when the roller is carried up the entire 
length of the thigh, around the perineum and over the outer arm of thc 
instrument, and several times back around the perineum, and then across 
the pelvis, by which means the well limb is made a firm counter-extend- 
ing force. 
Two strips of adhesive plaster from two to four inches in width, ac- 
cording to the size of the patient, are then placed upon either side of the 
limb which has been operated upon, and secured with a nicely-adjustec 
roller over the foot and up the limb and thigh, as far as the abscesses on 
it or the wounds will permit, being careful to leave a sufficient length ot 
the plasters, at the lower extremity, free for the purpose of apply 
them to the foot-rest when extension is made. The foot-rest is then 
screwed up to meet the heel of the shortened limb, and these strips ot 
adhesive plaster are brought down around the foot-rest and securely 
fastened. The foot-rest is then extended by the screw, slowly and grad' 
ually, at times waiting a few moments for the muscles to yield, which 
have been so long contracted, until the limb is brought down to its fm 
extent. It sometimes happens that, from long contraction of the adduc- 
tors and the tensor vagime feraoris, subcutaneous section of those ten- 
dons and fascia will be requisite before the limb can be brought to ds 
proper position, even after the head of the femur has been removed* 
After the limb is brought into this position a roller is carried from tn° 
foot over its entire surface; a large wad of oakum is placed around the 
wound to absorb the discharge, and the roller is carried firmly over the 
wound, inner surface of the thigh, and around the pelvis. I place greil 
stress upon this latter part of the dressing, as we thereby compress th 
tissues and prevent the burrowing of pus, the oakum, which has already 
been placed in the wound, allowing of free drainage, no matter hoW 
tightly the roller may have been applied. 
Immediately after the patient is dressed in this way, and has recov- MORBUS COXARIUS. 
591 
e,ecl from the anaesthetic, he is capable of being stood up against the wall, 
°r riding out in a carriage or boat, and can take his daily exercise in this 
'VaJ. I have, in several instances, had patients removed a long distance, 
s!).tne miles, in fact, within an hour of the operation and without the 
I]ghtest inconvenience or pain. This dressing will probably not require 
0 be changed for from forty-eight to sixty hours, or until,sufficient 
Seeretion has been formed to moisten the dressings, when the oaken plug 
Catl be removed without hemorrhage. If this dressing does not come 
a'Vay easily, warm water injections will readily float it out. The wound, 
laade clean, is again filled with Peruvian balsam and dressed as before. 
this it may require dressing once or twice a day, according to the 
amount of discharge, and the child should be removed from the entire 
Instrument as often as it is requisite. The well leg should be removed 
*crn the instrument at least once a week, and free movements given to 
d 1 the joints, ankle, knee, and hip, otherwise we may anchylose them, 
'Though they are not diseased. The wire cuirass should be used from a 
month to two months, or more, according to necessity, after which the 
Patient can be put upon the long or short splint, and allowed to exercise, 
hereby increasing his prospects of perfect motion of the new joint, 
111 many of the cases which I have exsected, the motion has been as 
Perfect and complete as in the normal joint, and in one case, that of Adolph 
■moused (Pigs. 16, 17, 18), the motion is greater in that joint than upon 
Fig. 16. 
Fig. 17. 
Fig. 18. 
Ie opposite side, and the limb less than a quarter of an inch shorter than 
i e otber, although it was sawn three inches below the top of the tro- 
anter major, the head and neck having been entirely absorbed, and 
acetabulum perforated. (Fig. 19. The four small pieces of bone are 
jagrnents from the acetabulum.) Only one of my exsections has recov- 
red by anchylosis, and that was from neglect in the after-treatment, I 592 
SAYRE, 
never having seen the patient after the operation for two years, and the 
gentleman who had it in charge having had no experience in the treat- 
ment of this class of cases. All the other patients that recovered have 
more or less good motion, and infinitely less deformity than those which 
have recovered by nature’s process. 
Fig. 19. 
If the surgeon has not the opportunity of obtaining the wire cuirass* 
the after-treatment can be carried out just as successfully by applying 
extension and counter-extension, while the patient is in bed. But, of 
course, the patient loses the advantages of out-door exercise and fresh air* 
which in many instances will be found to be of vital importance. 
From the foregoing observations, I am led to the following conclu- 
sions :—• 
I. That morbus coxarius is a disease most frequently met with in early 
childhood, or the age of reckless indifference. 
11. That it is almost always of traumatic origin, and not necessarily 
connected with a vitiated constitution. 
111. That rest and freedom from pressure of the parts involved, while 
at the same time the rest of the body is allowed free exercise in the open 
air, and a nutritious diet, is the best treatment that has yet been dis- 
covered for this disease. 
IY. That if this plan of treatment is adopted in the early stages of 
this disease, the majority of cases will recover with nearly if not quite 
perfect motion, and without deformity. 
Y. That in the advanced second stage of the disease, when absorption 
of the effused fluid cannot be effected, then it is better to puncture oi MORBUS COXARIUS. 
593 
the joint, and remove its contents, than to leave it to rupture by 
"Ration. 
' That in the third stage of the disease, when the treatment reconi* 
coded in this paper has been properly applied without satisfactory ira- 
P °veinent, but progressive caries continues, then excision of the diseased 
°Bes is not only justifiable but in some cases absolutely necessary. 
Vil, That the operation of exsection of the hip is easily performed, 
11 itself attended with little or no danger. 
yni. That after exsection of the hip-joint, in cases of progressive 
r'es, the recovery is much more rapid and certain, and infinitely more 
t®|tect as to form, motion, and the usefulness of the joint and limbs, 
lan when left to the slow process of nature. 
a 0 11 motion, the Discussion on Dr. Sayre’s paper was postponed until the 
meeting of the Section, in order to afford the members an opportunity of 
cessing a practical demonstration of the modes of treatment recommended, 
e(P°n several patients who had been courteously placed by Dr. W. H. Pan- 
ast at Dr. Sayre’s disposal. 
Pl Accordingly, the next day, at 11 A. M., many members of the Section assera- 
p . 111 the surgical amphitheatre of the Philadelphia Hospital, when the first 
sta, Presented was a stout woman suffering from hip-disease in the first 
I),1 She had been under treatment for some time in the hospital, and had 
I®11 almost cured; but the splint had been removed too soon, and the disease 
p ! ')een re-developed. The night extension and short splint were reapplied by 
cjessor Sayre in the manner described in his paper. 
Par lG Seconcl case exhibited was one in the first stage very far advanced. The 
lei\t presented the characteristic symptoms of this stage of the disease, but, 
t 'lo instrument of a proper size was at hand, the case was referred for future 
watruent. 
rj,| le third case presented was one in the stage of effusion, or the second stage. 
SPatient was wholly unable to stand or bear the slightest pressure; weight 
*rp llsi°n in the line of deformity was applied. 
jjj le fourth case was one in the third stage of the disease, and the following 
ah °1 Was elicited : Thomas S., aged six, had been a healthy, active boy until 
i'ec? e'B’llteen months ago, when he was knocked down and kicked in the 
grg1?11 flle left hip* Soon after this he began to limp, but complained of no 
buy arnounf °f pain, that which he did experience being referred to the knee, 
dis fbis fime be was seen by several physicians, who did not discover any 
bir G<lfe’ ble continued to become more and more lame, and at the end of six 
tPj ' 18 a swelling made its appearance on the upper and outer part of the left 
and ?'i fben began to complain of pain which was spasmodic in character, 
tiei a VVaJB increased at night. The swelling was punctured, and, after poul- 
*°r a ew dayB? discharged a large quantity of pus. He has gradually 
ba eslb and has become pale. This case was kindly furnished by Dr. J. M. 
p olb clinical assistant to Professor Gross. 
add condition.—Extremely emaciated and anaemic; left thigh flexed, 
~cfefl across the middle of the opposite one, and fixed. (Fig- 20.) There is 
aiul°*>eil*n® *n bie outer part of the thigh, about the junction of the middle 
ap.-, Ul3l3er thirds, which discharges considerably. The orifice has all the 
absedlances leading to dead bone, which is detected by the probe. A large 
■jjCSs over the trochanter major is yet unopened. 
bur<i|)0 t> eoilsnlfation with Mr. Adams, of London, Professor Lister, of Edin- 
b *’ Professor Hueter, of Griefswald, Professor Hjort, of Christiania, Profes- 
-38 594 
SAY RE, 
sor Kingston, of Montreal, Professor Post, of New York, and others, exsecti011 
of the head of the femur was decided upon, as affording the only chance 0 
recoveiy. 
Fig. 20. 
While chloroform was administered by Dr. Sayre’s son, Dr. Sayre said th;l 
his plan of using chloroform was entirely at variance with that taught in 
books, and with the doctrine of most authorities, viz., that air must be inhalet 
with the anaesthetic. Air, he said, was the antidote to the anaesthetic, and 
long as it was introduced anaesthesia would be prevented ; he therefore caie 
fully excluded all air not saturated with chloroform, and found that five, 
fifteen, or twenty drops thus administered, according to the age of the patie11 ’ 
produced prompt anaesthesia, without that muscular resistance and contorti011 
of the body which followed its administration mixed with air. If, by anyPPs°s 
sible contingency, this small quantity should produce dangerous or unpleasan 
symptoms, a few artificial respirations, effected by compressing the chest, worn 
exhale the small quantity of poison, and thus avoid any fatal result. Whel' 
chloroform was given in the usual way, i. e., mixed with air, anaesthesia was 
produced until a large quantity had been inhaled, in some cases many ounce8’ 
the patient during this time struggling violently; and the damage done to 
inflamed joint by these struggles more than counterbalanced the good result111® 
from the anaesthetic. If, under these circumstances, failure of the heart 
respiratory organs took place, the system was so saturated with the chlo*0 
form that resuscitation by artificial means was almost impossible. 
The administration of the drug in the present instance confirmed the cd 
rectness of Dr. Sayre’s statements. 
The operation was performed in the manner described in Dr. Sayre’s pape ’ 
and the child placed in the wire cuirass (Fig. 21); great stress being laid llP°e 
the importance of careful dressing, after-treatment, and nursing. Dr. Say 
remarked, as he stood the child in the cuirass against the side of the ampll 
theatre, ‘‘now this child is ready for transportation.” t0 
Professor Lister, of Edinburgh, being called upon by Professor Pancoast 
address the company, spoke to the following effect;—We must all regard it 
an extremely fortunate circumstance that Dr. Sayre has had at his dispo8 
a series of cases so well adapted for illustrating his admirable diagnosis all MORBUS COXARIUS. 
595 
be the various stages of hip-joint disease. As these subjects are to 
Bought before the Surgical Section of the Congress this afternoon, it is 
Fig. 21. 
neerb f. 
Hot, . 8 *or me ahude to them in detail on the present occasion, but I can- 
H'iti le^’ain from expressing the admiration which I feel, in common lam sure 
ex - Present, at the mode of execution and the immediate results of the 
Htaij81011 the bip-joint which we have just witnessed. Dr. Sayre, indeed, has 
® 110 attempt at display, and he emphatically endorsed a remark of mine 
a/e 16 days °f such exhibitions in surgery were over. For when pain and shock 
the ,evented by anaesthetics, and when all loss of blood is avoided, whether by 
the -ISe. °.f a tourniquet, or, as in this instance, by the skilful manner in which 
a ’Visions are planned and carried out, mere rapidity of operating becomes 
bette er abs°iote indifference, except that the work is probably somewhat 
\ve j^1 done if a little more time is spent upon it. Nevertheless, gentlemen, 
ti0n ave seon an extremely skilful performance, not only as regards the opera- 
aftGj. a*so in the application of the highly ingenious apparatus used for the 
Cup. eatment. The manner in which the sound leg, firmly fixed upon the 
illfi is made to serve as a perfectly efficient means of counter-extension, is 
rabl eautiful •, and to see that boy who was but a few minutes ago a mise- 
fovi orouching object, and on whom a capital operation has since been per- 
Ham. • Ending erect before us upon this apparatus, with a smiling counte- 
If' aS ast°nishing as it is delightful. 
fov that this demonstration would of itself have been a sufficient reward 
VoteVo^6 across the Atlantic, and I beg you to join with me in a cordial 
r*rof lan^s t° Dr. Sayre, 
thank essor Lister’s suggestion was instantly seconded, and a resolution of 
vS to Dr. Sayre unanimously adopted. 
Tl 
Dr> allowing notes of the subsequent history of this case are furnished by 
Was n* Lolland, Resident Physician at the Philadelphia Hospital;— There 
Was o-0t east untoward symptom following the operation. The patient 
three tf60 the pyrophosphate of iron and iodide of potassium, in small doses, 
lmes daily, and for the first few nights a few drops of laudanum, as an ano- 596 
SAYEE, 
dyne, though there was comparatively little pain. The limb was dressed eveO 
day, and a new tent placed in the wound ; after the first month, passive inoti011 
was instituted. The patient’s appetite gradually increased, and at no time ha( 
he any fever. His condition was excellent throughout, and within six week9 
the wound had closed by granulation. 
Two months after the operation, the patient was exhibited before the class » 
Bellevue Hospital as the most .successful case upon record. There was at th1® 
time good motion. The cuirass was now removed, and Hr. Sayre’s long sphll 
substituted. Within a week the child became accustomed to the splint, nIJ 
could walk without any exertion, and there was almost no shortening. HewaS 
discharged from the hospital, wearing the splint, November 11, 1876, (Fig- 2'-v* 
Fig. 22. 
The following note has been received from Dr. J. M. Barton, under wb°se 
care the patient came again after his discharge from the hospital:—: 
Professor Sayre: 
Dear Sir:—l examined the boy Shields to-day, and found that there was 
eighths of an inch shortening; that the small of the back and the 
space readily came in contact at the same time with the hard table on g 
he was lying; that the foot could be raised eighteen inches before the Pe'o.p 
moved ; and that the limb readily passed a few degrees to each side of an ilX,a'0, 
nary line at right angles to a line connecting the anterior superior spinous P 
cesses, so that the boy could quite readily bring his limbs parallel, though 
makes much more extended motion than that by moving his pelvis. n 
All the above motions, as well as pressure sufficient to move the boy llP^e 
the table, were totally painless. The limb rotated well; and the foot could 
made to touch the table by its external edge, the boy lying upon his back, 
could be rotated inwardly enough to touch the opposite foot. 
There was about one fluidrachm of discharge in the twenty-four hours, a 
the boy’s general health was excellent, and his appetite ravenous. 
Respectfully, 
J. M. Barton, 
201 S. Eleventh Street, Philadelphia* 
Jan. 18, 1817. MORBUS COXARIUS. 
597 
Discussion on Dr. Sayre’s Paper. 
tl jdie next meeting of the Section, the President having announced that 
yC of Dr. Sayre’s paper was in order, Dr. Alfred C. Post, of New 
°l*, said;—ln regard to the danger which attends excision of the upper 
‘ rernity of the femur, I would say that the operation in early childhood is 
lnparatively free from risk, but at later periods of life a very considerable 
* °P°rtion of fatal cases has occurred. Yet in many cases the danger of the 
Iteration is less than the danger of leaving the disease to pursue its own course. 
v some instances in which the operation is not necessary for the preser- 
-1 lon of life, yet, if the case be allowed to go on to a natural cure, after having 
ached an advanced stage, such an amount of deformity will result as will 
Rler the pmh au encumbrance, and in these cases the operation is of very 
ol(|at benefit to the patient. 
ROSS’ Philadelphia, said:—l came here this afternoon simply 
js a but it strikes me that the second conclusion of Dr. Sayre’s paper 
Gy entirely at variance with the received opinions of the profession, or at all 
cuts with my own experience. Many cases of coxalgia, according to ray 
serrations, have been cases in which it was impossible to trace as a cause 
like an injury. I have given special attention for many years to 
*r8e cases of coxalgia: I have inquired “ has the child received any injury— 
‘ now, or a fall, or a contusion, or anything of the kind ?” and in the great 
ajority of instances the answer has been “ no.” lam quite certain that the 
ajority of my cases—and they have been very numerous—have been of this 
cu'acter. That the disease may be developed or excited under the influence 
traumatic causes is unquestionable; but I maintain that in the great 
ajority of instances the affection is of spontaneous origin, and that it is 
ot necessary for a blow, or a fall, or anjr such injury to produce the disease. 
118 is my experience. In regard to the conclusion that it is not necessarily 
onneeted with a vitiated constitution, my teaching has certainly been greatly 
‘ fault if I err in this respect; I maintain, as the result of my dissections, 
jat this affection cannot occur in a child or in any person whose constitu- 
!?n is not in a state of degradation, or who is not laboring under some con- 
ffutional taint. I believe that it is impossible for a person to contract com 
llrnPtion without a predisposition to it. So, in relation to hip-joint disease, 
ORsider, if you please, the nature of the suppuration which occurs in coxalgia. 
le surgeon finds an abscess, and puts his knife into the part; what is the 
rai'acter of the matter that issues? Manifestly the same kind of matter that 
• expectorated by a patient laboring under pulmonary consumption. This 
*eyond all question. I have never seen any other kind of matter escape. 
g f ais, I think, settles the question that the affection occurs naturally in per- 
r°ns predisposed to such diseases. It cannot arise in persons healthy in other 
spects. There must be a constitutional vice as a predisposing cause. The 
°dy must, be in a state of debility or feebleness. This is my belief, nay, 
]-f solernn conviction. This degraded state of the system may arise from 
eieditary predisposition ; the parent may have had scrofulous disease of the 
mb 01 slRnei or some syphilitic taint; the predisposition has been trans- 
* led, and the system has become degraded in consequence of the transmitted 
aint. The chdd has hip-joint disease, just as in other circumstances it might 
had disease of the lungs, or tubercular phthisis, or disease of the spine, 
we not unfrequently find more than one of these affections coexisting 
1 rp, er®nt parts of the body, 
rp Re hip is affected in any particular case, simply because it is a weak point. 
e child may have taken cold, and the disease fixes itself in that locality. It 
j.g1 .f have fixed itself in the ankle-joint, or in the spine. The child may have 
ceived a blow, or a fall, or what not, but I maintain that that part is in a state 
predisposition at the time when this takes place. I maintain that it is im- 598 
SAYRE, 
possible for a child, horn of healthy parents, well nourished, well taken cai® 
of, unless there is a previous predisposition or some degradation of the const1' 
tution, to have coxalgia, pulmonary consumption, or diseased spine. 
, Dr. Henry Fraser Campbell, of Augusta, Georgia, said :—ln regard to the 
explanation of Dr. Gross, as to why the child has hip-joint disease instead 0 
lung disease, I would say that scrofulous affections are developed in various 
forms at different ages. I agree that this disease is frequently produced h) 
traumatic causes ; I might go further and say that most cases which I kaVe 
seen have been the result of some fall from the bed, or some carelessness of th® 
nurse, or some twist of the child’s limb or joint. But the same fall or twist) 
or the same carelessness, would not produce such a result in a healthy child) 
without any disposition to scrofula—in a child that had no syphilitic parent' 
age. I recall one case in a very scrofulous child, in which an ordinary fractal® 
of the arm resulted in the exfoliation of the entire bone. But this never worn® 
have occurred had that child not been of a scrofulous constitution. I belieyC 
that coxalgia may be one manifestation of scrofula, in childhood, just as at a 
later period of life tuberculosis of the lungs is another manifestation of fi)C 
same general vice. 
Dr. Wm. H. Kingston, of Montreal, said:—l formerly believed that scrofma 
or struma had everything to do with common coxalgia, but of late I hay 
come to think that it has little to do with that affection. Some years ago, 
reading the papers of Dr. Sayre, Dr. Bauer, and others, I asked myself whethei 
I was not in error in regard to the constitutional nature of this disease, an® 
whether we were never wrong as to its treatment. In the large hospital a 
Montreal, the largest in Canada, to which I was surgeon for fifteen or sixteen 
years, I collected a number of cases which I published a few years ago-"' 
twenty-nine cases I think—and of those twenty-nine cases, I believe I cpuK 
trace twenty-six to traumatic injury. And the treatment to which we have 
resorted is I think conclusive upon this point, differing as it does so mtica 
from the treatment formerly adopted. Without any constitutional treatmellt; 
whatever, local measures suffice in a great number of cases. Again, we often see 
one child, out of half a dozen, having morbus coxarius, while the other children 
of the same father and mother are not affected with the disease. Now, is 1 
the most sickly one that is affected ? Not at all. In four cases out of five 1 
is the healthiest child of the whole family. The child has a predisposition t° 
the disease, but it is a predisposition to climb and to fall about. The sickly 
child rarely has hip-disease. I believe also that the affection is more commoll 
among boys than among girls, because they climb more ; and it is more com- 
mon also at that period at which children are cut loose from their moth®1’ s 
apron-strings, and are allowed to run about. As soon as they acquire sufficient 
intelligence to take care of themselves, the disease becomes rare; it is onty 
in the period between infancy and adolescence that it is frequent. , 
Dr. E. M, Moore, of Rochester, said :—Like Dr. Gross, I have often aske< 
whether or not there has been any injury, and I have largely failed to find any 
recollection of such an occurrence to which the disease might be attributed. Du 
then we all know that these little bodies are constantly tumbling around, falbn» 
and straining themselves, and I have asked myself how is it that this particular 
joint, and no other joint, should be the one affected ? It seems to me that the 
explanation of the fact has not yet been given. In the hip-joint we have a surfac®) 
small as compared with the ankle-joint, and very little larger than the should^1 
or elbow-joint; and yet at this particular point in the body we have an immense 
mass of muscles surrounding the whole, and these huge muscles take hold o 
the bone whenever there is an injury inflicted, as they do in any other locality* 
So we have a reflex action set up in these cases, these muscles taking a sort o 
tetanic hold, night and day, to steady the joint. Why? Because nature is 
determined to secure rest, which is the cardinal cure of everything. So these 
muscles hold the bone up, and the surface is so pressed upon that whenevei 
there is the slightest degree of inflammation, it must continue. Day by day MORBUS COXARIUS. 
599 
increase, while the child has forgotten the fall, until perhaps a deep- 
a ateti abscess is formed in the tissues. Dr. Gross asked whether we ever saw 
v'Uing n°t like a scrofulous discharge from these abscesses ? I answer, No ; 
sib!) reason 1® that they are chronic abscesses, but there may not be the 
g'dest evidence of scrofulous disease. In the same way we were formerly 
cljUgltt that Pott’s disease originated from scrofula, but I have seen it traced 
' eetly to falls in cases in which no scrofula could be found for three or four 
o ‘aerations backward. Again, we are told that these diseases originate from 
j aePosit of tubercle, and the mere fact of finding tuberculous disease in coll- 
ection with these affections is received as affording proof of their origin. But 
(! connection be reversed. It is what our medical friends are every day 
aiing more and more to do. If there is no consumption but such as comes 
f0OrQ hereditary taint, I ask why men who pick mill-stones never live above 
years. They do not expect a longer duration of life. I had one man, 
be 1 a familJ dependent upon him, to tell me that he did not expect to live 
}°ud forty years, but he was more.fortunate; he lived to forty-five years, 
d then died of consumption. The grinders of needles and axes die of con- 
option. But is it of hereditary taint? It is because the particles of steel 
pet into their lungs, and then produce chronic inflammation. These facts 
lce themselves upon us. We all appreciate and understand perfectly well 
le force of hereditary taint, but it is unsafe to say that such is always the 
aase °f tuberculous disease. I have myself become thoroughly convinced that 
illge number of cases of consumption can be traced to disease of cancellated 
o|?ne- I recall one case of a young man of nineteen years who had inflammation 
e> tile tarsus, and a year afterwards presented evidences of tuberculous dis- 
j.ASe; I could not with the utmost care trace any consumption in that man’s 
aufrly. jam firmly convinced that a large number of cases of Pott’s disease, 
' llch are followed by consumption, come from inflammation of the bone, and 
,'.°t from hereditary taint; because a large number of cases of the same affec- 
°u which are cured can be traced to injury. 
~ kfr. George Cupples, of San Antonio, Texas, said :—ln regard to the ques- 
why the hip-joint is more often affected than any other, I would say that 
fid haps a physiological fact may throw some light on the subject; this is the 
‘‘frurnstance that the long bone of the body, the femur, is the last to be com- 
Jfrfoly ossified. 
Dr. T. G. Richardson, of New Orleans, said:—l would like the positive 
'ocates of the local origin of coxalgia to explain why a severe injury in an 
p' u!t is never followed by hip-disease. You cannot mention a case of the kind 
\ Uch has been followed by this affection. Then, too, I deny that the age of 
1M i o<fo’ or age carelessness, is the age at which the hip-joint is most 
a . to injury, as is shown by the fact that we seldom or never have dislo- 
i°n of this joint in childhood. Then, again, I call on those who maintain 
c coxalgia originates from traumatic causes to explain why it is that in 
clses of congenital dislocation of the femur we sometimes find hip-disease. 
~r* William Adams, of London, said:—l am satisfied that, in a large 
l°portion of cases, it will be found that the exciting cause of hip-disease 
aas keen some slight injury ; yet years of practice have taught me that there 
ta6 Cases ki which the disease occurs without any injury. We used to be 
Ught that hip-joint disease often originated as a bone disease, but my own 
lef is that it is usually the result of a ligamentous lesion. We have very 
'T P°st-mortem examinations of cases in the first stage of hip-disease to 
e fo? but, in those which are reported, we find that an inflammatory 
ndition of the ligamentum teres and a slight exudation into the synovial 
cuibrane were noticed;1 and I believe that, in seeking the cause of the 
report of post-mortem examinations, made by Aston Key and by Mr. Adams 
Voi • ’ 111 Ohelius’s System of Surgery, edited by South and Norris, Philadelphia, 1847r 
• p. 290.—Editor.] 600 
SAYEE, 
affection, we maj’ look to an injury or wound of the round ligament, as ft’olo 
some strain, or twist, or jump, when the muscles of the child are in a relax® 
condition. The injury, however slight, causes subsequent inflammation, thc 
extent of the disease depending much on the constitutional condition of e 
patient. This inflammation may lead on to secondary bone disease, or, 111 
other cases, and in particular states of the constitution, we may have primal) 
bone disease. 
Dr. D. Hayes Agnew, of Philadelphia, said:—lt is important in discussing 
this subject to understand what we mean by the term traumatic injury, a 
preliminary to the whole question. Now, if it is necessary that a joint shorn _ 
have a powerful twist, or wrench, or that a blow should be inflicted upon it, 0l_ 
that the patient should be projected from some height—that is one thing) 
but, if it is meant that a child by jumping down, for instance, two or thl’ee 
steps, or by tripping on the floor in walking over a carpet, can in such a way 
receive traumatic injury—that is another thing. My impression in regard t° 
hip-joint disease is this: It is impossible to follow a child in all its in or®' 
ments. Most of the time the child is out of the notice of its mother, in the 
care of nurses, many of whom are exceedingly careless. The child ran) 
receive a great many slight injuries which may yet be quite sufficient W 
produce such a contusion or such an irritation of the joint as, in a chib 
predisposed (for I must confess that there is after all a predisposition, which 
may remain latent if the child be kept absolutely at rest), may kindle up the 
slumbering elements and bring on the disease. I see a great many of th®se 
cases, and I must say that I usually find it not difficult to trace behind all a 
constitutional predisposition. In the family, perhaps, one child may bav® 
phthisis, and another enlarged glands, and another hip-joint disease, an( 
another knee-joint disease. But, in most cases, the immediate cause of the 
disease is some external injury of the joint. 
Dr. Sayre said:—Both Dr. Gross and Dr. Campbell agree that some littl® 
injury may produce the disease. That is all that I claim ; Ido not assert tha 
it is necessary for a child to be run over by a railroad car. If coxalgia is con' 
stitutional, I would ask why it is that, having recovered from hip-joint disease, 
the patient becomes perfectly well, and sound, and hearty ? why is it tha 
simply having hip-joint disease cures the constitutional taint? 
Dr. Gross said :—The difference between Dr. Sayre and myself seems to I-10 
simply this; He says that hip-disease is almost always of traumatic origlll’ 
and not necessarily connected with a vitiated constitution. I, and those who 
think with me, do not deny that injury may excite the disease; on the coO' 
trary, we confess that it frequently does so ; but we maintain that the disease 
is always necessarily connected with a vitiated condition of the system. 
Dr. J. A. Grant, of Ottawa, said :—I must acknowledge that for man) 
years I entertained similar opinions to those now expressed by Dr. Gross ) 
but in one or two cases observed during the last few years, in the hospital a 
Ottawa, where I see many cases of hip-disease, I have been forced to a 
different conclusion. One case came under my observation about three yealS 
ago, which I investigated most closely, and in which I failed to trace the 
slightest predisposition of a scrofulous character, either in the boy, or in eithel 
of his parents, or in any of his ancestors. In another case that came unde1 
my notice, the disease arose purely from irritation or excitement in the join ’ 
entirely independent of scrofulous complication. We must acknowledge, 0 
course, that persons laboring under a scrofulous taint are much more Uab 
to irritation, and to the development of this disease, than others; but we 
must also acknowledge, from the peculiar construction of the hip-joint, that i 
is one extremely susceptible to irritation, whether in a scrofulous constitute11 
or in a constitution not of scrofulous character. lam of those who adhere 
the view that we may have coxalgia occurring in an individual entirely lllC c 
pendeutly of scrofulous taint. MORBUS COXAEIUS. 
601 
r> J. H. Pooley, of Columbus, Ohio, said:—l will go further than Dr. 
1 yi’e’s proposition, and say that I believe the disease is not only not neces- 
•■ luy connected with a strumous diathesis, but never connected with it except 
the accident of coexistence. What is scrofula? Take all the gentlemen 
tins room, one by one, and make each man give his description of scrofula, 
d. •7°,T wdl have as many separate descriptions as there are separate 
escribers. We hear a great deal about scrofula, and hardly know what we 
fr,°aU' Rot only endorse the proposition of Dr. Sayre, but I would have 
anied it in stronger language. 
r* Hunter McGuire, of Richmond, Ya., said:—l think I can reconcile in 
e °r two words the different views expressed in regard to the occurrence of 
' Cl‘°Mous pus in hip-joint disease. I cannot believe that anybody here ever 
" any other kind of pus in coxalgia than scrofulous pus, but it does not 
Cessarilv follow that coxalgia is of strumous origin, I was taught five and 
twenty : 
yTears ago, and I think I have profited by the teaching since, that 
lo>ula resulted very frequently from pain or irritation, or from the privji- 
°ns of life, such as insufficiency of food and clothing ; so that, if a little 
U(l gets afa rapid coxalgia may follow, and then, in consequence of the 
*aill and loss of appetite, struma may be developed, and there will then be 
Cl'ofulous pus. 
s John T. Carpenter, of Pottsville, Pa., said:—The point at issue, it 
rns to me, is the local origin of constitutional diseases, upon which Professor 
_ ,emeyer has laid so much stress. I published a paper recently, in the Trans- 
loas of the Pennsylvania State Medical Society, in regard to the diseases 
rp| miners. Miners are subject to phthisis, and rarely live over 45 years. 
lat disease, which we always belieAred to be constitutional, is caused by 
j°tliing but the inhalation of coal dust. We find solid carbon in the patients’ 
Ungs. rppe men (|j anf\ p[ie oiq women live in the villages. Now, if their 
leave the mines and go into the agricultural districts, they live as long as 
W i Pe°ple* Here is a local origin of constitutional disease, and so it is 
~ltb coxalgia. Every one of us knows that the first sign of constitutional 
l!?ease in cases of coxalgia is an irritative fever, and thereafter sinuses form, 
there is a discharge of pus, and phthisis may follow. The struma does 
exist in the case until after long suffering and long disease. It is the 
and not the cause. Children whom I have treated by Dr. Sayre’s 
_ °d are now healthy and happy, and have never had any phthisis, or 
‘lefulu, or anything of that kind, 
vi fr* ILLIAM Brodie, of Detroit, said :—Some years ago, when Dr. Sa3Tre’s 
(pC"S VVere first promulgated, I had occasion to see a great many cases of this 
in Detroit, and, with my friend Dr. Pitcher, had occasion to examine a 
PI eab wiany people who came in from the surrounding country, all supposing 
cIM Uley 
were going to be cured by the new method. Some of these patients 
te°r Hieir coxalgia, and some from other causes. A great many post-mor- 
c 111 examinations were made, and I came to the conclusion that the disease 
, ttinienced in the cartilage, and that, when this was absorbed, the bone itself 
*a*e affected. 1 noticed in these cases the presence of a low grade of con- 
j , ’P'ion, as if the patients had suffered from typhus, or were in an impover- 
Concl‘Hon from cold. We know that children frequently lie exposed at 
Su p’ ol] get into Avater, or get chilled in other Avays, and then the external 
1 ace is affected, and a low grade of inflammation produced, which results 
of tlie cartilage. I have alAvays considered hip disease as 
c in its nature, but 1 believe that it originates in inflammation of the 
dl’tiiage. 
w,He President, Mr. Joseph Lister, of Edinburgh, said:—The question 
ether this disease is or is not constitutional, must not be allowed to deter- 
a (pC absolutely the treatment to be adopted. We must not say that because 
is constitutional, that it is therefore hopeless to produce a permanent 
e6y treating it Avith local means. Take cancer, for example; that may be 602 
SAYRE, 
in many cases constitutional, yet we know also of many cases of cancer which 
recover if operated upon early enough. There is a local manifestation of a 
hereditary taint, but if we take away the local manifestation, there may never 
be any other. This is the case also with struma. Glandular abscesses in the 
neck are strumous, and yet how many persons live to be healthy and sown® 
after having these! It seems to me that if we have such a disease as strains 
at all, we have that disease in morbus coxarius. A child came to me in G|as" 
gow to be treated for disease of the tarsus. He was treated with a long spUnt'’ 
and after a while, though still lying in bed, with the splint, several weeks alt®1' 
wards, morbus coxarius showed itself. In that child there was a 
tendency which developed itself without traumatic cause. But I admit that 
traumatic causes are frequently operative, and we know the constant liability 
of children to be affected by traumatic causes. 
Dr. Gross said:—Have you ever seen suppuration in disease of the hip-joint? 
in which there was not scrofulus pus? 
Mr. Lister said:—l must confess that I have. In affections dependent upoll 
strumous disease, there are great varieties of pus. The treatment which I hav® 
adopted has been, if there has been flexion of the limb, to extend it on a long 
splint, and keep the patient at rest. In the great majority of these cases n 
Edinburgh, perfect cures are obtained. In Glasgow, a considerable number ®> 
the cases are cured, but not so many as in Edinburgh. Then, again, in Man' 
Chester the number of cures is a minority. Now* I believe the reason for tin® 
is that Edinburgh is a more healthy place than Glasgow, and that Manchester 
is a less healthy place than Glasgow. 
Dr. Sayre said I can hardly find language to express my feelings of regi'e 
whenever I am compelled to differ in a professional point of view from my ®h9' 
tinguished friend Dr. Gross. But we must not let personal friendship, or p®1' 
sonal respect and veneration, guide us in the expression of our opinions up°n 
points of science. It seems to be conceded that an injury is often the exciting 
cause of the disease. Now, with regard to the matter of predisposition, I 
that the ordinary teaching has been erroneous, and I believe that the doctrio 
has led to bad results in treatment. If the disease is necessarily of constitu- 
tional origin, it cannot be cured by local means. You must get rid of the con- 
stitutional poison or taint. If it is of constitutional origin, the development 0 
some constitutional cause, the treatment ought to be constitutional, to afi’®c 
the blood and the whole body. What has been the result of the belief in th® 
constitutional origin of hip-disease? The use of internal remedies to corre® 
the constitutional taint, and of local applications to the parts that are simpv 
irritating. Dr. Gross has referred to the character of the pus: 1 happened t° 
be present at an autopsy in a case of hip-disease in Berlin, made by Prof. Mu’' 
chow, where an examination was made of the lungs, and heart, and intestine®* 
In the specimens taken from that case there was not a trace of tubercular matte® 
to be found. It was simply a case of pure chronic coxalgia. The pus was 
not of the kind referred to by Dr. Gross. Had that case been carefully exam- 
ined and properly treated, in my judgment it would not have terminate1 
fatally. The trouble was a local one, and the constitutional effects ot th® 
local trouble wrere mistaken for its constitutional origin. Prof. Gross wn 
remember seeing a little child whose hip 1 exsected in Brooklyn. If thei® 
ever was a strumous condition, that child’s condition was certainly entitled to 
be called so. In fact the child was almost dead at the time of the operation* 
It had lain in an exhausted condition for five or six years, with continue® 
suppuration, yet by removing the cause of the trouble, without any constitu- 
tional treatment, or medicine of any sort or kind except something to eat an 
fresh air, from being a dead child, the child is running about to-day in perfe® 
health. I sent its picture as a Christmas present to Dr. Gross himself. 
in reply to the remarks of Dr. Richardson about cases of congenital disloca- 
tion, I may say that congenital dislocation has never been seen, although 1 
has been described by Dr. Carnochan and others, and I believe that I am justifi®® MORBUS COXARIUS. 
603 
11 saying that the term is a misnomer. There is no congenital dislocation, 
an arrest of the development of the acetabulum, the bone having never 
een completed. It is a congenital displacement, from an arrest of devclop- 
Gllt, but not a congenital dislocation. The dislocations that occur in the 
jc mt are immediately recognized and attended to, and after reduction the 
* arts are kept at rest until all danger of inflammation has passed; whereas the 
'Tght injuries which cause hip disease in the child are overlooked, and atten- 
-1011 is not called to them until, by continued irritation, inflammation has 
and the general health frequently becomes involved before the 
ll»ht local injury is recognized. Moreover, in the adult the head of the femur 
s urn eh less vascular than in the child. 
. yl'- Kingston said:—We are told that hip-disease may originate from in- 
JUiies to the cartilage and bone, and also from ruptures or injuries of the liga- 
eßtum teres. Now, I am wholly prepared to admit that in the first set of 
uuses local treatment would probably suffice to effect a cure, but I wish to know 
the same degree of probability applies also to cases originating in lesions 
the ligamentum teres? 
j,. r* Sayre said:—l can answer that question by a practical illustration. 
lve or six years ago a case of coxalgia was brought to me Dr. Jourdon 
0l excision. There was an open abscess, which had gone through all the 
arioug stages, the disease having originated from a blow two and a half years 
ufore. the time I saw the case the child was hardly in a condition in 
11 ch it was deemed advisable to operate, and so I thought it better, in order 
u save the child, to get it in a better condition. In the mean time, to make 
*e child as comfortable as possible, and put it in a condition for treatment, I 
*olight it out of its surroundings, and got it out of doors to build it up a 
fftle. When the time came for the operation, the child was so much better 
at I concluded to give it a chance without excision. I made a free incision 
*lto the joint, and took away a comparatively small portion of the bone only, 
impair took place; the child got entirely well; and ran around a year and a 
!alf without any splint, and with only slight deformity, and with a tolerable 
! °&i’ee of motion. Some year and a half ago, through exposure, the child got 
!Uo a very bad condition, and the physician in attendance informed Dr. Jour- 
j 011 that it was going to die. The child did die, and 1 have the specimen. The 
lead of the femur and the ligamentum teres have entirely disappeared ; a new 
overing had been formed, of what I do not know, but it was smooth, hard, 
tl.nd cartilaginous. So that that child lived two or three years without any 
teres at all. 
Dr. Post said :—With regard to the necessity of resorting to excision, we 
a have known of advanced cases of the disease in which there has been a 
d'orable result. I was called, two or three years ago, to see a patient in 
teiSey City. The knee was thrown up almost to the chin. It was impossible 
jP the child in a position even approximately straight, in consequence of 
le extreme pain which the effort gave him. He was almost ready to die from 
le constitutional disturbance attending the advanced stage of the disease. 
e Was placed under the influence of ether, and the limb brought into as 
might a position as possible. It was during cold weather, when there was a 
ic hi the grate, and I put a poker in the Are, and made a thorough application 
ff behind the great trochanter. Improvement began from that time; and 
time afterwards the child was brought to me free from deformity. Here 
an entire recovery, and this case goes to show that excision is not always 
ofeolutely necessary. 
dis V" AYIIE sald :—I have only advised the operation in cases in which the 
case progresses in spite of proper treatment, 
an Ti * kISTER said:—l think that a distinction between the stage of effusion, 
le s^aSe °f suppuration, would be more in accordance with the general 
Hi !°loSy of the subject. I believe the last stage ot hip-joint disease is inva- 
a)y the stage in which suppuration is present. Where effusion exists 604 
SAYRE, MORBUS COXARIUS. 
without suppuration, a permanent cure may result by drawing off the fluid- 
If the case has gone on to the condition in which sinuses present themselves? 
I should be prepared to endorse the proposition that excision is the prop6l 
treatment; but if there is suppuration without an external opening, I ava 
bound to express ray strong conviction in favor of merely opening the abscess* 
I know of numerous cases in which the abscesses have been treated anti' 
septically, and in which the patients have recovered. Certainly in these cases 
the treatment had better results than if excision had been resorted to. -*■ 
remember one patient, a healthy young woman in Glasgow, whose two linihs 
became exactly alike, except that there Avas the mark of the small incision 
made in opening the abscess; and this result was a great deal better than 11 
excision had been adopted. 
Dr. Kingston said :—I wish to ask Dr. Sayre if he can tell from the position 
of the sinuses, whether the acetabulum or the head of the bone is diseased ? 
Dr. Sayre said:—l cannot; the pus will, in either case, gravitate in tb6 
easiest direction. 
On motion, the conclusions of Dr. Sayre’s paper, with the exception of tb6 
second, were adopted as expressing the opinion of the Section. With-tb® 
second conclusion, the Section could not unanimously agree. 605 
Report of a case of sub-periosteal excision and 
DISARTICULATION OF THE ENTIRE INFERIOR 
MAXILLARY BONE FOR PHOSPHORUS 
NECROSIS. 
BY 
JOHU W. S. GOULEY, M.D., 
Professor of diseases of the genito-ueinary system in the medical department of the 
UNIVERSITY OF NEW YORK, SURGEON TO BELLEVUE HOSPITAL, ETC. 
The record of the case I have the honor of presenting was intended to 
3e incorporated in a paper on extirpation of the entire inferior maxillary 
which I have in course of preparation, and in which I am desirous 
ot including as many as possible of the illustrative cases contributed by 
of different parts of the United States and of foreign countries, 
venture to report it now in order to recall attention to the subject, and 
!ereby elicit information regarding cases, the notes of which I have not 
cls yet been able to obtain, and also to gain access to unpublished cases. 
. J-he following is a list of names of surgeons whose cases have appeared 
111I11 divers journals and surgical works, or have been communicated to me 
U the operators. The operations were done for tumors, as well as for 
porosis ; some of them were intra-buccal, but the majority wrere by ex- 
°rnal incision, at one or at two sittings, by one or, as in three instances, 
two different surgeons at a considerable interval of time. 
Name of Operator. 
Residence. 
No. of Cases. 
Valentine Mott, . . . 
New York, 
. . 1 
John G. Perry, . . . 
England, 
. . 1 
James Syme, .... 
Edinburgh, 
. . 1 
Signoroni, 
Padua, 
. . 1 
J. F. Heyfelder, . . . 
St. Petersburg!}, 
. . 3 
Ackley 
Cleveland, 
. . 1 
J. M. Carnoehan, . . . 
New York, 
. . 1 
Maisonneuve, .... 
Paris, 
. . 2 
J. R. Wood, .... 
New York, 
. . 1 
G. C. Blackman, . . , 
Cincinnati, 
. . 1 
J. H. Pooley, senior, . . 
New York, 
. . 1 
Pitha 
Prague, 
. . 1 
Borelli, 
Turin, 
. . 1 
Langenbeck, .... 
Berlin, 
. . 1 
Holmes Coote, .... 
London, 
. . 1 
Rizzoli 
Bologna, 
. . 1 
John Adams, .... 
London, 
. . 1 
Thomas Smith, . . . 
London, 
March 
Albany 
A. B. Mott, .... 
New York 
Boker, 
Philadelphia, 
W eir 
New York, 
J. J. Hull, 
New York, 
Trelat, 
Paris, 
Obalinski, 
Cracow, 
Miner, 
New York, 
Carnoehan and Pancoast, 
New York and Philadelphia, . 
. . 1 606 
GOULEY, 
Name of Operator. 
Residence. 
No. of Cases. 
Enos and Cochrane, . 
. Brooklyn, 
.... 1 
Bodgen and Mudd, . 
. St. Louis, 
. New York, 
.... 1 
Willard Parker, . . 
.... 1 
J. Mason Warren, 
. Boston, 
.... 2 
Maunder, .... 
. London, 
.... 1 
W estmoreland, . . 
. Atlanta, 
.... 1 
Dr. Blackman (American Journal of Medical Sciences, October, 1856) 
mentions Walther, of Bonn, Marsh, of Cincinnati, Hutton, of Dublin* 
Gauwesky, of Westphalia, Cusack, of Dublin, and Liston, of London, 
having each once excised the entire inferior maxillary bone,but I have uot 
as yet found the original accounts of their cases.1 
The subjoined notes of my case embrace the principal points I am de- 
sirous of obtaining from surgeons whose cases have not been published. 
Mary N aged nineteen, came to this country from Ireland when nine 
years old. At the age of thirteen she was employed in a lucifer-match factory* 
where she remained for more than two years. Within a few months after enter- 
ing the factory she had a decayed right inferior molar tooth extracted, and 
resumed work on the following day. But this does not appear to have caused 
any trouble. A year and a half afterwards another inferior molar was removed, 
also from the right side, and as before she at once went to work. Very soon 
after this she was attacked with phlegmonous periostitis, accompanied by inor- 
dinate swelling, which rapidly extended and involved the whole jaw. Die 
abscess opened spontaneously at a .number of points along the base of the jaVi 
on both sides of the face, and also in the buccal cavity. She lost successively 
the molars of the right side and the two left incisors. The fetid pus which 
continually issued from these various fistulous openings was so profuse as to 
greatly drain her vital powers. Her appetite and strength soon failed ; she 
became anaemic; and her condition was worsening so steadily that, at length, 
she applied for treatment to a surgeon who made an incision along the rigid 
ramus, and removed a sequestrum which afterwards proved to be the coronoid 
process. This operation was of little use, as only a very small part of the dead 
bone was removed. 
I found the patient at St. Vincent’s Hospital, early in March, 1864, still fn1’" 
ther reduced in strength by her great suffering and by the profuse discharge 
already referred to. The right side of the face was paralyzed from division ot 
the facial nerve at the time the incision was made to remove the coronoid pro- 
cess. The jaw was extremely rigid and mastication impossible. For nearly 
year the patient had lived entirely on fluid food, and with it always swallowed 
a considerable amount of pus. All the sinuses led to dead bone. She was 
much disfigured by an enormous under jaw, made up of an unusually larg6 
involucrum with the overlying soft parts greatly swollen. On consultation 
with my colleagues, I proposed to remove the whole of the involucrum, as wed 
as its contents, by external incision, as it did not seem expedient to attempt 
to save such an unwieldy bony mass, and because it was believed that its extir- 
pation would not only remedy the existing deformity and distress, but also 
greatly facilitate the ingestion of proper food. To this proposition they 
assented, and, on March 19, 1864, I proceeded to operate after the mannei 
described below. 
The patient having been etherized and placed on her back, with the head 
1 I shall be greatly indebted to those who will have the kindness to indicate to me m 
writing the operators whose names may have been omitted, and to furnish me with facts 
regarding such unpublished cases as may have come to their knowledge. Each case m"s 
be one of disarticulation of both condyles, and ablation of the whole body of the bone, 
whether done at one or more sittings, by one or more surgeons. Communications relating 
to the information solicited may be addressed to 311 Madison Avenue, New York. EXCISION OF INFERIOR MAXILLARY BONE. 
607 
an incision, including onlj’ the thickness of the skin and superficial 
, .Scia, was begun in front of the left ear, carried downwards along the poste- 
Vj/s., | o ' o I 
. ‘ border of the ramus to the angle, thence close under the body of the jaw, 
. continued around until it reached the right ear, at a spot corresponding 
lts starting-point, so that, in a front view, nearly the whole line of incision 
as out of sight. The left facial artery and vein were soon exposed, tied 
°ve and below, and divided between the ligatures. The dissection was then 
H’led to the bone, and the periosteum separated with a blunt steel knife, begin- 
• at about an inch to the right of the median line, under the chin, and extend- 
..«> UP to the coronoid and condyloid processes. To avoid its sudden retrac- 
°'b the tongue was secured by a strong ligature, passed vertically through its 
in the median line near the apex, and confided to the care of an assist- 
. The periosteum of the buccal surface of the jaw was detached from below, 
1 8 lt could not be reached through the mouth on account of the rigidity of the 
111 ts. The whole left side having been so far enucleated, a chain saw was passed 
no the gap between the right central incisor and left canine, and the bone 
a'vn through a little to the left of the symphysis. Then,seizing this partially 
1 crated segment with the left hand, and depressing and rotating it outward, 
?e temporal and external pterygoid muscles were made tense, and successively 
lyided with the scalpel close to their insertions. Further use of the knife was 
cndered unnecessary by the previous destruction, by disease, of the capsular 
11(i adjoining ligaments, and the bone being free was laid aside. The right 
Cgment was detached from its position by a process similar to that described 
j°ve, but the capsular and other ligaments, which were intact, were divided 
I.** the scalpel from before backwards. The vessels, on either side, requiring 
b?atures were the facial and their submental and masseteric branches, the 
and the inferior dental. 
the lips of this extensive wound were brought together by six fine silken 
on each side, and a few strips of adhesive plaster; and the ends of the 
'gature which held the tongue were brought out, one at each corner of the 
and secured to the cheeks by adhesive plaster. 
. J®t“ore the patient recovered from the effect of the anaesthetic, a dose of ten 
of Magendie’s solution of morphia was administered hypodermically, 
this was repeated twice daily for five days, during which time she lay in 
1 s°mnolent state and had to be roused to be fed. Her diet consisted of beef- 
e^a and milk-punch. She said afterwards that during those five days she had 
xPerienced no pain whatever. 
]io-ihe greater part of the wound healed primarily, and the sutures and the 
gature confining the tongue were removed on the third day. Four weeks 
si ] °Perjltion, a slight facial erysipelatous blush appeared, but soon sub- 
c under the application of evaporating lotions and the internal adminis- 
ation of chloride of iron. In May, 1804, the patient was discharged from 
le hospital, the remainder of the wound (at the seat of the cloacae) having 
eavls’ healed. 
jt he patient called upon me on June 5, 1865, feeling quite well and strong. 
ei appetite was excellent, her food consisting chiefly of hashed meats and 
atoeg, eggs, bread and butter, and cream. She had gained very much in 
eight, and her condition was all that could be desired under the circum- 
ances. I last saw her in September, 1811, seven and a half years after the 
when she was in excellent health, and when I took the opportunity, 
had done before, of making a careful examination of the parts with a view 
.ase®rtaining the extent of bone production, which I found to consist of a 
r In lam or plate including the mental portion, and the body and part of the 
1 m.Us 011 either side, all of which existed in June, 1865. 
Ie pathological description of the parts removed will be given elsewhere. 
Wl' )Ve learned that the patient was in 1874 seized with variola, from 
11Cl she died, and that no autopsy was made. 608 
GOULEY, EXCISION OF INFERIOR MAXILLARY BONE. 
It is unusual, in cases of phosphorus necrosis, to find an involucrunG 
but in the case just reported there was a large one, and, on the other 
hand, very little of the “pumice-stone deposit” so frequently seen. Th]S 
is probably to be accounted for by the existence of violent phlegmon°u& 
periostitis in the preceding year. 
Another point to which I wish to call attention is the method °I 
making the incision. Various lines of external incision have been sug' 
gested from time to time, but I wish particularly to elicit the opinion ox 
the Section in regard to the intrabuccal operation, which, as applied to 
the entire bone, is said to have originated with Signoroni, in 1848. 
7 , *->.7 • 
It is generally considered safer to divide the operation of extirpating 
the lower jaw into twro sittings, removing one-half at a time; but He/' 
felder advises that the whole operation should he done at once. ISTearly 
all the cases included in my table were operated on at different sittingB’ 
the intervals in some instances having been as long as six months. *■ 
have, however, tabulated them as single operations, as the removal 01 
the second half of the bone is but the completion of a previously unfin- 
ished proceeding. 
Discussion on Dr. Gouley’s Paper. 
After the reading of the preceding paper, Dr. J. C. Hutchison, of Brook- 
lyn, said:—l think that the intrabuccal form of incision is an unsafe one f°x 
the removal of malignant tumors, since there would then be a greater proba- 
bility of leaving behind some portion of the diseased tissue, but for the re- 
moval of sequestra, or even of the bone itself, I consider it perfectly feasible* 
It is even more applicable to the upper than to the lower jaw, as externa 
incisions in the region of the superior, are more difficult to conceal than those 
in the region of the inferior, maxillary bone. I have myself, by this plaffi 
broken up and removed the whole upper jaw, together with the malar bone 
and even the orbital plate. 
Dr. Frederick Hyde, of Cortland Village, V. Y., said:—The circumstance 
of the individual case, the location of sinuses, etc., should determine the forni 
of incision. For the removal of sequestra I usually employ the intrabucca 
operation, but for other cases I make such incisions as seem best suited t° 
the accomplishment of the object. 
The President, Mr. Lister, of Edinburgh, said:—l was yesterday shown a 
specimen, in the Museum of the Pennsylvania Hospital, from a case in whic 1 
more than half of the jaw had been removed by Dr. Hunt, from within the 
mouth; and I was informed that the patient had recovered with very sligh 
deformity. Ido not think that the intrabuccal incision is permissible in nia' 
lignant disease, but for other tumors it may be practised when the circum- 
stances of the case admit of its use. An external incision, however,, gives th 
operator much more freedom for both sight and manipulation, and, espechyv 
in the male, I should prefer its employment in the majority of cases in wine i 
the entire jaw was to be removed; even in females the scar can be partial1) 
concealed behind the ramus and beneath the base of the jaw. The method 0 
Maisonneuve, which consists in making the incision further forward and thus 
avoiding the facial nerves, is also a good one, and I have recently remove 
half of the jaw by a median incision, the resulting scar being but slight. 609 
the causes and geographical distribution 
OF CALCULOUS DISEASES. 
BY 
CLAUDIUS H. MASTIN', M.D., 
OF MOBILE, ALABAMA. 
Tl\Vestigating the etiology of calculous affections, it will be neces- 
‘ jy briefly to examine the composition of the secretion in which they 
ake their origin, to see what is the normal condition of the fluid, so 
alat we may observe any changes which take place in its departure from 
standard of health. In this research, we must consider the relation 
tween healthy or normal urine, and urine which has been changed by 
,°0(1 alterations; we must observe the causes which produce those 
f0 anSes, and then decide upon the probable causes which induce the 
Ration of urinary calculi. 
Wealthy urine is composed of certain constituents, water being the 
en§truum which holds in solution the organic products of digestion 
h! i limitation. First among those ingredients characteristic of 
althy urine, which are furnished from destructive assimilation of the 
ssues and separated from the blood by the liver and the kidneys, are, 
g ea> uric acid, creatine, coloring matter, and odorous principles, 
fondly, and derived chiefly from the food during the process of assimi- 
loth are, hippuric and lactic acids, together with certain accidental 
fistituents, and also some inorganic products—saline combinations 
ll°h have been separated from the blood, such as the sulphates, the 
£ Abates, and the chlorides, of which the bases are respectively soda, 
■ ,assa? lime, and magnesia; soluble salts which have been introduced 
0 U*e economy along with the food, and have undergone decomposi- 
n m the system, or such as have entered into new combinations during 
f Process of destructive assimilation, as is especially the case with the 
in Pha?es an(i the phosphates. In addition to these, we find certain 
Bnts cleiavecl from the lining membrane of the urinary passages, 
an] ]e °I epithelium, from the kidneys; mucus, from the bladder; 
bu .pk°sphate of lime, the result of the decomposition of mucus and 
cases of cystic inflammation, 
tii * 1 know that, during health, the composition of the blood is con- 
-ofll|akyfll|aky changing by the introduction of new matter through the process 
8t„C bastion, the 'primary assimilation of the food; and that it is con- 
regn^v being altered by the presence of waste or effete material, the 
Secuk of the breaking down of the tissues in the course of nutrition, or 
res° l limitation. Then we find constant changes going on, the 
Mf i excretion by the liver, the skin, and the kidneys; changes 
der* con^ an(l govern the healthy condition of the urine, and any 
arparture from which produces certain pathological alterations, which 
is n eitPer general or special. We also know that, in disease, the blood 
rbat°n^antJy un(Jergoing change in its component parts, receiving new 
erial of a morbid character through the process of either primary or 
39 610 
MASTIN', 
secondary mal-assimilation, or through the co-operation of both ; the 
first representing the process of deficient digestion, the latter of fault} 
nutrition. The blood is necessarily changed when these morbid matters 
are not properly eliminated, as is the case when we have mal-excretion 
by the kidney, liver, skin, or other secreting and excreting organs. 
How, as general pathological changes depend upon some general sys* 
temic disorder, as, for example, fever, rapid waste of tissue, anaemia, etc.? 
so also special changes depend upon some special unnatural ingredient 
present in the circulation and showing itself in the urine, as, for instance? 
albumen or sugar; or some natural constituent may be present in unn&' 
tural proportion, and thus form a leading feature in disease; or agalll 
this natural constituent may become so altered in its physical conditio11 
as to produce a particular morbid state, as when uric acid in combination 
with soda gives rise to gout, or when uric acid, oxalate of lime, earth} 
salts, and such materials, produce calculous concretions. 
Whenever we have mal-assimilation in the process of nutrition, one 01 
its consequences is what Liebig has termed “destructive metamorphosis 
of the tissues: and, as the various tissues are composed of certain cbem1' 
cal constituents, w7e have as the result of their disintegration particular 
chemical agents which bear upon and constitute a diathesis. For exam' 
pie,, when those textures which are rich in albuminous material &re 
broken down, they furnish an amount of lithic or uric acid which suf' 
charges the blood, and gives us the expression, “ a gouty diathesis. 
Like changes taking place in the destructive metamorphosis of highly 
nitrogenous tissues, as the muscular structures, or even where obstinate 
constipation has locked up in the alimentary canal the excrementiton9 
residue of ill-digested food, urea is formed too rapidly for elimination* 
and it is also found in excess in the urine. Then, again, when the bran1 
and nervous system become overtaxed from any cause, a consequent 
prostration follows, and, abounding as they do in phosphoric acid, the 
result of this destructive metamorphosis, so to speak, is an excess of the 
phosphates, and we have what is known as the “phosphatic diathesis- 
Here we find the debris of the nervous system adding an undue propot' 
tion of phosphoric acid to the blood, a combination resulting with hs 
alkaline and earthy bases, and, as a consequence, a deposition of the 
phosphates in the urine. In certain conditions of the bladder, as 111 
cystitis of long duration, or in enlargements of the prostate where & 
change has taken place in the mucous membrane, these salts becom6 
precipitated, and phosphatic calculi result; injuries to the spine, ft’olo 
which jDaralysis follows, produce similar results. 
Following this course of investigation, we see that when there has 
been a destructive metamorphosis of the gelatinous tissues, there i 9 a 
conversion into oxalic acid, which, entering the circulation, gives all 
“ oxalic acid diathesis,” with a tendency to deposit of oxalic concretions- 
In like manner, we could trace the formation of sulphuric, hippuric, a 11( 
lactic acids, and show that a destructive metamorphosis or transformation 
of the tissues in general will produce the chlorides. 
We also observe that, during the process of digestion, changes take 
place in 'primary mal-assimilation, by which certain constituents enter 
the blood in the same manner that they do during the process of secondly 
mal-assimilation, or destructive metamorphosis of tissues. These change9 
are referable to the stomach, duodenum, and chyliferous organs, and thus 
it is that we find lactic or uric acid the result of imperfect digestion 0 
albuminous food, urea following an excess of nitrogenous material, 01 CALCULOUS DISEASES. 
611 
_ phosphates resulting from an undue proportion of alkaline ingesta 
ef fas a base with the free phosphoric acid contained in other articles 
tood which were eaten at the same time. Then, again, we find that 
rtain articles of food supply certain chemical constituents which enter 
h Cl.rculation during the process of digestion ; for example, oxalic acid 
•c , rived from special articles of diet, as sorrel, rhubarb, tomatoes, and 
vvl ’ ai' ar^c^es5 an(l this acid, acting on the lime contained in hard water 
rnay be drunk at the same time, furnishes the oxalate of lime, one 
i ,e varieties of urinary calculi. In the same way an excess of sul- 
{ ‘l!rie, lactic, and hippuric acids, is formed from articles of food in 
*^ey respectively abound. 
' hhout pursuing this line of thought or reasoning further, we now 
o/f1 process of mal-excretion, and perceive that certain structural 
tunetional alterations of either the kidney, liver, or skin (the great 
Parating eraunctories of the system) may interfere with their healthy 
and, through a faulty process of elimination, cause an excess of the 
s- lnary constituents to remain in the blood, thus constituting a diathe- 
n deferable to the particular ingredient which may predominate. Where 
lc acid is the morbid product, we have a blood change giving the 
Pression of a uric acid or gouty diathesis, which may under certain 
• develop a gout, and under others precipitate urinous salts 
le pelvis of the kidney, and give rise to sand or gravel. For during 
j e Process of elimination, uric or lithic acid is separated from the blood 
f combination with a base, as soda or ammonia; the former necessary 
production of gout, the latter for the formation of gravel; arid as 
a°rl °* are soluble in the urine only when they are not in excess, 
lj when the urine is at the normal temperature of the body, it follows 
lat they must become precipitated whenever they exist in abnormal 
1 aatitles, and whenever the urine is changed in temperature, 
vd lroru anJ cause we have a structural alteration of the kidney by 
as lch the proper excretion of these substances is prevented, they must 
in COnseciuence be either retained in the blood, or stagnate, so to speak, 
a§ le tubules of the kidney, and thus give us the disease of that organ, 
de a Cau.Se f°r the effect. In the same manner, the skin, acting as a great 
Purating organ, eliminating effete material from the blood, becomes by 
e arrest of its particular function (either from disease or accidental 
f‘oj?Ses) a factor in the production of certain pathological conditions, as 
{•>r example, rheumatism and nephritis; and certain structural altera- 
ci°]1S the liver give rise to functional irregularities, which leave spe- 
uiorbific matter in the circulation, and thus produce a blood altera- 
I 1 which may aggravate an existing diathesis; for, when “ oxidation 
bl performed in the liver, there is a production of insolu- 
res i-^c an(f hthates instead of urea, which is the soluble product 
Wu‘ting from the last stage of the oxidation of nitrogenous matter.” 
S6e even health, when individuals surfeit themselves by an 
ss °f food which is over rich in nitrogenous principles, 
pii .lere ai'e some persons who, from habit, are remarkably prone to form 
ye lc acid in the liver, and, when this tendency exists for a series of 
p a diathesis is formed which controls the system, and the constant 
ey c Ucflon of the lithates establishes either gout or calculus; for when- 
pl -r a diathesis produces in one person the lifhate of soda, and in another 
ag>Ul.lllac ucid, it can with propriety be said to give rise to two different 
the°11S’ wo different series of phenomena which spring from one and 
Sanie root. Hence it is that we infer the identity of the causes of 612 
gout and calculus; the same causes which operate in the production oi 
the one, bear upon the formation of the other. Therefore as gout depends 
measurably upon lithsemia, so also urinary calculi depend for their origlll 
upon certain functional derangements of the liver acting in concert witd 
special affections of the kidneys, such as catarrhal inflammation of tbe 
urinary passages over-stimulated by an acid state of the urine. 
Next in frequency to uric acid, the oxalate of lime is the most important 
constituent entering into the formation of urinary calculi, at one tin1® 
forming the entire concretion, at another only the nucleus around wh1®*1 
other urinary salts may collect. This is not one of the normal constit11' 
ents of the urine, but is found frequently as a deposit, being probably 
produced through uric acid from the nitrogenized material of the I®°( 
or tissues—oxalic acid combining with the lime in the economy am 
forming the oxalate of lime. Time will not permit me to enter into tb® 
various theories advanced as to the production of this substance in tf*e 
system, and hence I will not refer to them. 
This product is never present in the form of sand, as is the case wdd 
uric acid, but often exists in microscopic calculi composed of durab-be** 
crystals aggregated together; we detect it also in the system in almost 
every form of debility, often in febrile affections, and most usually asso- 
ciated with an excess of urea. When this condition exists, we have what 
is termed “oxaluria,” a condition of the system referable to some inter- 
ference with healthy respiration; possibly produced by chronic bronchitis 
emphysema of the lungs, affections of the liver, or exhaustion of tbe 
nerve centres from either mental or physical labor, or, in some individuals 
the result of excessive alimentation during a too sedentary life whi®** 
interferes with healthy digestion and assimilation. It is evident tha 
this particular substance is the result of a retrograde metamorphosis beta 
of food and tissue, and hence it is unnecessary again to refer to its pr°' 
Auction from special articles of diet. There is, however, one circum- 
stance deserving notice, which is the uniform constancy of the 
proportion of oxalic and uric acid, a condition which exists uniform*) 
and which suggests the inference that the same causes are at work 111 
the production of both ; especially is this the case when we notice the 
remarkable correspondence in the proportion existing between the nucl®* 
•of the two varieties, showing that they are very closely allied, and tha 
the tendency to form one or the other in different individuals depend3 
solely upon some particular idiosyncrasy. 
Cystic and xanthic oxides are so very rare that we will not consum®. 
time in their investigation, but close this portion of our subject with a bn® 
notice of the phosphates, which do exist in normal urine; uncombineeb 
however, they are insoluble, being only held in solution by the presence 
of free phosphoric acid. Hence it is.that calculi composed of the phos- 
phates are not very common as constitutional calculi, and as nuclei they 
are exceedingly rare. 
It is not necessary to consider the circumstances which cause the pr®?' 
ence of the earthy phosphates in the urine, but it is essential to investi- 
gate the conditions which determine their precipitation ; these dep®ll 
entirely upon an over-alkaline state of the urine, which has been r® 
dered so by the presence of ammonia, the phosphate of ammonia au 
magnesia being precipitated as crystals from the urine in combinati®1* 
with the phosphate of lime; here the ammoniacal condition does a° 
arise from an increased excretion of ammonia, but is the result of t*l 
decomposition of urea, setting free carbonate of ammonia and water. 
MASTIN', CALCULOUS DISEASES. 
613 
This state is favored by any persistent obstruction to a thorough evacu- 
‘ 1011 °f the bladder, producing an irritated or inflamed condition of the 
Ucous membrane, and causing it to secrete a muco-purulent discharge; 
ns discharge contains an alkaline pus which is acted upon by the phos- 
mric acid present with the phosphates of ammonia and magnesia (which 
r,e held in solution in the urine only by the excess of this acid), and the 
y .s are precipitated in the form of insoluble phosphates. Such con- 
ations are favored by enlargement of the prostate, which prevents com- 
f e*e evacuation of the bladder, the retained urine becoming decomposed, 
‘j the free ammonia given off, increasing the cystitis and reacting upon 
ie pus, forming an adhesive gelatinoid mucus which cements and binds 
°gether the precipitated phosphates in a mass. In the same way the 
Iflesenee of gravel or foreign bodies in the bladder produces cystic irrita- 
,,°.n with its resulting arnmonio phosphatic deposits, and thus calculi of 
nature are formed. 
y\Q have now shown that all calculi are either of local or constitutional 
1!§1n; that local calculi depend for their cause upon some disease either 
PrUnary or secondary within the bladder, whilst constitutional concre- 
. are dependent upon some vicious action—some error of assimilation 
mierent to the system ; and constitute by far the larger proportion of all 
rinary deposits. For convenience of description, we will divide calculi 
nt° two classes: the first including all those formed of uric acid and the 
lates of ammonia, soda, lime, and magnesia, with the rarer forms of uric 
xanthic oxide, and fibrinous and blood calculi; the second, embracing 
various phosphatic deposits and the combinations of the oxalates. 
H examining different collections of calculi, it has been discovered that 
Wee-fifths of all calculi met with in adults of all ages are composed of 
l>le acid and the urates, nearly two-fifths are phosphatic, and only some 
tree or four per cent, are oxalate of lime ; three-fifths, then, are the pro- 
uet 0f Ulqne abounding in an acid, of which they are the expression ; the 
Gaining two-fifths are the products of urine, generally alkaline, mostly 
‘ wirnoniacal, of which they are the result. It follows, then, that the 
lates, the oxalates, and a few of the phosphates, which are formed in the 
I(fney must be the result of certain constitutional derangements ; whilst, 
Oil fl . 0#77o#77 
lne other hand, the phosphates, which, whether pure or mixed, are 
1 l°duced solely in the bladder, must be the consequence not of constitu- 
but of local disease within the bladder itself. 
..hereditary Influence.—In 1776, just one hundred years ago, Scheele 
uric acid; and so frequently is it now observed to form the 
fading constituent of urinary concretions, that, with Dr. Owen Rees, 
n ao has examined the subject most closely, we may safely state that, 
wUhout its presence, calculi would become much less common than 
c iey are.” This being true, we first consider calculi in reference to this 
o|istituent. In doing so, we perceive that in all those cases in which 
j ric acld is in excess, a particular diathesis exists—a diathesis which 
ay have been acquired, but which in all probability has been intensi- 
ve! by some pre-existing habit of the system referable to hereditary 
; in fact jf may be safe to state that it nearly always depends 
n a previous vice of constitution which is entirely hereditary, for if 
f f examine the history of one of these cases, we will almost surely find 
Vreditary causes at work in its production, and, as Sir Henry Thompson 
j as rernarked, “ either gout or calculi will be traced in the family of 
Gariy every patient who presents himself for treatment.”1 
Sir Henry Thompson, Preventive Treatment of Calculous Diseases ; London, 1876. 614 
MASTIN, 
We all recognize the hereditary tendency of gout—a fact too wel 
established to admit of a question ; therefore, as gout depends in a very 
great degree upon the formation of urate of soda in the system ; and a 9 
five-sixths of all renal concretions and vesical calculi which have recently 
descended from the kidney are composed of uric acid (substances so very 
nearly the same), we infer that hereditary influences have controlled the 
one as Avell as the other. It is very true that hereditary tendencies vary 
in force in different families ; that some members manifest the pecuh*1' 
diatheses under which they labor, at one period of life, whilst others 
the same family develop the same disease at another, and that particula1 
circumstances, or accidental causes, control the pre-existing 
and either hasten or retard the affection ; thus, for example, Ave see soiffe 
members of a family suffering from gout in youth, others in middle lne 
or old age ; and likewise we find some who develop a calculus in infancy’ 
others not until adult life; or gout and calculi may alternate, one gene- 
ration producing the one,and the next the other; or then again we myT 
meet a person with gouty symptoms and deposits of chalk stones, whic)l 
after a lapse of years subside, when a uric acid gravel may form in the 
kidney. Here we certainly have a manifestation of two different eftec*'s 
which arise from one and the same cause. lam aware that hereditary 
influences, as causes of calculi, have been questioned by many of °ul 
best informed investigators of this subject; but in view of such facts a 9 
have been produced from the concurrent testimony of Civiale, Le RO/ 
d’Etiolles, Thompson, and others of like reputation, I am led to believ6 
that hereditary influences stand first in the scale of causes which produce 
calculous affections. 
Seeking a cause for this particular diathesis (uric acid), we find it iu a 
great measure due to defective assimilation in the organs forming the 
primse vise; we see the stomach failing to digest food in a proper manner > 
primary mal-assimilation furnishing improper materials for the healthy 
constituents of the blood ; the liver defective in its action, and failing to 
excrete its due proportion of the urinary salts; the solid constituents o 
the urine becoming augmented; and the over-worked kidneys unahl 
to eliminate the excess of uric acid from the super-saturated blood, the 
remainder being thus precipitated in crystalline form. Uric acid bein£ 
very insoluble, unless in a large proportion of water, and that too at the 
normal temperature of the body, it follows that whenever the solution 
becomes denser, or its temperature lowered, the uric acid must be p1’6' 
cipitated and left in some portion of the urinary organs, forming in the 
kidney renal calculi which afterwards become vesical. , 
As we have seen a certain diathesis cause an excess of uric acid an 
the urates, so likewise it can be shown that other trains of circunp 
stances will provoke diatheses which produce the other varieties ol ca ' 
cuius. 
Climatic Influences.—Climate doubtless exercises more or less influence 
in the production of these affections, for in very changeable regionB 
calculous diseases are more common than in those localities where a nioi® 
equable temperature exists. This is especially the case in the temperat 
zones, whilst in very cold or hot countries the disease is not so frequently 
met with. Still there are certain districts of the earth’s surface, bound® 
by the same lines of latitude and longitude, and subject to the sam 
climatic influences, that develop the disease in one section, whilst \ 
another section similarly situated it is never encountered. This 18 
especially noticeable in England and the United States. CALCULOUS DISEASES. 
615 
Calcuioug affections are ranch more frequent in Kentucky, Ohio, Yir- 
TjnJa, Tennessee, and Yorth Carolina, than in any other portions of the 
Ulled States, although we have a vast area of territory similarly located, 
ge°graphically, geologicall}', and climatically, in which stone is rarely 
j ever encountered. The same may be said of England, where calculus 
,^ery common around Norfolk and Manchester, while in other regions 
•, .ich are within the same latitude, and subject to the same temperature, 
18 almost unknown. This is also the case in Hindostan and those 
Portions of China in the vicinity of Canton ; there, calculous disorders 
bound to a greater degree than in any other parts of the globe. These 
countries are noted for their variableness of temperature, which is one 
the causes assigned for the frequency of this disease ; and it may be 
Possible that a due regard to a change of clothing is not sufficiently ob- 
served at such times as these changes occur, and that this neglect may 
Jave an important bearing upon the subject; for when the skin is not 
Ploperly protected, its functions become disturbed, and the kidneys are 
re<ffiired to perform an excess of labor. 
Poverty.—The poorer classes are more liable to the affection than the 
|ch; and it may be noted that they are worse fed and worse clothed 
Jan those in more affluent circumstances. Upon such a class of the 
Population, climatic changes have a more depressing influence, and in 
way may prove a cause of the affection. 
• Pood.—The belief that food is one of the causes of calculous affections, 
sprobably not altogether without foundation; for we find certain articles 
0 iiigesta, already mentioned, which have a tendency to induce acidity 
flatulence, and thus directly produce dyspeptic troubles which maj'' 
'Snt up a diathesis lying dormant. Dyspepsia being one of the most 
bsual of the causes of calculus, almost any article of food which deranges 
U.e of assimilation, may stand in relation of cause to the effect, 
ighly nitrogenous food, when combined with acescent ingesta, increases 
to deposition of uric acid, and lessens the formation of the phosphates 
b the urine; again, an almost exclusively animal diet contributes to 
. le rapid formation of uric acid, and, in persons who labor under a calcu- 
-0118 diathesis, lays the foundation of stone. We believe that the various 
aiticles of diet which are considered productive of calculous concretions, 
jUeso secondarily, first producing irritation in the alimentary canal, fol- 
owed by dyspepsia with mal-assimilation of the food, and thus becoming 
(|.e remote cause of the affection ; it is not probable that food properly 
Rested is ever the cause of calculus. 
1 Water.—Excepting in the case of oxalate of lime concretions, it will 
e Sade to assert that water does not exert any direct effect upon the 
Production of calculus. It is very true that, in the case of the oxalic 
clriety, water may furnish a proportion of lime, which being acted upon 
y the acid, will produce the oxalate of lime deposit, but in regard to 
•\e °fher varieties, we see no sound reason urged, why it should be cen- 
tered as a direct factor in their production. The assertion that water 
clause of calculus, is not sustained by the facts in the case, analyses 
the calculi themselves proving that none of them correspond in chemi- 
composition with the salts which exist in the waters drunk in those 
•stricts where the calculi make their appearance. 
„ It is self-evident that the only way in which water could have any in- 
salfn°e *-n formation of calculi, would be by causing a deposit of those 
8 which exist naturally in the urine itself; and to this end they would 
ave be of alkaline reaction, and this would favor only a phosphatic 616 
MASTIN, 
deposit; but even this view is not sustained by experience, for, on the 
contrary, alkaline waters, such for example as those of Yichy and YaK 
and others of like constituents, enjoy a reputation for counteracting a 
calculous tendency, and even for dissolving the stone when formed. Then 
again the water of the Seine abounds with carbonate of lime, and were 
we to attribute to its use the calculous affections which are so frequent 
in and around Paris, we would naturally expect to find calculi composed 
of carbonate of lime; but both observation and analysis prove that cal’' 
bonate of lime calculus is the least frequent of all varieties. 
The same may. be said of other regions where stone is prevalent. Tbe 
sandstone districts of Kentucky and Tennessee, where soft water is used? 
furnish just as many cases of calculus as do the limestone sections where 
hard water is commonly drunk; and in Alabama, where stone is but 
seldom encountered—there having been only some fifty to seventyJD6 
operations performed upon her natives since the settlement of the State 
in 1817—it is a fact worthy of consideration that the greater number oi 
cases has originated in a belt of country running east and west through 
the State, just above and including Tuscaloosa ; a pure sandstone regiell? 
with the softest and best water in the State. On the other hand, tbe 
northern and eastern sections abound in blue limestone, and the water 
is very strongly impregnated: yet we rarely, if ever, hear of a case 01 
either gravel or stone within these limits. Again, in middle and south' 
ern Alabama, the base of the soil is what is known as “ rotten limestone? 
and the water strongly alkaline; this is also the case in eastern Miss18' 
sippi,and still we have been unable to obtain reliable information of evell 
a half dozen cases of stone having ever occurred in these regions. 
The testimony of Dr. James Guild, of Tuscaloosa, who has been the 
leading physician and surgeon of that vicinity for the last forty years? 
and who has probably operated for stone a greater number of times than 
any other surgeon in Alabama or Mississippi, is, that his cases have an 
come from the sandstone districts wffiere soft water is commonly used. 
Many other interesting examples could be brought forward to prove 
that water does not directly favor the production of calculous affection8? 
but the time allotted for the reading of this paper will not permit an 
extended investigation of the subject. It may be well to suggest, how- 
ever, that hard water as a constant drink may secondarily become one 
of the causes of stone, by deranging the digestive organs. 
Exercise.—Deficient exercise is an important factor in the production 
of these concretions ; they being more frequently found among those wh° 
are engaged in sedentary pursuits than in that class which leads a m°}'e 
active life. Inhabitants of large and densely crowded cities, as Pan8? 
for example, who are confined within doors and live chiefly upon a stintin' 
lating diet of a highly nitrogenized nature, with deficient respiration and 
neglect of necessary muscular exertion, become fit subjects for the inva- 
sion of dyspeptic troubles, which, when supervening upon an hereditary 
diathesis, favor the formation of uric acid, with its sequelse gout and 
calculus. 
Respiration.—Respiration, which is in a great degree controlled by tne 
amount and character of exercise taken, exerts indirectly a powerful in- 
fluence over the production of the urinary salts. We have shown tha 
a large proportion of all urinary concretions are composed of uric acid? 
and that this acid is usually precipitated in the form of one or another 
of the urates. We know that, in health, there are only about eigh 
grains.of this acid excreted per diem, whilst of the well-known substance CALCULOUS DISEASES. 
617 
(which, on account of its greater solubility, is never precipitated) 
ere is nearly half a.n ounce separated from the blood daily by the kid- 
tl 8’ -^ow, chemical analysis shows that the only difference between 
•^ese two substances is the varying amount of carbon and present 
CAAre^e*r composition; nric acid being represented by the formula 
io-N 4H408, while the composition of urea is C 2H2II402. If then the prin- 
pal difference is made up by carbon and oxygen, the elements of car- 
°Ule acid, we naturally refer an excess of uric acid in the circulation to 
. process b}T which carbonic acid is produced, and we know this to be 
Hence we infer that deficient exercise, by interfering with 
ee respiration, healthy digestion, and assimilation, favors the produc- 
°f calculous concretions. 
(r. 9e>—Next in order, age seems to exert an influence in the production 
.calculi, the urine of infants being more abundantly supplied with 
ric acid than that of adults ; which condition is doubtless the result of 
e changes to which they are exposed, only a few hours after birth, 
’ light, and deficient or improper nourishment, tending to disarrange 
■ ® Proper performance of the functions of their various organs. Taking 
* p consideration their defective digestion, errors in their diet, the irri- 
a lon of dentition, with the consequent excitement of the brain and 
,L! Ve'Centres, we find them in the very pathological condition most favor- 
V e the formation of a diathesis which, when acted upon by heredi- 
ty influences, will produce these deposits. 
r is not probable, however, that calculous affections are a great deal 
ah/'6 re(luent among infants and young children than among adults, 
hough statistics would lead us to infer that such was the case, since 
uiese go to show that operations for stone have been performed oftener 
tjh°o children than upon adults, and more frequently upon the aged than 
10se xmiclcllg life; but when we investigate the subject, we find, as 
r- Coulson has remarked, “ that an error has crept in from not using the 
,p°per precaution to distinguish between absolute and relative numbers. 
p^ermiue liability, the absolute numbers should be corrected by the 
qi] rribers of persons living at the several periods of life enumerated. 
luh if all persons under twenty were affected with stone, and all over 
were affected with the like complaint, it is evident that the lia- 
\v lY Woui(i be the same, though the absolute number of persons attacked 
. ke very different.” Then, to enable us to determine the liability 
be° i ren °f a certain age to stone, we must correct the absolute num- 
]j,.rs the numbers of persons of all ages living at the several periods of 
kj e enumerated. Corrected in this manner, statistics would most proba- 
.°w that young persons are much less liable to calculous affections 
W}111 18 genei'ally believed. In fact, we have observed that in India, 
8e -fGre s^one ig exceedingly prevalent (more so, perhaps, than in any other 
ot? lon of the world), old men are more liable to the disease than any 
If1' class of the population. 
afl‘ 6X-—^ex ias been considered as exercising some influence over these 
arTecti°1>ls, simply because stone in the bladder is comparatively infrequent 
ernales- This is no doubt chiefly due to the fact that they have short 
to j Jarge urethrae, without prostatic portions, thus affording a ready exit 
itl ?e nuclei of stone which pass to the bladder after having been formed 
as ]• f Sidney. We are not aware of any reason why the female is not 
tq labl° to the formation of calculous concretions within the kidney, as 
VV| • rilale; for women are subject to the same general laws and affections 
llc 1 produce the disease in the other sex. Indeed they are liable to, 618 
MASTIN, 
and frequently suffer from, attacks of calculous nephralgia, and are oft®I*'1*' 
times the victims of gout, when exposed to the same exciting causes all 
when governed by the same hereditary influences which produce these 
diseases in men. 
Eace.—On the other hand, race evidently does exert a direct bearin» 
upon the formation of these concretions. In America, where we ha^6 
ample opportunities of examining the subject, it has been shown that ca' 
culous affections are exceedingly rare among the negro population, anc 
that gout is seldom, if ever, seen in the black. During the past yeai’? 
have been engaged in collecting statistical information of American litb°' 
tomies, and in examining the various reports in reference to this point?1 
find that out of some 8039 reliable cases which I have to this date tabm 
lated, there are only 102 operations reported as having been perform®1 
upon the negro, and only 31 upon the mixed blood or mulatto. 
observations have beenmade amongthe native African tribes,and stone hab 
not been found as a frequent affection. Dr. Thomas Winterbottom states? 
in his Medical History of the Native Africans around Sierra Leone, tba 
“ notwithstanding the excesses committed by the pagan nations of All’10**, 
in the use of spirituous liquors, etc., I have never heard of an instance 6 
gout among them, nor is it probable that they are acquainted with tb 
disease;” again, he says, “ except gonorrhoea, I have never met with any 
affection of the urinary passages, such as gravel, calculus, etc.” This i® 
further corroborated by the testimony of Dr. Livingstone, who state® 
that “ stone in the bladder and gravel are unknown ; I have never me 
with a case, though the waters are often so impregnated with sulphat6 
of lime that the kettles quickly become encrusted with the salt, an 
some of my patients who were troubled with indigestion, believed tba 
their stomachs had got into the same condition.”1 
This apparent immunity from the affection cannot be due to color, f° 
we find some of the dark-skinned races, as for instance the Asiatics, e*' 
ceedingly prone to the disease; and in the peninsula of Hindustan? 
especially in the central and upper provinces, stone is met with probably 
more frequently than in any other locality of equal extent on the 
In a paper upon this subject, by Dr. Curran, of the East India Service, n 
is mentioned that “ from Peshawur to Calcutta the diathesis is genera 
and almost universal;” and we note that at the Medical Missionary ®°' 
ciety’s Hospital, at Canton, Dr. J. G. Kerr operated for stone more than 
300 times in the short space of three years. Other instances of the remark 
able frequency of this operation at the hands of the native surgeons o 
India could be cited if it were necessary to do so. 
Like the negro or black man, the aboriginal tribes of North Amei’lC‘ 
seem to be peculiarly exempt from stone affections; whilst, on the oth® 
hand, the white races are its constant victims—a fact which evident J 
can be used as an argument to prove the influence of race in the prodn6 
tion of a diathesis favoring the formation of stone. If not, how 
shall we explain the fact that the negro and North American India 
are exempt in a great degree from an affection to which the white mall’ 
and his darker coraplexioned Aryan brother of Asia, are so liable ? g 
Habits.—lt is possible that habits and modes of life of the white rac6j 
may influence in a great measure the production of the disease, expo.36 
as they are to all the cares and excitements of civilization ; inhabit 
sections of the globe subject to sudden vicissitudes of climate, with a 
1 Livingstone, Missionary Travels and Researches in Central Africa. CALCULOUS DISEASES. 
619 
the errors of a life which is not led in accordance with the great laws of 
nature, it is reasonable that we should find stone more frequent with 
than in those races which live in a comparatively natural state. 
On the contrary, the negro and American Indian are not only 
accustomed to a life in the open air, and to a diet suited to their diges- 
!°n, but having the finest teeth, they masticate their food properly, and 
thus still further favor healthy digestion. Their skins are more active, 
as great depurating organs, eliminate much eftete material which 
ln other races must pass off by the kidney. It is also probable that 
B°nie inherent principle exists in the negro which in a great measure 
exempts him from this disease, just in the same way that he is to a 
exempt from certain fevers and other affections. What that 
Principle is, I am at a loss to suggest. The inhabitants of India live 
Principally upon rice and other cereals—materials rich in nitrogenous 
fatter, and, being careless in guarding themselves against sudden changes 
°|. temperature by suitable raiment, they invite as it were the formation 
a Uric acid diathesis; and any exciting causes which supervene to 
disturb the normal relations of the urinary constituents must naturally 
end to produce calculus. 
- Occupation.—Certain occupations seem to exert an influence in prevent- 
lng or producing these affections, seamen and soldiers being peculiarly 
eXempt; so much so, that it is a noticeable truth that the disease is 
p.rely met with in persons who follow either of these modes of life, 
riiviale in his large experience saw only three cases among sailors ; and 
A. Copland "Hutchison states that, in the British hTavy, with a 
number of patients estimated at 86,000, there were only eight cases of 
Btpue encountered in sixteen years, and that three of these were afflicted 
this disease before entering the service. The records of the Green- 
'vich Aaval Hospital, during a period of twenty-seven years, show that 
n°t a single operation for stone had been performed. This is equally 
lUe of the American Navy, as there is not a single case reported at our 
tfaval Bureau; and the testimony of I)r. W. S. W. Ruschenberger, 
Medical Director, U. S. H.,1 whose experience in this service extends 
?Cer fifty years, is that he has known of only one operation, and that 
d® personal observation has been confined to but one calculous sailoi, 
wh° had the disease at the time he enlisted. _ . 
A similar exemption seems accorded to soldiers, if we receive the 
of Sir James M‘Grigor, which show that out of 840,000 
Patients, among soldiers serving in the Peninsular Campaign, no case of 
Calculus was met with from 1811 to 1814. Like results are obtained 
,r°m the French and Russian Army records; and the experience of our 
ate civil war is that there have not been more than two cases of calcu- 
?s recorded as the result of a systemic condition ; although probably the 
ri(mest collection in existence of stones having bone nuclei, has been 
?°Hected for the Army Medical Museum, at Washington, thiough the 
gable energy of that accomplished gentleman, Dr. Geo, A. Otis, 
0 rim Surgeon-General’s Office. 
'v ithoul definite facts to guide us in forming an opinion, we believe 
at the most probable cause of the infrequency of stone among seamen 
aild soldiers, is that they are generally men in the prime of life, there being 
C(ffi>parative]y few of either children or old men among them—classes 
rich are considered the most liable to stone; again, the rigid examina- 
1 MS. letters to writer. 620 
MASTIN', 
tion of recruits for both services, naturally excludes all those suffering 
from that state of constitution which would favor a formation of sucD 
deposits. We cannot, therefore, consider that occupation, per se, exert8 
any protective influence against calculous concretions. , 
Moral and Physical Emotions.—Yery different is it with moral apf 
physical emotions ; they evidently exert a powerful causative effect in 
the production of these affections, and, if time would permit, some ver) 
interesting examples could be adduced to prove the effect of the passionß 
—fear, anger, joy, and grief—over the normal secretion of the urine. 
Dr. Debout D’Estrees, in his treatise on the “ Causes of Gravel anu 
Stone,”1 narrates quite a number of clinical cases, showing the effect o 
mental excitement and depression; and M. Bouchardat, in his Memo11 
upon Gout, gives instance after instance in which violent emotions havT0 
produced polyuria; while Civiale himself often remarked how frequently 
severe exercise and great trouble of mind were followed by the form*1' 
tion of much red sand in the urine. 
Foreign Bodies.—We now come to a fertile cause of calculus, which 18 
the presence of foreign bodies introduced into the bladder, either b> 
accident or from design; they irritate and inflame the raucous mem bran6’ 
thus causing the secretion of an alkaline mucous or purulent fluid by 
which the urine is rendered alkaline, and hence a precipitation of the 
phosphates around the foreign body which acts as a nucleus. , 
Injuries to Spine and Urethral Stricture.—lnjuries of the spinal cor 
produce phosphatic deposits, and thus become one of the causes of vesica 
calculi; and it has been asserted that stricture of the urethra favors the 
production of these concretions. In relation to the latter cause, I alll 
inclined to believe that its effect has been over-estimated ; for, after hav- 
ing carefully investigated this point, I am struck with the fact tba 
authentic cases of calculus, resulting from urethral stricture, are exceed- 
ingly rare. My friend, Prof. Fessenden IST. Otis, of Hew York, says, 111 
a MS. letter on this subject, “ in over five hundred cases of stricture, t° 
which I now refer, I have met with but (3) three cases in which ston6 
was coincident with stricture,” In my own experience with stricture 0 
the urethra, I find, among the notes of over three hundred cases, tba 
there are but (2) two in which calculus and stricture have been aßßo' 
ciated ; one of them occurred in an old man sixty years of age, suffering 
from enlargement of the prostate; the other in a youth in whose uretbra- 
ft small uric acid calculus was lodged in a pouch posterior to the stricture* 
It is not improbable, however, that, in very close strictures of lo*G 
duration, an arrest to the passage of urine may produce vesical irritate11 
and inflammation, causing the secretion of a muco-purulent discharge 
from the bladder, which will favor such deposits. 
Colloids.—Besides the presence of urinary salts, there is somethuG 
more required for the formation of calculi, for in their natural state tb 
salts are not capable of entering into the agglomerated condition essen- 
tial to such formations ; nor should we consider calculi as mere prectp1' 
tates of ordinary crystalline and amorphous deposits held together by 
plain mucus. Some other agency is necessary, and this will most proba- 
bly be found in the presence of the colloids—certain glutinous products, 
the result of subacute inflammation of the urinary passages, the kidney8’ 
the ureters, and the bladder itself; they evidently exert an influence 
over precipitated crystals, changing their forms into amorphous, or, a 8 
1 Les Causes dela Gravelle et de la Pierre, par le Dr. Debout d’Estr6es; Paris, IS'iC- CALCULOUS DISEASES. 
621 
I r* Carter1 designates them, “ submorphous structures,” which, 
the presence of an animal basis, become embedded in the colloid 
and thus form calculous masses. 
. the experiments of Mr. Ord2 prove that crystalline forms, when asso- 
rted with a colloid, are altered by two processes—first, by modification 
surfaces and angles; and secondly, by a corresponding rearrangement 
the molecules themselves. He proved that the strength of a urate 
ution, with a concentration and excess of the acid supplied, controlled 
e form of the resulting crystals, and that uric acid, in many of its as- 
sets, verged upon the nature of a colloid. He found that albumen 
•Seised a more powerful influence than any other substance in produc- 
es a change of crystalline form, and a disposition to assume an agglome- 
‘ded condition. Still, we find it difficult to say what is the chemical 
ature of the animal basis which, in the living being, causes uric acid 
0 phange its pure crystalline form to some other, more prone to agglome- 
jltl°n. But, judging from the experiments of Mr. Ord, we conclude 
it is albuminous, and, as “ mucin” is derived from these formations, 
1 mucin is the cement. 
the general conclusions which we deduce from these experiments are, 
that albumen and the other colloids, when placed in the presence of 
l!e acid, cause its crystals to be deposited in the shape of small, thick, 
ab-cuboidal bodies, without curved faces, and sometimes as dumb-bells 
,1 spheroids; secondly, that grape sugar and other crystalloids cause the 
to be thrown down in long tabulated or toliaceous crystals, with 
, sides and sharp angles and edges—forms essential to the process of 
dSglo me ration into masses. 
Oxalate of lime crystals are in like manner altered in form by the pre- 
\jGLce °i a colloid; but it seems to be requisite that the colloid should be 
onser than for the same change in uric acid. This fact led Mr. Ord to 
j fa'v the inference that, as small calculi which pass from the kidney in 
I ePhralgic colic are generally of the oxalic acid variety, they are doubt- 
de88 formed in the recesses of the kidney, where the colloid medium is 
pser than in other portions of the urinary tract. 
lle triple phosphates are less frequently influenced by the presence of 
le c°lloids than the other varieties, and consequently they are less dis- 
u *ed to form spherical or agglomerated masses. 
11 the urine we find four groups of substances which are capable ot 
urinary salts into conglomerate masses, and thus ot favoring 
ie formation of calculi, viz., mucus, urea, coloring matter, and salts. 
a andiug first among them is mucus, a colloid prone to decomposition, 
\v\ ac^foe as a ferment in promoting putrefaction of organic substances 
a] ea associated with them in solution; now “an excess of this mucus, 
m e.red in character in the urinary passages, or an effusion of albumen, 
i Fllh °r blood, as often results from congestion of the kidney, or from 
’■‘Ration of the urinary tract, will furnish a colloid medium with which 
lc acid, the urates, or oxalates (themselves perhaps in excess), will com- 
rl.? *n the manner before described and thus form a calculous mass.” 
tele microscopic examinations of urinary calculi, by Hr. Vandyke Car- 
sustain the views advanced by Mr. Ord, that the spheroidal forms of 
masses are not entirely due to the mechanical influences at 
Cai.t^*croscoPic Structure and Mode of Formation of Urinary Calculi, by H. Vandyke 
* W’X'D.; London, 1873. 
also\i‘r 0rd’ M.8., London, M.R.C.P., St. Thomas Hospital Reports, vol. i., 1870; 
1 edico-Chirurgical Transactions, vol. Iviii., 1875. 622 
MASTIN, 
work in their formation, and show that there has been a molecule d*9' 
turbing power acting in the presence of the colloid medium; and als6 
that the form and cohesion of the crystalloids in the formation of calc1}11 
may be accounted for by Mr. Rainey’s theory of molecular coalescence 111 
the production of shells. 
From the microscopic examinations of urinary calculi by Dr. Carter? 
and the experiments upon urinary salts by Mr. Ord,we are led to the I°*' 
lowing conclusions: All crystals of urinary salts are modified in sha£e 
when they are deposited in a colloid medium; the animal basis of nr,c 
acid tends to produce this change; and like causes bring forth the sawlo 
alterations in the crystals of the other salts. The necessary condition9 
favorable for the operation of molecular coalescence may at any time n 
brought into action; and wherever there is an excess of mucus whien 
has been altered in character in the urinary passages, or an effusion 0 
albumen, fibrin, or blood, from congestion of the kidneys, or from irrit*1' 
tion along the urinary tract, we have furnished a colloid with which un 
acid or the other salts will combine in the manner described. Such 01 
state of system is found during certain fevers, inflammations, etc., wher6 
the urine becomes loaded with sediment, and the first nucleus of a grave 
begins; this being accomplished, the little nucleus becomes surrounded 
by a thin layer of protective mucus, in which continued layers in mol6' 
cular coalescence are deposited, and a calculus is formed. , 
We do not desire to be understood to say that calculi are accident*1 
formations, dependent wholly upon bare physical causes, but rather th® 
they depend for their production upon an association of hereditary innll' 
ences with certain physical causes; and that the defects of structure 
development which we find in certain hereditary conditions probaby 
produce certain elements which are formed into calculi through tn 
agency of the colloids, these being themselves the result of such an he red p 
tary state or condition. It seems necessary for the formation of calcul 
that these conditions should remain constant and unvarying for a peno . 
of weeks, months, or years, thus furnishing time for the slow growth 0 
these concretions. 
Time will not permit me to refer to the changes which take place in <l 
calculus after the nucleus is formed in the kidney, and during itspassag6 
through the urethra and its lodgment in the bladder; I will, therefor6’ 
close with a brief notice of the geographical distribution of calcul°uS 
affections in North America. j 
Geographical Distribution of Calculi.—Calculus is not universally f°ull, 
over the Western Continent, there being certain localities where it is r°e 
with much more frequently than in others; and then again there are se° 
tions where it is almost entirely unknown. The central portions of f}1 
United States have furnished more cases than any other parts, whilst to 
extreme Southern and Northern States rarely produce a case. Along t° 
Gulf coast, the Canada line, and the Pacific shores, stone is very uncorll 
mon; as it is also in the Canadas, the British possessions, and Mexico- 
In the United States, we find it more frequently in an area of county 
comprised within the boundaries of Tennessee, Kentucky, Ohio, IndiaI'} ’ 
Missouri, Western Pennsylvania, Virginia, North Carolina, and Gcorg 
than elsewhere ; there is also a tract of country adjacent to and including 
Salt Lake City, Utah, where the disease is said to be remarkably 
mon. On the other hand, stone is comparatively infrequent in Alabam ’ 
New York, Maryland, and Illinois; whilst in New Jersey, Delawai ’ 
and the New England States, it is so rare that there are very tew 
geons who have operated for stone in those States. The Warrens, CALCULOUS DISEASES. 
623 
aft have performed the greater number of all the operations for this 
v ectlon which have been done in Ffew England; and that number is 
J sriiall when we take into consideration the density of the popula- 
ce,oll’ and the lapse of time since the settlement of the country. The 
a!es .^or(^er^n& 011 the G-ulf of Mexico—Florida, South Alabama, Mis- 
I Slhpi, Louisiana, and Texas—are almost entirely exempt from calcu- 
Us doubles; not more than two or three cases have occurred in Florida; 
more in either Southern Alabama, Mississippi, or Louisiana; 
0£ hough in Southwestern Texas, along the Mexican line, quite a number 
stone cases have occurred, and have been taken to San Antonio for 
hutment;, hut in all other sections of the State the affection appears to 
of infrequent. It is a strange circumstance that in the State 
Minnesota calculous affections, in the form of nephralgic colic, are 
ceedingly frequent, whilst stone in the bladder is so very rare; yet 
LhS 3s.'true, and after a very extended correspondence with the leading 
h Jsicians and surgeons of that State, I have been able to hear of only 
Dee operations for stone upon persons who have resided there. The 
may be said of Arkansas,, with the difference that gout and cal- 
,3 us are so very seldom seen that they have not been classed among the 
leases of the State. 
taking into consideration the recent settlement of lowa, and its scat- 
population, it is a little remarkable that stone has been met with 
r requently as is shown to be the case by the number of operations 
fP°rted. To this date I have been unable to gather any reliable in- 
frNation as to the frequency of calculous affections in the far West; but, 
So>rri before me, I am led to infer that they are uncommon, 
it T cases °t stone have been operated upon at San Francisco, but 
i aas, so far, not been ascertained whether they were of foreign or 
°oiestic origin. 
of U losing, it may be interesting to notice that almost the entire tract 
c c°uutry in which stone has been found to abound, belongs to the 
Coniferous and sub-carboniferous formations, in which gypsum, lirae- 
tivUe’ rnar^e’ and cretaceous deposits abound; regions the most produc- 
j® of any others of the temperate zone, furnishing all the varieties of 
Ve l0gen°Us and non-nitrogenous materials of food, both animal and 
diSf tf-ble’the very kind of aliment most calculated to derange the 
festive organs. 
Place SUmminS together the probable causes of calculous affections, we 
Hereditary influences which control a diathesis, 
jj’j l&estive troubles produced by an excess or deficiency of proper diet, 
be 1 i edentary life, with indulgence in stimulating food, by which 
* Jy nutrition and assimilation are altered to mal-assimilation and 
of h ’ matic changes, deficiency of clothing for the proper protection 
ie body, and an arrest of the healthy function of the dermoid tissue. 
0l ’ A ant of harmony between the great secreting and excreting 
UroailS~l~^e skin, and kidneys—with catarrhal affections of the 
poetic viscera, which favor the formation of a colloid medium. 
oVe, Injnries of the spinal cord, by which a proper nervous influence 
* the mucous membrane of the urinary organs is lost. 
its Foreign bodies present in the bladder, producing cystitis with 
tjleCo.llse(luent rnuco-purulent discharge, and becoming nuclei upon which 
Phosphates are precipitated. SUBCUTANEOUS DIVISION OF THE NECK OF THE THIGH- 
BONE FOR ANCHYLOSIS AT THE HIP-JOINT. 
BY 
WILLIAM ADAMS, F.R.C.S., 
PRESIDENT OF THE MEDICAL SOCIETY OF LONDON, ETC. 
Mr. President and Gentlemen : 
The observations which I propose to offer to-day for the considerate11 
of the Surgical Section of the International Medical Congress, refer 
the operation of subcutaneous division of the neck of the thigh-bone j° 
anchylosis of the hip-joint, with malposition of the limb ; an operatic1 
which was first performed by myself in London at the Great iSTorther11 
Hospital on the first of December, 1869. I propose to refer to the expe' 
rience which we have gained during the past six years, since its ffrS 
performance, as far as I have been able to collect records of the caseP 
operated upon ; and to offer some observations on the mode of performer? 
the operation, the selection of appropriate cases, and the results to 0 
obtained as to the permanent condition of the limb, i. e., whether anchf' 
losis in the straight position is to be the result, or whether we 
endeavor not only to rectify the deformity, but to obtain a false j°in 
at the seat of operation with free voluntary motion of the limb. 
Anchylosis of the hip-joint may result from any inflammatory affect'011 
of the joint, and formerly, or I would rather say in our own time, uud° 
the teaching of Sir Benjamin Brodie, and the generation of surgeons n°' 
just passing away, this was the result which all surgeons desired to s°e 
as the termination of hip-joint disease, as well as other joint aftecti°llS' 
Their treatment was directed to the production of this result by loj 
continued and absolute rest, with the application of straight and irl?' 
movable splints. In connection with the subject of anchylosis, Bl& 
important that it should be borne in mind that its prevention in a lar£ 
number of cases, and prevention is always better than cure, is due to tn 
advance of American Surgery ; and that Professor Sayre, by disprove 
one of the old surgical maxims of the English school, that absolute all 
long-continued rest, and recumbency with a long straight splint 0 
some other form of splint to maintain absolute immobility of thej°lllJ 
are essential to the cure of the disease—and by substituting his appai’al 
acting on the principle of maintaining motion during the treatment 
the affection—has added a great practical improvement to the mode1 
treatment of hip-joint disease. 
As the result of the more severe forms of hip-joint disease, however 
anchylosis must necessarily take place, unless resection has been P° 
formed, and must be regarded as the best possible compromise, and 11 
best termination of a very formidable disease which threatened even t 
life of the patient, provided always that the anchylosis has taken p|a t 
with the limb in a natural and useful position. In the hip-joint, the b° 
position for the patient in which anchylosis can take place, is with 
thigh slightly flexed, without any adduction or abduction of the bnl SUBCUTANEOUS DIVISION OF THIGH-BONE. 
625 
We shortening is easily compensated for, and the patient can sit down 
a boat much inconvenience in a chair. Anchylosis with the thigh in 
j perfectly straight position, i. e., so straight that, when the patient is 
on his back on the ground, there is no arching whatever of the 
tl ll? fbe lumbar regions, is attended with very serious inconveniences; 
e Patient cannot sit on a chair except when resting on one buttock on 
'e edge of the chair, the anchylosed limb being stretched out with the 
st v'es^n& 011 the floor, and as a result of this habit, in cases of long 
ndmg? the knee-joint bends preternaturally backwards; this is in- 
„ eaSeA by a habit sometimes acquired of crossing the sound leg over the 
limb. This condition of straight, it might almost be called 
t er-straight, anchylosis is rarely met with, but I have been consulted by 
0 patients, one a married lady, and the other a gentleman about forty 
Fs pi age, who suffered so much from this condition of straight an- 
in n*8 Ibey were both anxious to submit to the operation of divid- 
a ljie Deck of the thigh-bone, if motion could be obtained, but as I was 
able to promise this, and they had become habituated to the incon- 
iur.nCes, n°lbing was done. I may mention that it was not only the 
Bie 011 a °bair, which annoyed these patients, but they told 
th at the bowels could only be relieved in the standing position, so 
a they were anxious to submit to any operation promising relief if 
could be obtained, 
tylosis with the limb in a deformed position is, however, the con- 
lUll tor which surgical aid is generally sought. In the great majority 
ljrCjasps °f anchylosis of the hip-joint, contraction of the joint with tiie 
Xlon ot the thigh having occurred with very little adduction or abduc- 
in other cases, severe adduction with a comparatively small amount 
u exlon, and again, in others, the distortion will be found to depend 
pro*11 Xlon with abduction, or adduction, of the thigh, in about equal 
thPortion, The inconveniences will vary according to the extent and 
Section of the contraction, being greatest in those cases in which 
]jn ,lon and adduction are combined, so that the knee of the anchylosed 
in r ls flrawn across the opposite thigh ; more especially when this occurs 
ipttiales. 
etlc aerp can be no doubt that an urgent necessity for surgical interfer- 
arJL Gx^s^s In many of these cases, and it was in the city in which we 
th a<}w assembled that the first operation, having for its object not only 
Ijd rectifying the deformity, but of obtaining motion by the estab- 
yea? °f a false joint, was performed by Dr. J. Rhea Barton in the 
thi-1 A large external incision was made, and the bone sawn 
between the two trochanters. The deformity was rectified, and 
tai CilSe Proceeded favorably. It is said that useful motion was ob- 
Ujne(h but that seven years afterwards anchylosis took place, and the 
So b oled of phthisis nine years after the operation. This proceeding, 
b «*hat modified, was afterwards repeated by J. K. Rodgers and others, 
perf le next operation of importance for this class of cases was one also 
Jif. 0l^e(l by a distinguished American Surgeon, Dr. L. A. Sayre, of 
f0 v f°rk, who removed a transverse section of the femur, of elliptical 
’Just above the trochanter minor, by means of a chain saw, the 
Atneri U Hle freatnient of Anchylosis by the Formation of Artificial Joints,” in the North 
and Surgical Journal, April, 1827, with further remarks in the American 
omhe Medical Sciences, vol. xxi. 626 
ADAMS, 
external incision being necessarily of large size. This operation Dr. Say1’6 
successfully performed on June 11, 1862, and as late as April, 1868, th 6 
patient is reported as able to walk with free motion of the limb. Dr' 
Sayre repeated this operation on November 6, 1862, and the case pr()' 
ceeded favorably at first, but abscess with some necrosis of bone occurred? 
and the patient died of tubercular deposits in the lungs with pneumon 
on May, 17, 1868. It was found, however, that a very perfect artifice 
joint had been formed, and that so far the object of the operation bad 
been accomplished. 
I shall next refer to the case in which I divided the neck of theffeumu1’ 
subcutaneously at the Great Northern Hospital in London, on Decembe1 
1, 1860,1 A case of bony anchylosis of the hip-joint with the leg in dn 
extremely deformed position came under my care at that time, the 1er 
being flexed at a right angle, and abducted, in a man aged twenty-1 Jlll- 
- occurred to me that the neck of the thigh-bone was the spot to winch 
attention should be directed, and that if I could divide the neck of the 
bone by means of a very small saw passed through a wound not much 
larger than that made by an ordinary tenotomy-knife, and thus preserve 
the true subcutaneous puncture, I should be able immediately to cure tbe 
deformity, and might, perhaps, succeed in obtaining motion. The instru- 
ments used were a long tenotomy-knife, and a very small saw three' 
eighths of an inch in width, and with a cutting edge an inch and a ha1 
in length, made by Mr. Blaise, of 67 St. James Street, London. I enterej 
the tenotomy-knife a little above the top of the great trochanter, anJ 
carrying it straight down to the neck of the femur, divided the muscle8 
and opened the capsular ligament freely. Withdrawing the knife, I caL 
ried the small saw along the track made—preserving this by pressure ° 
the fingers—straight down to the bone, and then across the anterior sur- 
face of the neck, the flat side, and not the edge, of the saw being applieC 
to the bone as it was gently carried along its anterior surface; the edg6 
of the saw was now turned upon the bone, and by a very wiggling sa'v' 
ing movement the section of the bone was accomplished in five minute8* 
No hemorrhage followed, and I immediately applied a compress of dry 
lint, retained in position by strips of adhesive plaster and a bandage. 
As soon as the bone was cut through, the leg moved freely in all db’66' 
tions; but, before it could be brought into a straight position, it 
necessary to divide the tendons of the long head of the rectus, and of th0 
adductor longus muscles, and to cut through the tensor vaginte feinor18 
muscle. The limb was fixed in a straight position, and bandaged to il 
long interrupted Liston’s splint. No inflammation whatever followed th 
operation ; no swelling, or redness of the skin, or any deep suppuratio11’ 
but the wound healed slowly, two or three drops of pus in the day ooziug 
from the track of the wound or the granulations at its orifice for thr®6 
weeks. This did not prevent my applying weight extension on th 
fourth day, and commencing passive motion. At first the progress 
couraged the hope that a false joint would be established and motio1 
retained. After a few weeks, however, the limb began to stiffen at th 
hip, and all attempts at movement were so painful that I abandoned th 
idea of obtaining motion, and kept the limb in a straight or nearly straigh 
position for bony anchylosis, which took place, the man obtaining a veij 
useful limb. At the present time this man is able to walk any reason 
1 British Medical Journal, December 24, 1870; and also a pamphlet, “ A New Operah0 
for Bony Anchylosis of the Hip-joint London, 1871. SUBCUTANEOUS DIVISION OF THIGH-BONE. 
627 
a distance without stick or crutch, and earns his living by an active 
?Ccupation. I have mentioned the details of this, the first case, because 
very fairly represents the general course of events in others, 
deviations in several respects will have to be made in particular cases; 
the exact point of puncture and the direction of the same 
VIU require to be varied in reference to the altered relation of the thigh- 
?ne to the pelvis, i. e., whether the thigh is simply flexed upon the pel- 
Vls> °r flexed and adducted, or abducted. The altered direction of the 
jleck of the bone, thus produced, must be very carefully calculated by 
m surgeon before making the section, which should be at right angles 
0 the long axis of the neck ; great care must be taken to avoid cutting 
through the neck, or in a direction parallel with the shaft of 
le bone, a mistake easily committed if the altered direction of the neck 
apd shaft of the bone be not carefully considered. A good general direc- 
-1011 in the majority of cases seems to be to place the saw, just before 
ornrnencing the section, parallel with Poupart’s ligament, and from 
of an inch to an inch below it, I have found in the dead- 
°Use that this direction will generally enable the operator to cut through 
lleck a little below the articular margin of the head of the bone. 
"ben with regard to the number of cases which have been operated 
up to the present time, and their results: I possess the records of 
.Plenty-four cases, including five operated upon by myself; four by Mr. 
ryant, of Guy’s Hospital; two by Mr. Sydney Jones, of St. Thomas’s, 
‘lnd one by Mr. Croft, of the same hospital; two by Mr. Jessop, of Leeds ; 
w° by Mr. Lund,- of Manchester; one by Mr. Hardie, of Manchester; 
Slle by Mr. Maunder, of the London Hospital; one by Mr. Willett, at 
-j • -Bartholomew’s j one by Mr. Jowers, of Brighton ; one by Mr. Furneaux 
ordan, of Birmingham; one by Mr. Jonathan Hutchinson, of the Lon- 
. 011 Hospital ; one by Mr. Brodhurst, at St. George’s, and last, but not 
east, one of the best and most successful, in which motion has been re- 
ained, by Hr. Sands, of Hew York. Out of these twenty-four cases only 
Pjle death, from pyaemia, has occurred, and that in an extremely unfavor- 
Case> ln a veiT strumous boy, aged eight years, operated upon by 
r* Croft, at St. Thomas’s Hospital. In another case, the last operated 
P°n by myself, deep-seated, chronic suppuration followed and gradually 
xhausted the powers of the patient, a very strumous girl, aged eighteen 
ears, who died eight months afterwards, having suffered from albumi- 
and phthisis. 
Such a result bears good testimony to the general safety of the opera- 
.l°u, and although the dangers even of subcutaneous sections much 
with the magnitude of the operation, these may be kept within 
leir narrowest possible limits by the judgment of the operator in select- 
cases, and the skill shown in the performance of the operation, 
ith regard to the selection of cases there can be no doubt that 
. e most favorable are (1) Cases of rheumatic anchylosis, because, in 
jciunatism, no destruction of bone ever exists, and the head and neck 
1 16 b°ne always remain of their full natural size. (2) Cases ol anchy- 
°?is after pyasmic inflammation, more especially in its subacute form, 
ilOlll "which the patient generally recovers. In these cases destruction of 
C°110rai’ely if ever exists, the cartilage only being more or less destroyed, 
s Bases of anchylosis after traumatic inflammation, in healthy adults, 
j-Uch as follows wounds of the joint, and gunshot wounds in the neighbor- 
ood of the joint. As a general rule, in these cases, little or no destruction 
Jone occurs even after acute suppurative inflammation. (4) The most 628 
ADAMS, 
unfavorable cases for operation are those belonging to the strumous class, 
because, as a general rule in these cases, disease of the bone, with de- 
struction of the head and neck of the thigh-bone, to a greater or less 
extent, takes place; and consequently, in the worst forms of this class, 
the operation either cannot be performed, or would be attended with 
such difficulties that it should not be attempted. In many cases pi 
anchylosis after hip-joint disease in children, however, especially those m 
which there is little or no evidence of a strumous constitution, and in 
which the disease has been arrested in an early stage, without the occur- 
rence of suppuration, not more than superficial caries exists, and some- 
times the mischief is limited to the articular cartilage. In these cases 
the head and neck of the femur may be but little altered in form aim 
direction, and the operation can generally be performed ; and Mr. Bryant, 
of Guy’s Hospital, has especially extended the operation with the most 
marked success to this class of cases. 
Originally my idea was that the operation should be limited to cases 
of bony anchylosis, generally occurring in the adult; but the ease aim 
safety with which Mr. Bryant has performed the operation in children 
from eight to fifteen years of age, will induce me also to operate in si mi' 
lar cases. 
When the operation of dividing the neck of the femur cannot be per' 
formed in consequence of extensive destruction of the head and neck oj 
the bone, then the operation first performed by Mr. Gant at the Royal 
Free Hospital in London, on December 10, 1872, should be adopted. & 
consists in dividing subcutaneously the shaft of the femur just below the 
small trochanter. The bone is cut from without inwards, and not alway3 
completely through, a portion of the femur on the inner side being broken- 
instruments similar to my own are used. Mr. Gant has twice performed 
this operation with success. 
Mr. Maunder, of the London Hospital, has also operated subcuta- 
neously, or nearly so, in the same situation, but has substituted a chisel 
for the saw—as, it appears to me, without any advantage—the small 
saw being the more manageable instrument, and never more than one 
introduction being required. Mr. Maunder has, however, very success- 
fully employed this method in several cases. 
The conclusions to which, I believe, we are justified in arriving from 
what has been stated are— 
I. That bones can be divided subcutaneously like tendons; and that 
the operation of completely dividing the neck of the thigh-bone by a 
small saw, introduced through a small subcutaneous puncture, is a well' 
established surgical operation attended with very little risk. , 
11. That the long bones can be completely divided by the same method 
in any part of their length with very little risk. , 
111. That in a large proportion of these cases the healing of the wound 
takes place by the first intention, and that no swelling, redness, or in' 
flammation follows. These cases of subcutaneous osteotomy proceed as 
favorably as subcutaneous tenotomy. 
IY. That in some cases a little suppuration from the track of to® 
wound, amounting only to a few drops in the day, does occur for a wee 
or more after the operation. 
Y. That, in a very few cases, deep-seated suppuration occurs; but m 
only one of these, so far as at present known, has death resulted from 
pysemia out of the twenty-four recorded cases. In one other case deat i SUBCUTANEOUS DIVISION OF THIGH-BONE. 
629 
accelerated by the operation, or rather by the prolonged suppuration 
followed. The patient died eight months afterwards from albu- 
minuria and phthisis. 
. vI. That the permanent result of the operation has hitherto generally 
. eeu to correct the deformity, and obtain bony anchylosis with the limb 
*n.a straight position; but in several instances free motion has been ob- 
ained, and remained only for a few months, when it has been gradually 
j°st- In a few cases free motion has remained for about a year, and we 
lope will be persistent through life ; but time and further experience are 
pessary before this can confidently be stated to be a reliable result of 
*le operation. 
Discussion on Mr. Adams’s Paper. 
After the reading of the preceding paper, Dr. Alfred C. Post, of New 
ol’k said :—Many years ago I performed Dr. Barton’s operation upon a young 
an who had had coxalgia resulting in anchylosis in such an abducted and 
0^Xed position that the genitals were hidden from view. I divided the neck 
the femur, according to Barton’s plan, but on the second or third day the 
became emphysematous, gangrene followed, and the patient died. At the 
b°st-ruortem examination, the femoral artery and vein were found hooked 
Jer the sawn end of the bone. Such an accidental complication would not be 
to occur again, but Mr. Adams’s plan of dividing the bone within the 
uPsule would certainly avoid it. 
0 ■Ur* Leopold Servais, of Belgium said:—Anchylosis may result from vari- 
Us causes, such as rheumatism, scrofula, syphilis, wounds, etc. The use of 
aU anesthetic is necessary to distinguish between true and false anchylosis. I 
sm of the opinion that true anchylosis does not occur save in cases in which 
has taken place. When it is necessary to divide the femur below 
e L'°chanters, it is, I think, better to employ brute force, and break the bone, 
fo ’^e len have but a simple fracture to treat. From experiments lately per- 
illed in France, it has been proved that the femur is weakest at this point, 
diff1 Consecluently will be likely to give way there. The breaking is not 
lcult, as I have ascertained bv fracturing the femur accidentally in other 
derations. 
Lewis A. Sayre, of New York, said :—I would ask Mr. Adams when he 
§His extension, and how long he continues it ? 
Bjj jr* Adams said :—I have heretofore applied extension on the fourth day, but 
com- u^ure be disposed to employ it at an earlier period. It should be 
p !nued about as long as for an ordinary fracture, but, after a few weeks, 
lmfve motion should be practised, and this should be continued once a week, 
~er chloroform, for a long time, in order to prevent the anchylosis which is 
80 >‘«Me to follow. 
800 - ®ATRE said;— The cases upon which I operated are fully reported in ray 
Witl * .^ne was the case of a female whose legs were so crossed as to interfere 
an , micturition. I took out a section of the bone, rounding off the surfaces, 
les 51ii°wing the psoas and iliacus muscles to x*etain their attachment to the 
otlSei trochanter. The recovery was perfect, and, when the patient died from 
twe°l Causes5 a ligamentous connection was found to have been formed be- 
0f 611 tile resected parts, and there was also a Y-shaped ligament and a form 
goJ?embrane resembling the synovial. The results of my cases have been 
’ Jut I am decidedly in favor of Mr. Adams’s operation, as the more 
Ad G safe one, provided anchylosis does not subsequently occur. Mr. 
thearns s statement confirms my opinion that this result is quite probable, yet 
°Per aS-6S *n wLicli it does not take place are sufficiently numerous to make the 
ation a desirable one. I shall in future use this method, but shall apply 680 
ADAMS, SUBCUTANEOUS DIVISION OF THIGH-BONE. 
extension at once, and make passive motion frequently. A divided bone, 
tendon, or fascia, should be at once put in proper position, as the effused 
lymph, being poorly vitalized, does not bear the process of subsequent stretch* 
ing at all well. The danger of extending the muscles beyond their origin 3-1 
length, and consequent!}* separating the bones, although possible, }*et will not 
deter me from putting on extension at once. 
Dr. T. G. Richardson, of New Orleans, said:—l recall a case in which 1 
fractured the neck of the humerus in trying to reduce an axillary dislocation 
of long standing. lat once pushed the broken bone up into the glenoid cavity? 
bound it firmly in place, commenced motion on the third day, and secured 3 
good and movable joint. 
Dr. E. M. Moore, of Rochester, said:—Dr. Ely, of Rochester, has made 
some experiments upon the extensibility of living muscles. He has found that 
the force required to stretch a muscle is very great, but that a weight of 300 
lbs. will cause decided lengthening. The practical inference is that too 
great extension should not be used after Mr. Adams’s operation, lest the ends 
of the bone be drawn too far apart. Remarks upon penetrating wounds of the abdomen, 
with the suggestion op a change of practice 
IN SUCH OASES. 
BY 
L. A. DUGAS, M. D., LL.D., 
PROFESSOR OF SURGERY IN THE MEDICAL COLLEGE OF GEORGIA. 
-Penetrating wounds of the abdomen are full of interest to the sur- 
erfH’ not on^r because of their frequency, but also because of their 
h treine fatality. The marked susceptibility of the lining membrane of 
o^e abdominal cavity to morbid action, and especially to'the absorption 
t .deleterious agents, together with the importance of the organs coil- 
ed, accoullt satisfactorily for the gravity of these wounds. 
the danger of these injuries varies according to their character 
‘lc to the organ implicated. It is, therefore, not a matter of indiffer- 
>ce whether the injury be a puncture, an incision, or a gunshot wound; 
r5 while punctured and incised wounds are more liable to induce 
enaorrhage, they heal more readily by first intention ; whereas gunshot 
°uncls are less apt to be attended with serious loss of blood, but will 
invariably be followed suppuration. In penetrating wounds 
abdomen, our first concern then is with regard to hemorrhage, 
Teh itself will depend upon whether a large vessel be opened or a 
T Tnchymatous organ be injured; for punctured and incised wounds of 
VesseK and of the liver, spleen, and kidneys, are usually attended 
j rapidly exhausting loss of blood. If the patient escape this first 
the question presents itself as to what we should apprehend next; 
, y, tbe determination of this question is of the utmost importance to the 
f _ lent, as his life may depend upon it. 
i UP°P this point there exists among written authorities the most strik- 
j TTformity in the belief that peritonitis is the condition most to be 
eaded when primary hemorrhage has not carried off the patient, and 
extraordinary fatality of these wounds is the necessary conse- 
I euce of this inflammatory action, whether induced by the mechanical 
ext- °r con^ of atmospheric air, of effused blood, or of fecal 
th ?Vaaation- -A.nd yet, when we come to examine into facts, we find 
reatho great majority of deaths occurs so early after the injury as to 
oer such an explanation exceedingly improbable and unsatisfactory. 
fa h» lln_less from hemorrhage, usually takes place within from twenty- 
e ! thirty-six, or at most forty-eight hours after the injury ; a rapidity 
iiely too great to be accounted for by any process of inflammation, 
ter^l^-80 cabecb true inflammation ever runs its course to a fatal 
in so short a time. Moreover, the peritoneum is not an 
fafT-1 
tr. a ’ a,jd when death does attend this inflammation from other than 
Tiiatic causes, dissolution rarely takes place in less than a week, 
hifl l2'ain’ maJ be doubted that the peritoneum is as susceptible to 
a,nmation as is generally supposed. Indeed, with the light thrown 632 
DUGAS, 
upon this subject by the multiplied operations for ovarian disease, is d 
not evident that the danger of a traumatic injury, 'per se, of the perito- 
neum has been enormously exaggerated ? Is it not also true, on the 
other hand, that the mortality resulting from these operations has gradu- 
ally lessened with the additional care taken by the surgeon to prevent 
the retention of blood or other septicsemic materials in contact with the 
peritoneum? 
With these preliminary considerations we now feel prepared to advo- 
cate the doctrine that the frightful mortality of penetrating wounds ot 
the abdomen, and the rapidity with which the fatal result is brought 
about, point directly and immediately to septicaemia or blood-poisoning’ 
as the only condition at all adequate to the production of such effects? 
and that the blood-poisoning is the almost necessary consequence of the 
plan of treatment recommended by standard authorities and carried out 
in daily practice. 
If the intestines protrude and are found to be wounded, we are advised 
to cleanse, stitch, and return them into the cavity; otherwise the case 19 
to be trusted to nature, and perhaps treated by antiphlogistics with a 
view to prevent or to subdue peritoneal inflammation. In the mean- 
time the blood necessarily effused, whether much or little, is left in con- 
tact with the peritoneum, rapidly undergoes putrefactive decomposition? 
and is as promptly absorbed. Magendie long since demonstrated the 
wonderful celerity with which agents were carried into the circulation 
through the serous membranes. But if the system may be contaminated 
by the retention of blood alone in contact with the peritoneum, wind 
should we not expect from the addition of fecal extravasation. Assuredly 
not inflammation, but most rapid septicsemic poisoning. In view of the 
rapidity with which toxic agents reach the circulation through the perl' 
toneum and other serous membranes, we may safely infer that the fecid 
poisoning begins very soon after the extravasation, and that it must have 
much to do with the rapid prostration so uniformly observed in such cases? 
and usually attributed to nervous shock. 
The awful fatality of penetrating wounds of the abdomen revealed by 
statistical observations wrould seem to indicate the necessity for a chang6 
of practice, and I have accordingly been teaching for a number of yearS 
to the classes of the Medical College of Georgia the propriety of looking 
upon septicaemia as the paramount danger of such wounds, and of takm£ 
such steps as would be best calculated to avert this poisoning. The 
recent occurrence of several fatal cases in my neighborhood prompts m® 
now to a more formal appeal to the profession for a reconsideration 0 
the principles by which we have been governed in such cases, and to sag' 
gest that in all instances of penetrating wounds of the abdomen, in whicll 
there may be any suspicion of the existence of effusion of blood or teces 
into the peritoneal cavity, the surgeon should proceed immediately aS 
follows: 
(1) Induce anaesthesia. 
(2) Lay open the abdomen along the linea alba, freely enough to make 
a thorough inspection of the parts contained. 
(3) Ligate all bleeding vessels as far as possible. 
(4) Examine carefully the whole length of the alimentary canal,111 
order to detect any wounds, and to stitch them. If the intestinal wou» 
be ragged, it should be trimmed down to a straight edge. ? 
(5) In gunshot wounds reduce the channels of entrance as well as ° 
exit through the abdominal walls to the form of incised wounds, so tha PENETRATING WOUNDS OF ABDOMEN. 
633 
• ese may be closed and left to adhere by first intention. In some cases 
may be found necessary for this purpose to remove the uneven track by 
double elliptic incision. 
w) Cleanse the wounds and peritoneum of all extraneous materials, 
1 *d close the abdominal walls with suitable sutures and adhesive 
plasters. 
(p Finally, control the peristaltic action with opium, and administer 
Ucb nourishment as will leave least fecal residuum, as milk, eggs, etc. 
supplementary to these suggestions it may not be out of place to 
d- that for anaesthesia I would prefer ether, as being less enervating 
jj safer than chloroform ; and that, for stitching the intestines, animal 
matures of catgut or violin-strings, wet with an antiseptic solution, 
Bl>ould be preferred. 
dhese principles have been most successfully carried out by the writer 
ud others incases in which the wounded intestines have protruded; and 
<| et We have allowed other cases to die simply because the abdominal 
vFUl]d, has not been sufficiently large to permit the bowels to come into 
the practice now suggested be considered harsh and hazardous, I 
(j ° ask what can be worse than the authorized plan, which makes 
eam the rule and recovery the rarest exception? Is it not time that we 
l°uld discard as groundless the fears heretofore entertained with regard 
•° tbe danger of opening the abdominal cavity ? change of practice 
the class of wounds under consideration can make the chances of 
Gcovery less than they are now ; and I feel confident that by adopting 
]<r plan proposed we would so alter the results as to make recovery the 
1 e and death the exception. 634 
. ON OPENING THE SAC IN HERNIOTOMY. 
BY 
FREDERICK HYDE, M.D., 
OF CORTLAND, NEW YORK. 
Both Pare and Franco, when performing Herniotomy, avoided opep' 
ing the hernial sac when its contents could be reduced without its dip1' 
sion. Their practice, however, continued to be exceptional until Peth’ 
in cases of large and adherent hernia, left the sac entire, and till Key an® 
Preiss adopted the method as a rule in all cases. It has been held by 
some surgeons that Sir Astley Cooper’s plan was to leave the sa° 
unopened in all cases. We think it will be found, from his records 
observations, that the examples in which he practised and advised leW 
ing the sac entire, were such, in the main, as he termed, “old large mp' 
tures.” In his Lectures on the Principles and Practice of Surge O’ 
edited by Frederick Tyrrell, will be found, in his terse description 0 
the operation of incising the stricture in the inguinal form of the dlS' 
ease, all the details of opening the sac to the extent of “ freely exposUk 
its contents.” He says, “if the stricture be seated in the neck of the bet' 
nial sac itself, of course the division of the part exterior to it will n® 
relieve the strangulation ; in this case, the sac must be opened carefulo 
at the upper part, only so as to allow a division of the stricture.” R 
also alludes to the advantage of “ dilating the stricture without cutting 
the sac itself, as it exempts the intestine from all danger of injury fr0®1 
the edge of the knife.” He advises, too, that the sac should not h6 
divided higher than an inch below the abdominal ring, as its divis10 
near the abdomen makes the wound more difficult to close, and exposp8 
the patient to greater danger from peritoneal inflammation. In b|s 
description of the operation for femoral hernia, Sir Astley concludes b}s 
directions for opening the sac in these words: “ We should further divid® 
the anterior part of the sac upwards and downwards.” In strangulate 
umbilical hernia, he says that the peritoneal covering should be cut int°’ 
and divided in the same way as when operating for other hernise. . * 
very large umbilical hernise, when strangulated, the umbilical openl®*? 
should be dilated upwards without dividing the sac.” . 
From this brief reference to the doctrines and practice of this eniin® 
surgeon on the question at issue, it will be seen that he generally ope®® 
the sac, and that while he expressed the belief, at least on one occasi®1 ’ 
that herniotomy without its division might become the more success! 
and general operation,yet through his long and distinguished profession® 
life, it was with him an exceptional rather than a general practice. 
Petit’s operation, called the minor operation, was adopted by K®/ \ 
its most extended application. In discussing its merits, he says that i 
the majority of cases, in which patients die after this mode of operatic®’ 
the death is caused by peritoneal inflammation consequent upon t1 
exposure of an inflamed or strangulated portion of bowel. He says, toe? 
that it is not so much the wound in the peritoneal sac that disposes 
inflammation, as the exposure of the bowel to conditions to which it b®a OPENING THE SAC IN HERNIOTOMY. 
j1 berto been unaccustomed. He also affirms that the inflammation fol- 
p 'vuig the operation for hernia spreads from that part of the bowel that 
as been strangulated, and does not have its origin from the incision of 
e gac, even if there are two wounds inflicted upon it, one to expose its 
r ri^eQts, and another, higher up, to cut the stricture. Sir William Law- 
llce dissents from the opinion of Key, that recorded eases are “ so largely 
'UBecl by the operation of exposing the intestine, and its attendant expo- 
r.e to air and light, change of temperature, and handling,” and says that 
g|.lß the presence of the stricture which affects the parts, not like the 
, violence of the operation for a few minutes only, but uninterrupt- 
Uly for hours, and sometimes days, disturbing the circulation, making 
1 lr*ipression on the intestine as if it had been tied with a string, and 
Retimes causing ulceration of the internal tunics, or of the bowel in its 
r b°le thickness. Here, then, is the chief issue between Key and Law- 
£eQce; the former objecting to opening the sac, not so much from the 
ar °f wounding it, as of the exposure of its contents to new circum- 
latfICes—as a^r aRd light, change of temperature and manipulation—the 
I®l' fearing the effects of the stricture, acting continuously for a longer 
£ Sorter period, with efforts at taxis, and not the exposure of the con- 
uts of a divided sac for a few moments; and declaring that under all 
ICI he is still disposed to continue the practice of opening the 
believing it to be the most safe. 
r uke, who advocates Petit’s, or the minor operation, in describing it, 
. rs to the different sites and textures in which the stricture may be; 
Ves some rules to govern the diagnosis, admitting that the girding of 
e parts may be found, in the inguinal hernia of the male, at any point 
°m the internal abdominal ring to the scrotum ; and adds, finally, with 
Sai'd to the necessity of opening the sac, when the stricture is caused 
ds thick and indurated neck, that, instead of a complete opening, only 
iv)6 ex^eiaor tissues of the thickened, hardened neck should be incised ; 
*en> be asserts, the neck of the sac is so far dilatable that the anterior 
Pessure of the hernial contents will allow their return by the taxis, and 
is that, case ie efforts are not successful, this partial division 
0 fie renewed, when by repetition of the process the strangulation may 
Relieved without entire opening of the sac. 
o after having divided the covering down to the sac, directs 
a at d should be “ cut into, and the opening of the sac increased upwards 
o lci outwards throughout its entire length.” He also says that the mode 
operating in which the hernial sac is not opened at all, but only the 
j on?dml ring dilated, so as to return the hernial sac together with the 
estiue, is in general to be rejected, and that the not opening of the 
tl)8 +IS-t° most especially confined to those cases in which it is certain 
r a,t a recen% produced, or extraordinarily large rupture, or in a 
8 Yentirely adhering to the neck of the sac, the strangulation is 
Uio>8( ie abdominal ring. Twenty-five years ago, Skey, in describ- 
s] * operation of herniotomy, used these words; “By proceeding 
t °wly through the various coverings, we reach the sac of the peri- 
. fteuna. Sometimes the sac is drawn so tightly over the contents as to 
lo ai'ated from them with difficulty. We select for this purpose the 
a V\ei* part, which is usually somewhat distended by gravitating fluid, 
eclV 18re maJ be opened without danger,” In the fourth American 
for 1011 -b,erSusson’s Practical Surgery, in the account of the operation 
all inguinal hernia, it is directed that, after having divided 
be overlying tissues, so as to lay bare the outer surface of the sac, 636 
HYDE, 
“ a small aperture should be cautiously made in this membrane, 
should then be more fully laid open.” Fergusson also says that, “1 
large protrusions, it would unquestionably be highly desirable to retu 
the contents without exposing the peritoneal surface. In the majority 
of such cases the stricture may be divided without penetrating the sflC’ 
but in some instances, even after this has been done, the protrusion 
not be returned in consequence of adhesions.” 
Prof. Gibson, in the sixth edition of his “ Surgery” describes the map 
ner of opening the sac as u an important part of the operation of hern1' 
otomy.” He refers to the operation of dividing the stricture outside p 
the sac, with his objections, and directs that the sac should be opened 111 
inguinal, femoral, and umbilical herniae. Miller, in discussing the ql|e9J 
tion of opening the sac, says, “ were it applied indiscriminately, nothmc 
could well be conceived more pernicious.” In the operation for 
hernia, he says, “usually the opening cannot be avoided.” In Erich sen ‘ 
description of the general operation of herniotomy, he says, “thesatb 
having been exposed, must be carefully opened towards its anterior as' 
pect, and if it be a small one, at its lower part.” When operating m 
the inguinal form, he says, “ if it be found after the division of the 
that the stricture has been removed, and the hernia can be reduced, 
would, of course, be unnecessary to lay open the sac, and the safety 0 
the patient will be considerably enhanced, and particularly if the opprft' 
tion is performed for an old scrotal hernia of large size, by not doip» 
so. . . . If, however,” he adds, “ as will happen in the majority of W 
stances, in inguinal hernia, it be found that the stricture is in the npp 
of the sac itself, it must be carefully opened.” In concluding his de' 
scription of the more common operation for femoral hernia, he sayß' 
“ When the sac has been reached, it must be carefully opened.” In 
bilical hernia, the stricture should, if possible, be divided without op6o' 
ing the sac. He further says that the operation without opening 
sac may be practised in all forms of hernia, but is much more readiy 
done in some varieties of the disease than others. It is especially apP“ 
cable in cases of femoral hernia, in which the stricture is commonly ou,' 
side the sac. In inguinal hernia, it is not so easy to perform Petitb 
operation; indeed in the majority of cases, the surgeon will fail to reiu°ve 
the stricture in this way. 
Thomas Bryant says; “ When the hernia cannot be reduced withm* 
opening the sac, the whole must necessarily be explored.” It will b 
thus seen that the question of opening or not opening the sac, turns upo1* 
the necessities of the individual case. After some arguments agalllS 
opening the sac, he adduces some statistics in favor of the minor operation’ 
but adds that it must be remembered that, as a rule, the cases in which th 
sac was not opened were of a more favorable kind than those in whm 
it was opened. In describing his plan of operating to cut the strictm6 
outside the sac, he says that if no indications of reduction show them- 
selves, or if part of the contents of the sac have disappeared, but n° 
with the characteristic jerk, or if some portion has been left behind, tb 
sac must be opened. “In all operations for femoral hernia, the reduc 
tion of the hernia without opening the sac should be preferred, and m 
recent herniae this minor operation is generally successful. Should 1 
fail, and the sac have to be opened, no harm can possibly have beeU 
caused by the proceeding, for the incision can readily be enlarged if 
cessary, the sac opened, and its neck divided.” In describing the pr° 
cedures of herniotomy, Gross directs how to recognize the sac, and the*1 OPENING THE SAC IN HERNIOTOMY. 
637 
js s’ “An opening just large enough to admit the point of the director 
no;v made, when, the instrument being carried upwards and then 
Wnwards, the sac is divided to the required extent.” Referring to the 
Sa Vaatages and disadvantages of division of the stricture without the 
j ■> he concludes in these words: “It would not be proper in the exist- 
-Biik* S^at'e °f our knowledge to pronounce a decisive judgment upon a 
fo Ject of so much importance as this unquestionably is ; we must wait 
further data, and in the mean time adopt the rule to lay open the 
hernial sac whenever there is any reasonable doubt in regard to 
e Slte of the stricture. Having divided all the fascial layers down to 
*n Amoral hernia, it may happen that the stricture is seated 
till -i the sac, particularly if the hernia be large and old, and, when 
efR 18 oase, the sac must of course be laid open, its division being 
in the same manner as in inguinal hernia.” 
i’a' Hilton writes: “The sac being fairly exposed, a small fold may be 
j. at its most depending point, and an opening made large enough 
jy produce a director, and upon this the incision may be enlarged.” 
forVlSlon of the stricture outside of the sac, if practised, should be reserved 
an ieXcePti°nal cases. In femoral hernia, the sac being reached, opened, 
jj the contents examined, then follows the treatment of the stricture.” 
oj>. adds that division of the stricture outside of the sac is probably more 
eu applicable to femoral hernia than to either of the forms of the in- 
ln lnal variety. “In umbilical hernia,” he says, “when it has been 
s ,c,essary to open the sac, the result has generally been fatal. It is advi- 
tn . 6’ therefore, always to attempt the reduction by division of the stric- 
re outside of the sac.” 
<ur object thus far has been to place, side by side, the opinions and 
°f the eminent surgeons to whose names we have referred, with- 
re a recapitulation of the arguments by which their conclusions are 
ed upon the questions at issue. The external operation has been 
It fle ie profession, at least since its earnest espousal by Petit, in 1718. 
Wl° strong advocates in Monro, Key, Luke, and some others, but 
Jy • llQt occupied the attention of surgeons generally until near 1833. 
0r jS thoroughly tested, but for a considerable period it has been more 
tha 688 Ull(ter consideration by surgeons in all countries. It is now more 
jU1,1. \ century and a half since it became a favorite operation with some 
tised • SurSeOII8> an(l t’°r the last thirty or forty years it has been prac- 
®tat Britain, on the continent of Europe, and in the United 
Uu tta,s the minor operation acquired for itself that reputation as 
la^e^ mode of treatment for strangulation which its earliest or 
vn- 8tl’ong advocates predicted for it ? 
Uoll e that it will be found that a majority of surgeons who advise 
the o^eu*ng of the sac, reserve certain conditions as incompatible with 
operation, and admit that in those cases division ot the sac is 
WlVely re(lllired. Then, again, believing the case one favorable to 
tion Sac entire, but finding as the operation progresses that reduc- 
A-moCann0t accomphshed, they finally resort to cutting the sac. 
t0 rr ~J» aH the surgeons who prefer the minor operation, we do not call 
ture 11 • on? who denies the necessity for opening the sac when the stric- 
In ef,18^s hi the latter structure. 
favhhe statistics on this question, in which the results appear more 
1 Hole for the non-opening of the sac, it is conceded that the cases 638 
HYDE, 
were of a more promising character for either mode of procedure; tbl ’ 
we think, raises the question, whether the conditions of a case wb10 
entitle the minor operation to be preferred, can be recognized before t 
operation. While some of the average conditions of strictured ingu 
and femoral hernias may be pretty well determined before exposure 
the interior textures, the writer’s experience compels him to say 
more of the important relations of the structures, as well as their pal° 
logical conditions, cannot be so well known while in this occult sta 
If a century and a half, or more, of well-directed surgical acumen ba 
determined the fixed, uniform, pathological conditions in the dise*1, 
under review, then could our diagnosis enable us much better to 
when a strictured protrusion could be successfully reduced with its s‘ 
intact. The majority of examples of hernia, it is true, embrace prllT1? 
rily only definite anatomical structures; but from the first day of lbe 
history their relations are liable to change, and, with these, occur fatl 
tional aberrations and structural alterations. The age of the patie 
how far the disease is congenital or acquired ; whether it is indebted 1 
any way, and if so how far, to strictly traumatic causes; the site ot 1 
rupture ; the contents of the protrusion ; the distance it has gone ft’o . 
its normal home and the direction taken; the volume of the mass; aCC } 
dents to which it may have been subjected ; the varying of the sac ft'o 
extreme tenuity and pliancy to great thickening and induration; 1 
range of contiguous relations to either or both its surfaces ; the more 
less frequent transit of the contents through the abdominal apertures 
either direction ; and occasionally the permanent extra-abdominal sft13 
tion—are some of the circumstances which will, to more or less exteV ’ 
influence the case when strangulation exists, bearing directly upon,1c 
treatment, both by the taxis and herniotomy, and which will deterrn 
largely the results of the latter. The history of all forms of herfo 
made up of varying conditions which we believe must contribute 
pathological changes, and aid in individualizing cases to an extent 
entitle each and every one to its own consideration. • 
These are some of the reasons why the operator cannot predict p° 
tively what are the morbid changes in a given case of the disease, as t°] 
as these are hidden from his vision. With his increased facilities 1 
observation he is all the more certain of disappointment if he expects ■ 
find marked sameness in the pathological appearances in a number , 
examples of either of the leading forms of the disease, but more especis j 
of inguinal hernia. What surgeon, before he commences the operati 
of herniotomy, is quite willing to specify what will be the depart1*1 ,g 
from normal anatomy, either in tissue or relation, until disclosed by 1 
incisions? While he is positive enough concerning the presence of so 
of the conditions, he is obliged to admit that he is doubtful of 0 
and these are most likely to be the important factors in the res a 
These ever-varying phases, sure to be present to a greater or less deg* 
in a great majority of the examples in every variety of hernia, are ne 
to be ignored, but carefully analyzed and considered, whatever treating 
is chosen ; and until we can make our diagnosis more satisfactory^0 e 
ing the interior state of the sac and its contents, including their 1 
condition and relation, we shall be compelled to accept the major ®Pe jj 
tion instead of leaving the sac unopened. It will be conceded by 
authorities, we think, that no part of a hernial tumor or swelling 
such high importance as the contents of the sac, and that these, more t ‘ 
all others, are the textures both primarily and secondarily impoll OPENING THE SAC IN HERNIOTOMY. 
639 
j. len strictured. These are the parts which our treatment seeks to re- 
• as early as possible when in this state. The taxis having failed, the 
b ming point or points are found and divided. Has this been done out- 
e ai'd the protrusion returned, with or without manipulation, it may 
WeH, it may be otherwise. This will depend wholly upon the fitness 
not of the returned parts to occupy their original place in the abdo- 
®n. How is this to be known? It may be said, because the hernia was 
nuced so readily after the stricture was relieved. Hoes it follow certainly, 
°ni this ready return of the mass into the abdomen, that it was free from 
that would not permit it to remain there safely, or that it might 
yn this returned state prove more serious to the patient than if allowed 
q P ace outside the abdomen after the stricture had been divided ? Our 
s-"n observation has taught us that the readiness with which the protru- 
°u is reduced after the minor operation is by no means reliable proof that 
j e returned parts are in fit condition to allow recovery, as proved by 
spection after death. Hut what does it mean when all stricturing tis- 
r I(rs exterior to the sac have been severed, and the hernia cannot be 
juiced? \\re know no way to answer this inquiry but to open the sac 
q1(: expose its contents, when, if there be any form of internal binding, 
lxiay be readily reached and overcome, and reduction accomplished or 
|-0b as the state of the strangulated parts may warrant. In the opera- 
Q°n ot herniotomy, when the sac is made bare, how far will the vision 
1 fictile ability of the surgeon enable him to say what is the real state 
j, . elation of its contained textures? We answer for ourselves that 
• 18 scarcely more than inferred, and when we have succeeded in reduc- 
es an inguinal or femoral hernia in this way, our solicitude remains at 
jJ*l pitch until sufficient time has‘elapsed to prove that all signs of 
ranguiation are well over. 
hat are the objections to opening the sac? Perhaps the one most 
urged is, that it increases the liability to inflammation in the 
and its extension along the peritoneal tissue. Allowing that this 
Uire is readily inflamed from slight causes, we cannot see as a rule how 
as6 ?auSei'8 incident to a small incised wound in the sac should be as great 
th‘ o*86 incurred by returning the bowel in its average condition, in 
\8 kind of cases. In the minor operation, provided there be no other 
trri^Ured point beyond that outside of the sac, how readily are the pro- 
piled parts restored to the abdomen? Granting the usual proportion 
q e^aniples of adhesions of the sac more or less to structures extra-ab- 
-8 and that the contents are in a state to move freely within the 
teM len we think that the manipulations requisite for reduction having 
to i llla(^e through the walls of the sac, the whole depending upon the 
'*h, are so much embarrassed that much greater risk ot injury is in- 
rred than by the wound necessary to bring at once into view the true 
aa e. and relation of the already, it may be, highly sensitive contents, 
i Sain, when we think we succeed well in returning the contents wholly 
e 0 the abdomen, in cases of adherent and hypertrophied sac walls, by 
Jk/'I- Wa^ching, we may well doubt whether there may not be some 
in 1 .1011 intestme not quite within the abdomen. We remember that 
an°!e 0r less exudation has occurred during the period ot strangulation, 
0 taat a fold or process of intestine or mesentery, or even a portion of 
sio*61^1101’ may easily enough, in the midst of the more or less plastic etfu- 
-8o U’ both just below and quite within the upper aperture, and 
ne C^ause ai' incomplete reduction. In these examples much of the ful- 
Ss may disappear, leaving only so much as can well be explained by 640 
HYDE, 
1 
the firm thickened sac, with often a marked feeling of relief so express© 
by the patient, but soon to be followed by an exacerbation of the syflff' 
toms of strangulation. Under most circumstances, our choice would b 
to accept the risk of an incised wound in the hernial sac, rather than t°° 
long trial of the taxis before the coverings have been divided, or its aP' 
plication in the average state of cases after the stricture has been ©u. 
without dividing the sac. We cannot see how a wound in the hern10, 
sac is likely to be followed by more inflammation, or any more sen°u, 
results, than a wound of the same tissue in any other place, beyond wha 
would be inevitable from the already morbid state of the within and 
jacent structures. When we call to mind how rare an event it has be©11’ 
in the clinical history of the operation in question, that incising 
hernial sac has added to the inflammation, or contributed in any possm1' 
way to the untoward results of the case, we declare our conviction tba 
in a large majority of examples of inguinal and femoral strangulatm11’ 
the major operation is the safest. We put the question to all surgeollS’ 
whether their cases of herniotomy which have been fatal, have not be©n 
so from morbid changes already present before the division of the saC 
and stricture ? ~ 
Another objection to this operation of opening the sac is, that 1 
exposes the contents to accession of air and light, with change of temp®' 
rature, suddenly creating new relations which cannot be tolerated. ’ . 
cannot understand why the peril should be any more by the exposure fi1 
this operation than in others in which a much larger portion of the pell 
toneal surface, with a far greater amount of visceral texture, is sudden1) 
brought in contact with the atmosphere, as amply illustrated in t 
operation of ovariotomy, and other constantly occurring examples 0 
traumatic lesion of the abdominal textures. We believe that in a 
majority of instances, neither the liability of adding an increase 0 
inflammation by opening the sac, nor that of multiplying dangers by fb 
exposure to the air and light for a few moments, of the interior 
will add as much to the dangers as the untoward manner of applyll1/' 
the taxis with the sac-wall entire, together with the great liability 1 
unfitness of the contents for a safe restoration. If it be said that t1 
views inculcated in this paper are at variance with a commendable spir 
of surgical conservatism, then we affirm our belief that it is a much m° 
conserving practice to expose by a wrell made incision the real state a? 
relations of the suffering tissues, by which every subsequent step * 
relief can be aided by direct vision, than to adopt a procedure win© 
must be mainly directed without the aid of the surgeon’s eye, and ©olll 
monly, if it effect reduction, requiring a more protracted tactile lab | 
and always involving the risks of unrelieved strictures, and too oft©11 
structures returned to the abdomen, which should have been left oU^sl 0f 
The writer, restricting himself to only the authentic clinical histon©8 , 
a considerabl}T large number of cases, with their results, in which bo ■ 
non-opening and opening the sac tvere practised, and to the patholog1 
facts furnished by autopsies in a majority of the fatal cases, ©a 
truthfully arrive at any other opinion than the one already express© • 
It must be admitted that there are many surgeons whose opinions ‘ 
entitled to the highest respect, who would not adopt the major operat1 
as exclusively as we have indicated. The writer regrets to say that 
has met with more hindrance than he had anticipated in obtaining It? 
surgical practitioners their individual experience upon the respec 1 
merits of the operations in question. It is the honest difference of sen OPENING THE SAC IN HERNIOTOMY. 
641 
among surgeons which has chiefly led the writer to call attention to 
licrf Very important practical question, so that if he cannot reflect new 
upon his theme, other surgeons may be induced to make a more 
declaration of the results of their experience upon this important 
t|mject through the legitimate channels of communicating professional 
■pi 
i: I'orn what has been said, we conclude— 
That the examples in which the minor operation is most successful 
'L,le but slightly removed from a condition permitting reduction by 
taxis, and that the length of time during which strangulation has 
fisted is not of itself the true measure of the condition of the strictured 
t <li‘ts, these often presenting more morbid changes when strangulated hut 
hours, than in other instances of days’ duration. 
0 iT. That cases which furnish the most favorable results from the minor 
Peration, are also the most promising for opening the sac. 
Til. That there are many cases of strangulation in which the stricture 
amiot be relieved without division of the sac. 
That our means of diagnosis are insufficient to enable us to say, 
1 a vast number of cases, whether the strictured parts are in a suitable 
°iidition to be returned to the abdomen while the sac is entire. 
;• That a due regard to the credit of herniotomy, when every variety 
Uiguinal and femoral strangulation is included, requires that the 
laJ°r operation should be adopted in a large majority of patients in this 
t0 edition. 
vl. That opening the sac in strangulated umbilical hernia is not to 
o^Practised if reduction of the protrusion can be accomplished with- 642 
SOME COMMENTS ON THE HISTORY OF NITROUS OXIDE GAS 
AS AN ANAESTHETIC, AND ON THE ANALGESIC 
EFFECTS OF RAPID BREATHING. 
BY 
ADDESTELL HEWSOET, M.D., 
SURGEON TO THE PENNSYLVANIA HOSPITAL, PHILADELPHIA. 
It would seem impossible that a suggestion of such a practical cb*11' 
acter, of such immense value to mankind, and made by such authority’ 
as that proposed by Davy of using inhalations of a gas to destroy p**j11 
in surgical operations, should go absolutely unheeded for nearly hah 
century, and yet such was really the case; for Sir Humphry Davy, 
publication, in 1800, of “ Researches, Chemical and Physical, chicjv 
concerning Nitrous Oxide and its Inspirations,” suggested from inbat 
tions of that gas made by himself and others that “ as nitrous oxide 
its extensive operations appears capable of destroying physical pain,/ 
may probably be used with advantage during surgical operations 1 
which no great effusion of blood takes place.” This suggestion n 
never recalled or condemned during his subsequent brilliant career,wwe,he, 
everything emanating from his fertile brain was sought after and to 
lowed with avidity and zeal. There was no pretext of want of desire i 
such a means; the practice was almost universal of resorting to fj1 
effects of alcohol and opiates to deaden and as far as possible destroy P1 __ 
sensibility to pain during operations. The evil effects of the latter pra 
tice were also fully recognized, and yet, as I have said, this proposal 0 
Davy was absolutely allowed to go unheeded and to become 
for, when Dr. Horace Wells, a dentist of Hartford, Connecticut, in ’ 
thought of using nitrous oxide gas in extracting teeth, no one was tn 
ready to condemn it on the ground of previous failures, or because it ba 
been proposed so long before. , 
Wells’s idea would seem to have arisen in his own mind on witness]11- 
an effect of the inhalation at a public exhibition given by a travel! 
lecturer. On this occasion, one of the persons to whom the gas had be 
administered, whilst under its influence, struck his foot, and on recode1 
ing his consciousness it was discovered, by Wells’s inquiries, that he hf' 
sustained a severe bruise without being aware of it from any pain atA 
time. This fact led Wells to the inference that the gas could prod11 
insensibility to pain, and he determined to test this by having a toe _ 
extracted while under its influence. The lecturer was invited to t 
office to administer the gas, and during this administration Well 3 11 
the tooth drawn without experiencing any more pain than is produce 
on a person in a state of perfect consciousness by the prick of a P1 
This result led Wells to pursue the subject further; he tried the effect 
the gas in a number of cases of tooth extraction (about fifteen), but aa 1 
varying success; he then went to Boston and got permission from 
Warren to make a demonstration of the process in tooth-pulling bel( 
the class of the Massachusetts General Hospital. This attempt was cl ANALGESIC EFFECTS OF RAPID BREATHING. 
643 
f |?r failure, and was called “a humbug affair.” Wells went home, 
d his friends that the gas would not operate as he had hoped, “ and 
lolly ceased to experiment from the date of his failure in Boston (in 
eceruber, 1844), until the spring of 1847.”1 
j n the interval between these two periods, complete demonstration 
P been made by Morton, his former partner in dentistry, of the power 
( the vapor of ether to produce the desired insensibility. Morton had 
0 doubt had his zeal to discover some such agent excited by Wells’s 
b'evious successes; he would appear to have been impressed with the 
tiea that these were essentially the effects of imagination on the part of 
jle Patient, for on September 80, 1846, he went to the laboratory of Dr. 
<l°kson, whom he knew well, having been a student under him and re- 
ren% in his house, and took from a closet an India rubber gas bag. In 
ePly to an inquiry of that gentleman, he said in substance “ that he 
pleant to fill the bag with air, and by its aid extract the tooth of a re- 
J'ftetory patient.” A conversation ensued upon the effects of the imagi- 
‘djoii and, among other things, of nitrous oxide, in producing insen- 
J Jlhty.2 Jackson treated Morton’s proposition lightly ; he told him to 
f° an apothecary and procure sulphuric ether—the stronger the better 
Wvl‘ich would produce the insensibility he desired. The ether was to 
x.e spattered on a handkerchief and inhaled; in a moment or two per- 
insensibility would be produced. “Sulphuric ether,” said Morton 
y° S°es Jackson’s account), “ what is that; is it a gas ? Show it to me.” 
ftckson said he showed him some ether, and, after further conversation, 
y‘°rton went to procure it.3 Morton and his friends subsequently 
aimed that his expressed ignorance of ether at this interview was 
Pere|y assumed, to prevent Jackson from setting up any claim to parti- 
*PA ion in his own search for painless dentistry. He showed by the 
of Dr. Gould and of Messrs. Weightman and Metcalf, that he 
'as before this time a dentist who was experimenting upon the relief of 
ofln *n dootal operations, and that he was familiar with the properties 
ether. Hot only so, but by subsequent.experiments he proved that to 
0 certain and safe which may have been thought by others previously 
0 be a possibility. 
Morton possessed traits of character essential for success: he was ear- 
and persevering beyond conception, as we are told by Professor 
]gelow, who was personally acquainted with him, a participator in 
ainy of the steps in the early progress of the discovery, and who did 
| iUc‘h to bring it before the medical public of this country and of Europe, 
c assert its real value, and to point out the best methods of utilizing it.4 
f ?rt°u possessed these traits to an extent evidently far greater than his 
°imer partner, Wells, for,as I have before stated, the latter, disheartened 
‘ j discouraged by his failure at the Massachusetts General Hospital, 
his investigations and searches “for more promising enter- 
itises.” When Morton had got sufficient confidence by his trials with 
Jr161'? be went, like his partner, Wells, to the Massachusetts General 
in October, 1846, and made a demonstration there of his pro- 
tvSs- This demonstration was an eminently successful one. AVithin 
v° Weeks the whole world was ringing with wonder at the discovery. 
a 0; Bigelow’s History of the Discovery of Modern Anaesthesia, American Journ. of Med. 
C2B"ces. Jan. 1876. 
4 loc. cit., p. 171. 3 Ibid. 
jross, Century of American Medicine, Am, Journ. of Med. Sciences, April, 1876. 644 
HEWSOJST, 
By many its possibility was denied; by others it was ridiculed; J1) 
others its claim to originality was attempted to be ignored ; and, final!)’ 
it was preached against from the pulpit, as I heard myself, as being? |,n 
one of its proposed applications, viz., to midwifery, an attempt to del) 
the orderings of the Almighty. 
Morton, at once, on his first success at the hospital, seeing in the tmn» 
a source of great profit, wrote to Wells statingthat he was about sending 
out agents to dispose of the right to use his discovery, and ottered h 
an agency on shares. Wells, in his answer to this letter, says, “If t*l 
operation of administering the gas is not attended with too much trouble 
and will produce the effect you state, it will undoubtedly be a fortun6 
to you, provided it is rightly managed.”1 Here the question may vd’) 
naturally arise: Have we not in this answer of Wells a clue to the 
causes of his abandoning his searches after anaesthesia ? The admin19' 
tration of nitrous oxide was “ attended with too much trouble,” and be 
had not rightly managed it to make it “a fortune” to himself; for nlll 
(the medical) profession must not in judging of the conduct of 
members of another (the dental) profession overlook the fact that th° 
latter consideration can be entertained by them and not by us. To 
former consideration, that of “ too much trouble,” had no doubt alw»)9 
been in the way of using nitrous oxide, from the day of Humphl’) 
Davy’s proposal to that of Wells’s abandonment of the idea. It ,aS 
indeed an obstacle to the general use of ether, at first, for then it was 
supposed that it could not be confided to any but an experienced admin19' 
trator for whose service an extra charge had to be made. 
Morton’s demonstration that the secret of success with ether lay in W 
full quantity of the vapor used was slow in being recognized, an 
the dread of fatal asphyxia was so predominant in the minds of fh 
majority of practitioners, that for many years after the introduction 0_ 
anaesthesia the fact of its being unsuited to a large number of cases (othd 
than those of heart and lung disease) was considered to be beyond a* 
question. The partial recognition of this secret with ether, led man) 
(and possibly Wells amongst them) to the idea that the failures n-itn 
nitrous oxide had been from the insufficiency of the amount used. Th 
“traditional exhilarating gas bag and Davy’s exhilarating dose w°l6 
what had heretofore been used, and they were inadequate to product 
anaesthesia with any certainty.”2 The first demonstration of this filC 
was in a breast excision performed by Prof. Bigelow at the Massach11' 
setts General Hospital, in April, 1848, by means of about sixty gallons o 
gas.3 
This, however, did not give nitrous oxide its true position as & 9°' 
called anaesthetic agent, as for years afterwards it was ignored entire!); 
This may have been from the enthusiasm which existed for ether an 
chloroform (for the latter was proposed by Prof. Simpson, of Edinburgll* 
in 1840), and yet the “ too much trouble” in its administration s0 
undoubtedly exerted an influence against nitrous oxide. It was in fa° 
nearly nineteen years from the time of Wells’s first experiment until 
Q. Colton, the same lecturer who had administered the gas to Wells 011 
that occasion, recognizing its real value and that the secret of its sue 
cess lay in an abundant use of it, secured the aid of a competent extra0 
tor of teeth and then made it known as a safe and popular agent 1,1 
1 See Morton’s letter of Oct. 19, and Wells’s answer of Oct. 20, 1846. 
2 Bigelow, loc. cit. 3 Ibid., p. 168. ANALGESIC EFFECTS OF RAPID BREATHING. 
645 
Painless dentistry.1 Before that time dentists advertised frequently “to 
‘‘ voCt ee^l im(^er ether,” or “to administer sulphuric ether,” or 
Chloroform,” but no one thought of or used nitrous oxide. It was 
“ not to be as successful as ether “ not to be a safe agent;” “to 
More troublesome;” but since Colton’s successes we have “nitrous 
N I(*e gag administered” advertised on a host of dentists’ windows, and 
g *°®e dentists who do not administer it themselves, do not hesitate to 
n“ their patients to establishments gotten up exclusively for that 
I*l pose-—many of them designated as “ Colton Institutes” in recognition 
o what Colton did to popularize the matter. More than this, since 
the surgical profession has recognized the advantage of the use of 
roiis oxide gas over ether in a great variety of the minor operations of 
■ urgery, notwithstanding the inconvenience from so much trouble in its 
‘.c Ministration. Hosts of surgeons have experienced the annoyances and 
Conveniences of using ether or chloroform in their office practice, from 
r.e w post prandial” effects of those agents, and recognizing the absence 
.Sach with nitrous oxide gas, have since then availed themselves with 
qP ity of the proximity to their own offices of a “ Colton Institute,” or 
c an administrator of nitrous oxide gas, to employ the gas in many 
dlSes of ophthalmic surgery or of operations of short duration which 
could perform in their offices without detriment or inconvenience 
0 their patients, provided that they could do them in a painless way. 
4 confess myself to have been a full participator in this feeling, and 
p this was from no want of appreciation of the value of ether or chloro- 
-01 all who have known me have always been aware of my being a 
loßt enthusiastic friend to these agents, and especially to ether. I was 
the use of ether in Philadelphia. He was at that time the honored 
Resident of our most venerable medical society; he had held that posi- 
-011 for over twelve years, and was over seventy-three years of age, and 
PV.be was a most zealous student, always ready to adopt any measure 
b fl^l held out a prospect of alleviation to the suffering of his patients ; 
'd he was also possessed with the prudence and caution common to such 
rn Vanced years, and of this I had the full advantage in hearing his corn- 
ents after each clinic, and his discussions with his friends at home, 
wf been educated in England before Davy’s proposal was made, 
a en the practice of resorting to intoxication by alcohol and opium, as 
8] preliminary to major operations, was very common, and he was not 
Pj°'v at the time to which I have referred to perceive the relations of 
Mse with ether and chloroform in the cyanosed or carbonized state of 
j jfi blood produced by them ; and he considered the state caused by the 
al iTataon of ether as one of greater inebriation than that produced by 
u c°h°h He therefore argued that the vapor of the former should be 
‘plied persistently until that extreme state was brought about, but not 
abundantly or exclusively as to induce a state of asphyxia, 
hel iU?k a view then (my father died in 1848) was far in advance of that 
e j by the practitioners of that day. The cyanosing of, or retention of 
UiV°n^C blood, was then looked upon as an accidental and 
an ortUnate circumstance in a case, and I therefore refer to his view as 
evidence of the advanced schooling I had on the subject. My zeal for 
use of anaesthesia whilst a student on one occasion subjected me to what 
ds Meant to be a severe censure before a class of fellow students. It 
1 See Thomas’s Manual on Nitrous Oxide, p. 17. 646 
HEWSON, 
was on the occasion of prolonged efforts of over two hours to reduce a diß' 
located hip-joint at the clinic of one of our most conservative institution8’ 
and when whiskey and laudanum had been most freely used; several °r 
the class, myself amongst them, had been asked to lend a hand at the 
pulleys, and we had all failed. I, on failing, said sotto voce, to the surgeon* 
“Doctor, why don’t you give him ether?” And he turned round in 
most excited manner to the class of nearly two hundred students, antl 
exclaimed, “Gentlemen, one of your number asks me why I won’t giv® 
this man ether? I would as soon cut his throat.” Within twelve hour9 
after this, the ether was given to the man, and his hip reduced, appa' 
rently in a moment of time ; but I, as an interloper, was there amongst11 
few to witness the result. 
For the past twenty-four years, as a hospital surgeon in Philadelphia 
(at the Hospital of the Protestant Episcopal Church, at Wills Hospital 
and at the Pennsylvania Hospital), I have never lost an opportunity 
using anaesthetics, and no one can, therefore, even insinuate that I haVe 
been wanting in appreciation of their value. In private practice I ha're 
used freely ether, chloroform, nitrous oxide gas, and local anaesthesia (hy 
the atomizer, and by ice and salt and kindred articles), and yet I am h’ee 
to confesses I said before, that I have longed for some easier method,01 
some method free from after annoyances, with which I could save uff 
patients, especially in minor operations or physical explorations, fr°n* 
pain. It is, therefore, very certain that I most gladly availed myselt °r 
Dr. Wm. G. A. Bonwill’s first suggestion to me that simple rapid respl' 
ration would produce insensibility to pain, if prolonged for from three t° 
five minutes, and carried on in as rapid a manner as possible during that 
short space of time. I tried it first in a case of necrosed femur, whet0 
there was a state of great hypersesthesia, and where I was particularly 
desirous of avoiding the production of pain; and when (in my office) 4 
did not want to resort to ether or the like. Here I had most perfect 
success, using the probe freely with the sounding-board appended to d* 
and still causing my patient not a particle of suffering. I repeated tbe 
experiments with like cases in the wards of the Pennsylvania Hospital 
then tried the procedure in other minor cases, but not always with tbe 
satisfactory results that I obtained in the first of them ; the failures* 
however, were not such as to deter me from the further pursuit of the 
subject. 
My former experiences, with the first attempts at anaesthesia wit*1 
ether, were such as not to suffer me to become disheartened here. Wb° 
is there, who went through the early history of ether, who cannot recall* 
as I before intimated, the many failures to produce complete insensibility 
with that agent then, which would not be suffered to occur at the 
present day? It was then a novelty, and those who used it were ign°' 
rant of all the essentials for its invariable success.- Such I felt was the 
case with my experience with rapid respiration; I had a good deal to 
learn even in what looked like a very simple affair, and seemed to 
require no experience or even judgment in its use. My first attempt to 
demonstrate its value before the class at the Pennsylvania Hospitu 
showed this very clearly. I then had brought into the clinic room tw° 
boys for explorations with the probe, on whom I had tried the process 
in the ward with most satisfactory results. The first one of these was 
remarked by me at tbe time before the class as “ a bright little fell°'v* 
who looked at me very cheerfully on that day, and in this respect was 
very different from what he had been at the beginning of our interview* ANALGESIC EFFECTS OF RAPID BREATHING. 
647 
,?lYle clays before;” he then had dreaded the probing. He had been before 
c ,e class more than once, and had had on one of those occasions ether 
1, Illlnistered for an exploration by my predecessor, who then uncovered 
e tibia by a free incision, and, demonstrating most clearly its necrotic 
~ate, removed a large portion of it by the chisel and forceps, aided by 
j.le The little fellow, on the occasion of my lecture, espied, as 
e came into the room, the ether bottle and a lot of instruments on a 
ue-table, and nothing could induce him to believe that it was not my 
I urpose to deceive him, and to perform some operation with the instru- 
ments when he should become insensible. He, however, started to 
Jleathe rapidly, but kept glancing constantly at the table till I had it 
eruoved out of his sight; but his dread was too predominant; he began 
0 Cry, and finally positively refused at all to breathe with any exertion 
|>l rapidity. I left him and turned to the other boy, who had never been 
l] a clinic before; but he, participating in his companion’s dread, followed 
• 18 example, evidently for the purpose of making a like escape from hav- 
anything done with his case, 
p-ehe reporter of my lecture on this occasion, Hr. T. H. Bradford, one 
the residents of the Pennsylvania Hospital, then volunteered to try 
]e process before the class. “It was his first attempt, and was made 
fitting erect, with his right hand resting upon a table. Breathing 
apidly was attended first with a tingling sensation of the surface, espe- 
Sa% of the fingers, and a feeling as though the surface was all swelling, 
ben (in about three minutes of time from the beginning) there followed 
dizziness or compression in the head, with consciousness well preserved, 
with a feeling of inability to resist, or to act in an independent way.” 
“ad directed this gentleman, before he showed the least sign of loss of 
Ration or consciousness, to raise his left hand as soon as he felt me 
°Uching him on the right. At this point, when he began to become 
he raised the left hand, and, continuing the motion, got to 
Ringing the limb from the shoulder, much to the amusement of the 
£ ass, and so afforded a very positive proof that he was not perfectly 
II m self, In the continuation of his report,1 he says: “He remembered 
ije 1 being frequently asked by [me] the doctor, if he was hurting him, 
llt had no recollection afterwards of the pin sticking him, much less of 
s having been firmly imbedded in his flesh, as he found it when he had 
‘eased the rapid respirations, and the anaesthetic effect had passed off.” 
.he failure with the two boys was clearly the result of emotional 
Xcitenient and want of will on their part; obstacles to success readily 
aticipated in any such attempt, but which do not present themselves 
hi the use of ether, chloroform, or the like, for with them we do 
hesitate to, and can, compel the patient to take the anaesthetic; we 
independent of his will; but such was not considered to be the case 
j those agents when they were first used. It was then thought 
necessary to have co-operation from the patient. I saw many a case in 
we early period of anaesthesia, where the attempt was abandoned for 
, ant ot this. It is not at all possible that we shall ever be so indepen- 
with rapid respiration. Confidence in its success will, however, as 
las done already with me and my patients, diminish the frequency of 
of° i a cause f°r failure; I have profited well from this part of the lesson 
wfoi at the failures then also gave me, by the opportunity 
1 11 my assistant, to see that complete ancesthesia was not to be sought 
1 Medical Times, March 4, 1876. 648 
HEWSON, 
by such a procedure, and likewise, very positively, that it was not essen- 
tial for our purposes, for it must be remembered that I was not in search 
of an anaesthetic agent to supersede those like ether and chloroform, but 
one most convenient to destroy the sensibility to pain, and that alone. 
The destroying of pain merely was certainly more desirable than the 
state of full anaesthesia from ether, with its accompanying loss of m 
consciousness and will. Appreciating this advantage, then, from the 
rapid respiration, I had the opportunity at the following clinic of demon- 
strating it in a most satisfactory manner. During that clinic it W^3 
announced to me that a man was in the receiving ward—had just com6 
in—with, it was supposed by the nurse, a dislocation of his shoulder. 
Without going to make any preliminary examination, I directed him 
be brought before the class. As he came into the clinic room, 1 called the 
attention of the class to his carriage; to the manner in which he sup' 
ported the injured limb at the elbow, by the other hand ; to how he 
leaned forward on that side; and to how the shoulder was depressed 
and the elbow projected away from the body—all affording very good 
grounds for the supposition that his shoulder was dislocated. When he 
was stripped, these appearances were still more marked, and during the 
undressing he seemed in great pain. Then I announced to the class that 
I would proceed to demonstrate the existence or non-existence of disloca- 
tion without inflicting any further pain on the patient, and without 
touching him. I then directed him to breathe rapidly, assuring him that 
it would remove his pains. He did it promptly, and in the usual time 
began to show its effects. I then told him to raise the hand of the injured 
limb and place it on his head. This he did without any signs of suffer- 
ing. Then, whilst he was still urged to keep up the rapid breathing, he 
was directed to place the same hand on the opposite shoulder; then 
dowm by his injured side ; and finally behind his back. All these move- 
ments he made, sluggishly it is true, but with an absence of all indica- 
tions of pain. I, of course, then made free comment on the ad van tag 6 
we could have in all such cases with this mode of destroying pain, over 
that by ether or the like. 
This condition of u insensibility to pain with conservation of intelli- 
gence, of consciousness, and of voluntary movement,” recognized by re- 
cent authors, by the term of Analgesia (from a, privative, and axysw, f 
feel pain), in contradistinction to the loss of all these conditions to be 
designated by the generic term of Anaesthesia, or what I called a feW 
moments ago complete anaesthesia, was shown at the French Academy 
of Sciences, in March, 1872, by M. Guibert, to follow the partial use m 
chloroform inhalations, some time after a hypodermic injection of mor- 
phia ; and he then advocated the state as sufficing for obstetrics aim 
minor surgery. The non-recognition of the occurrence of such a state, 
or the want of appreciation of its value for such purposes, has, I know, 
led many to condemn a resort to rapid respiration ; and then again, many 
perceiving the preservation of intelligence, of consciousness, or of volun- 
tary motion, have condemned the process as incapable of producing 
insensibility to pain. They have evidently not been aware of the J’e' 
searches of Bernard, Guibert, and others in England, as well as in France, 
on this subject. The fortuitous experiment with my assistant, Hr* 
Bradford, as I intimated before, was the first circumstance to open my 
eyes to the value of the distinction. With the use of ether, and the like, 
I was always accustomed to look for perfect insensibility of the conjunc- 
tiva as evidence of my patient being fitted for me to begin any operative ANALGESIC EFFECTS OF RAPID BREATHING. 
649 
j °cedure. With that condition we all know there is always the perfect 
88 o± those mental and voluntary conditions which belong to complete 
(The combination of a previous hypodermic injection of 
. rphia with the aneesthetic, as suggested first by Bernard, holds out no 
c for a resort to such in the cases to which I have been re- 
terrine f 
111 rny earliest trials of insensibility by rapid respiration I had not 
of Guibert’s distinction of the two states. In many of these 
Q object was to avoid suffering in trifling operations—operations 
f rl<% of minor surgery; but, after Dr. Bradford’s trial, I could not re- 
j a!u fi’om seeing its value beyond cases of dislocation, even in really 
, aJ°r operations about the pharynx, on the tonsils, uvula, posterior 
and Eustachian tube, as well as on the tongue and maxillary bones; 
toV'1 Jese anßesthesia from ether and chloroform, when attempted 
.)e used, has always to be abandoned (particularly in the most exten- 
Ve °f them) on account of danger of strangulation from the absence of 
volition by which the patient can expel the blood from the mouth, 
j le mode of effecting insensibility to pain by rapid breathing is also 
s°. af all in our way as we proceed in these operations, which cannot be 
e‘u< when ether is used. In such cases we can, as I know from experi- 
-o|l|lc*e’ also keep up the insensibility produced by rapid breathing to the 
G the operation,even when there are frequent and prolonged inter- 
ruptions from hemorrhage, by urging the patient, immediately after or 
Urnig such, to blow out as rapidly as possible. In some such instances 
ii tave n°ticed the patient, either impressed with the advantages or act- 
e. S Mechanically as some would suppose, carry on this breathing most 
jMuestly until assured there was no further necessity for it. Here we 
pfVe also another advantage: we can always stop the procedure. I 
ave never seen a case in which I could not, and have, therefore, in in- 
aiiees where it became desirable to interrupt the insensibility, always 
**ed it very readily; and this advantage is a very great one even in 
ei> cases than those of operation about the air-passages. Thus, for in- 
r ailcp, us Guibert says, analgesia has advantages for obstetrical cases. I 
t]'m my own experience seen the advantage of this breathing process, 
y .°nly in the insensibility with co-operative action on the part of the 
us hi ordinary labor cases, but also in the facility of terminating it, 
sil]°r distance, in the supervention of flooding where it becomes de- 
y0 remove a]q causes of muscular relaxation, which cannot be 
prlle immediately where other processes of insensibility have been used, 
hmf km°vv that I have been able to save patients’ lives, where I feel," 
, hese special cases, it would have been impossible to do so if they had 
a Under the influence of ether or chloroform. All instrumental labor, 
know, can be carried on with perfect satisfaction under this process. 
yec/° °perations about the uterus, the vagina, the bladder, and the 
fen l\ni’ are a^so disarmed by this process of one of their terrors to the 
thm •’ as fkey cannot be as surely in the case of ether or the like, viz., 
t)/1 °* unnecessary exposure. I have frequently, in the past year, dilated 
it e u^erus by an Atlee’s or Ellinger’s dilator, straightened and replaced 
by exk!ored it by a Simpson’s sound and other means, dilated the vagina 
°f H tl 'Va^ve speculum, and dilated the urethra and rectum, in the former 
. iese last two instances to the extent that I could pass my index finger 
fjn° bladder, and in the latter so that I could pass three or more 
th(TeiS nt° Je kowel, with my patient lying; quietly on her left side (in 
e ol’dinary obstetric position), evidently satisfied that she was not being 650 
HEWS ON, 
exposed, and with friends about her able to assure her that the operate11 
was performed in such a manner. All such operations I have been at*1 
to perform in this way without pain, and many of them are as sevd6 
tests as could be required of the analgesic effect of rapid breathing. 
It has been universally recognized that the relaxation of the sphincter 
is one of the best evidences of anaesthesia, and experienced surgeons eai’y 
taught that it required more thorough etherization for operations 1,1 
these parts than in others on account of their hypersesthetic conditm11' 
Any one who has attempted the rapid dilatation of the urethra—b' 
recently proposed cure for irritability there in females suffering vlt 
many forms of womb trouble, which Professor Charles D. Meigs used 
describe as a pure sphincterismus—can sustain that view. On one day? ,I'l 
February last, I performed this operation most successfully in three <b ■' 
ferent cases, the patients living ten miles apart. In two of them I test*31 
the rapid breathing, and in the other I used no means whatever, _°u 
account of disinclination on the part of the patient, to prevent the palll. 
The former have no recollections of having gone through a severe ope1’1 
tion, and have frequently expressed themselves as being most willing * 
undergo the procedure again should it be required, whereas the last q 
dares that nothing could ever induce her to submit to such pain aga1’1’ 
although the operation gave her the desired relief. 
Amongst my operations for fistula in ano, under this means,! had pll 
case which had been operated on once before by the bistoury, and wm1 
out any anaesthetic. This patient actually laughed when I told him 
operation was done, and at first he was disposed not to believe me. -*■ __ 
his case I used the old-fashioned instrument for the purpose, a SyrinLJ 
tome, one that has been used for this purpose by my ancestors for ovei 1 
hundred years. It is nothing but a steel,sickle-shaped blade, a quadra-11 
of a circle of two and a half inches radius, with a long and very fiexm1’ 
silver probe-end. It renders the operation a very simple and quick j 
performed one. My operation was not through the track of the Torn1 
fistula—it had been well cured—but for one on the other side of the aiP 
orifice, and which seemed like a very much less serious affair than p 
first evidently had been. All these circumstances are worthy of bem» 
noted in a report of this man’s comparison of the two operations. 
my operation he had no pain; in the other, he said, he had had a greil 
deal. 
I could prolong this paper, already sufficiently long for the charac 
of such communications, by entering into details of a variety of paS 
other than those to which I have alluded; but I have certainly 
enough of facts to induce others to give the method a fair trial, and p 
shall have succeeded so far, I shall be perfectly satisfied ; ray purpose 
been to earnestly fix the attention of the profession to this subject, vl 
the conviction on my own part that the plan will prove a desideratum, eV 
with the many means of anaesthesia which we possess.1 It is to be ea,1oJ, 
estly hoped that none will show themselves too ready to condemn 
1 Here I would again most distinctly repudiate all idea or purpose of even proposi 
substitute this for ether or chloroform in major operations (save those about the mFjl 0 
I have used it in some such where it was not convenient or expedient to use either ot 
means, or where, I will confess, it was my object to test this in a severe manner; an g6 
results, as I have mentioned, have been satisfactory, but not such 
as to demand i e 
in the place ot those means which can produce a more thorough insensibility or coi i 
anaesthesia than I have claimed for this. ANALGESIC EFFECTS OF RAPID BREATHING. 
651 
gn°re procesg} as was the case in the early history of ether and chlo- 
ornh from failures in the first attempts, much less from the inability, 
‘ B°rne say, to see any philosophy in it, or, as some have expressed them- 
'es5 from its being too simple a measure not to have been discovered 
.Used with satisfaction before this late date if there had been any 
erit in it. We have seen the full value of such objections in our retro- 
fit of the history of nitrous oxide and of ether, and surely no one at 
?le present day is going to suffer himself to be misguided by want of 
Ca 0r by excessive conservatism in his profession. To prevent the occur- 
JlGe of these, I will now give minutise, as far as my experience will 
°w me, as to the way of bringing about this insensibility to pain, and 
giS° facts I possess towards the modus operandi of the process, or 
2wing any rationale for it. 
g "y1 °perations about the air-passages, I may also say about the face and 
a'Pi as well as about the ear, and even about the eye and its appen- 
ages, the sitting posture is the one to be preferred. This, however, is 
it° ’ according to my experience, the most advantageous one for the 
Uction of the analgesic state by this method. In all instances where 
tiCan, X now aflopt the recumbent posture on one side, as in such a posi- 
(v°ri fbe desired state is I find more promptly induced. To prevent the 
lversion of the patient’s mind from his part in the matter, it is frequently 
eneficial to cover the face by a handkerchief: this may, in some in- 
tff11068, Prove disadvantageous, from the idea the patient may take up 
Jat be is really to be etherized ;in other instances, it may be in that 
service. • 
I, strictly Dr. Bonwill’s directions, I always at first told my 
relents “to breathe as deeply and as rapidly” as they could but study- 
out their cases I was led to see that the rapidity of breathing was 
je most essential part, and that its rate of frequency was unavoidably 
j le expense of depth; a deep or full breath of course requires much 
nger time than one of an opposite character, and it is also essentially 
\ lnspiration; whereas a rapid breath partakes more and more, as it 
.increased in frequency, of the characters of expiration. This is not to 
t| Pondered at; it is clearly due to the difference of circumstances of 
p'° movements. All the circumstances concerned in respiration 
a v.0r the act of expiration. Both the elasticity of the lungs themselves, 
<tbat of the walls of the thoracic cavity, aid the expiratory movement, 
i ley oUbr a corresponding resistance to the inspiratory ; and, 
S]des these, we have also to take into consideration the atmospheric 
e os.SUrn over the surface of the chest which is not only favorable to 
d lotion, but which increases the resistance to inspiration as the 
r b 1 °f the latter is made greater, and, according to Dr. Hutchinson’s 
w^hes,2 this is in an arithmetical progression. These conditions, it 
hi . Beem from Dr. Carpenter’s calculations,3 require a muscular power 
1 ail aclult man to overcome them in an inspiration made to its full 
bio'l 1 .equivalent to “ not less than 1000 lbs.” All which is correspond- 
favorable to an expiration begun at the end of such an inspiration, 
Ui\r Vfn w^ere my patients were progressing well in their efforts, and I 
&ec them “to breathe deeper and faster,” the effort for depth would 
Mart|G\^r’-.ffra(ffr)r(l’s report of my Clinical Lecture, in Philadelphia Medical Times, 
2 V, 4, 1876. 
3 of Anatomy and Physiology, art. Thorax, p. 1056. 
bee Ms Physiology, p. 512. 652 
HEWSON, 
always produce an interruption of rhythm of the velocity, and I the11 
got to urging them “ to breathe faster and deeperthen “ to breathe *l9 
fast” as they could; and, finally, notwithstanding I had had the impo1’' 
tance of the depth of the breathing impressed on my mind, I recur r0( 
to my experiences with ether, chloroform, and other vapor, of 
advantage of urging the patient to blow out, and adopted with gr°at 
satisfaction here the plan of making my patients to expire as fast 
they could. The fact of the very circumstances of a deep inspiration 
making an increase in the power to expire, became then very evident’ 
the patient would always, after blowing as fast as he could several tim°s’ 
be compelled to take a deep inspiration ; here we demonstrated the 
French übesoin de respirer” against which the patient would show hi9 
inability to exert any excess of counteraction, and found a satisfactory 
proof that no effort of the patient’s will could carry the process to n 
point of serious suspension of respiration. These advantages of expiratl0’1 
over inspiration also come into play when we try to have efforts ma°e 
to exaggerate either for any length of time, especially if the patient ha9 
become stupefied by such; he then requires to be constantly urged t° 
go on with the breathing in as fast as possible, whereas, once started f° 
blowing out rapidly, he will continue the blowing when he becoru®9 
stupefied, although not with the same earnestness, yet with the sanlC 
rapidity. From recent conversations with Dr. Bon will, I find that he 
has been led to adopt the same directions to his patients. 
This altering, by an effort of the will on the part of a patient, the 
frequency and character of the respiration in the manner described, h**9 
an effect of course on the frequency of the heart’s action, but this is, *■ 
may say, not directly related to the frequency of breathing, but con’6' 
spends rather with the exertion made by the patient. The force of the 
pulse does, however, here, as with ether, chloroform, etc., furnish evideu® 
of the impression being made on the nervous system, never, howev01’ 
to an extent like that of either of those agents, and to a decided extoll 
only when the utmost impression to be made has been effected. Thl9 
change is one of diminution in the force of the heart, and is essentially 
like that of a natural sleep, but is as much more marked than the latt®1 
as that by chloroform is over that by ether. It never can become exco9' 
sive for the reasons we have given. Bourdon long sincel declared tha 
no one can by any exercise of the will over the breath destroy the heart» 
action. One can therefore continue, without any fear or hesitation; 
urge the patient to keep up this breathing process. It generally requh’®8 
from three to five minutes of constant urging to breathe in this mann01 ’ 
at a rate of from forty to fifty or more inspirations in a minute, to bi’Uk 
about the desired condition. . 
What will strike everybody, I am sure, as remarkable, anticipatnk 
the influence of dread, is, that females always require less time for 
purpose than males, no matter what may be their age relatively. Th°9 
of middle life always require more time than either the young or ageC' 
The very young, those under ten years, are the most difficult to manago’ 
chiefly, I think, through their fear; more time is also, I have alwaj 
noticed, required in a cold clear atmosphere, than in an opposite 011 ’ 
The same class of patients, as a rule, takes five minutes in a cool ro°jq 
of a winter’s day to induce the same state of analgesia which 
need only three of a close summer’s day. All these facts had been ca> 
1 Recherches sur la Mechanisme de la Respiration. ANALGESIC EFFECTS OF RAPID BREATHING. 
653 
1 b7 observed by myself before I had given the rationale of the process 
y serious thought or consideration, 
cl) 16 effect °f this breathing, appreciable to an observer, is a 
anSe in the color of the face; the lips, the cheeks, and the tint of the 
‘ Ce, at first brightened, generally become pallid, then leaden or bluish; 
‘ o with these latter changes the expression is altered and wanting in 
P Ration. If the eyes are open, they have a vacant look, and their lids 
to droop; the patient assumes the look of one much overcome by 
tlgue, and then of one on the verge of an ordinary sleep. Then often 
niSUes, especially in an hysterical young girl, a state of very positive 
Uscular rigidity ; before this however ensues, the state of analgesia has 
brought about, and is indicated by want of recognition of the 
t of pins or the like, for the patient will always feel the abrupt 
j lltact of obtuse bodies—even the touch of your hand—but will not 
ri^v experience any pain even from a bistoury or scalpel. The state of 
a§|c%, which I have just referred to, resembles much that of catalepsy, 
acT *8 frequently noticeable in cases where anesthetics are being 
ho The power to move is embarrassed by this; the will, 
\v<T?Ver, w°uld seem to have persisted, as the patients tell you after- 
bdl S)- and may even show you during this state, by their efforts without 
a V to follow your directions in moving or suffering you to move 
0 lrxib. This rigidity of the muscular system is by no means of constant 
cj cUrrence, is often very slight and transient, and gives way. It is 
fo b’om the semi-asphyxiated state induced by the patient’s breathing, 
, * 0,1 ceasing to urge on him the rapid rate, he relapses into a quiet, 
p rnial rate, and so, soon allowing his blood to recover from its intensely 
to . e ue’ be comes out of this state, and gradually recovers his ability 
aPpreciate and remember the contact of foreign bodies and to move 
from them. 
thill16 subjective phenomena of this process are, as far as they go, essen- 
J> bke those from nitrous oxide, ether, and even chloroform. There 
or ■ swimming or confusion in the head, and the loss of perfect 
si clCufe consciousness, attended with a sensation of tingling and disten- 
th le sul’t’ace—this latter beginningat the sentient extremities, and 
geiG la,1(l8 especially, and passing upwards, and closely following these 
l)a| comes the condition of analgesia, absence of appreciation of 
I’ei bnpressions on those sentient nerves. It is, as I have before 
of arked, to be particularly noticed that there is in this state the want 
8e abPreciati°n of ordinarily painful impressions, and in this respect we 
t}j , . resemblance most marked to nitrous oxide ;it will be remembered 
0p Yyjt was this effect of the laughing gas which attracted the attention 
Witl 6^S’ be ®bowed that the analgesia may be there most perfect, 
fio concurrence of the state of anaesthesia, although the distinc- 
pb U between the two states was not then known. These same subjective 
chillorriena,as I have intimated, occur in the administration ot ether and 
8000l? but they occur then in such rapid succession, and are so 
tben Showed by a profounder impression on the cerebral centre, that 
Uilj16 ?le 110 rec°bections of them afterwards, and this was more gene- 
ts ' tbecase in the early history of the use of anaesthetics than it is now, 
tic/1 - 0 that there is not the care taken now to secure a free dilu- 
°Mbe vapor by atmospheric air that there was then ; the anaesthetic 
ter-e 18 n°w hastened on as rapidly as possible by the mode of adminis- 
Ibe vapor, by giving it as undiluted as possible. In the 
uuistration of nitrous oxide, as originally proposed by Sir 11. Davy, 654 
HEWSON, 
the air expired into the hag at the close of each breath is charged 
carbonic acid and carbonic oxide gases, and, as the nitrous oxide becom6' 
exhausted from the bag,these same gases are breathed in and breath6* 
over, again and again ; and how much, it may be asked, does the insen 
bility from this administration depend upon these very gases of expil' 
air ? Who indeed, on careful consideration of the prodromes ot a 
anaesthetics, will not he disposed to attribute those very prodromes 1 
the same physiological conditions? All modern anaesthetics, so can6 J 
owe their property to their mode of impressing the nervous system, al\ 
that essentially through the respiratory organs, intoxicating the bltyV 
and this acting secondarily through the circulating organs by which d 1 
conveyed to the nerve centres. The prodromes in all of them are nd>9 
marvellously alike in their individual features as well as in their or(‘e 
of succession. 
Ether and chloroform are hydro-carbons, so called, and their vap°r * 
not only furnish those elements proportional to the specific gravity 0 
said vapors, but so relatively cut off the supply of oxygen by wldc 
those same elements, hydrogen and carbon, already in, are to he elan 
rated from, the venous blood of the lungs. Before they even impregna ,• 
the blood of the lungs, they thus arrest or interfere with its means 
purification, and this they do clearly by cutting off the oxygen of atn^9 
pheric air, for the moment you let that air in a state of purity ta* 
their place, you have that elaboration resumed, and, more than that, y° 
have all the abnormal impressions on the brain made to disappear, h 
the patient, however, breathe an impure air, one charged with so-cad 
carbonic acid gas, for instance, and the difficulty of breathing continn6 ’ 
and with it all the phenomena now recognized as belonging to the a 
phyxiated state show themselves in regular succession, 
however, as Felix Leblanc has shown, more especially to the quantity u 
carbonic oxide so thrown into the circulating fluid of the brain and spin3 
marrow from the lungs by way of the heart, thus affecting essentia 
the blood corpuscles and making them inert; nay more, they are then 
longer, as Bernard has shown, carriers or capable of being carriers 
oxygen, the great vivifying as well as purifying element of the fresh a^j. 
In 1854, Mons. Chenot1 gave a chemical explanation of this action 
the oxide of carbon on the system. He there admits two consequent 
of the action of the gas ; he says when it penetrates the blood by 
lungs, it takes the oxygen of the blood and passes into carbonic acid ga J 
and secondly it produces an exaltation of temperature which results d 1 
sort of inflammation of all the organs and tissues. But M. Chenot; , 
Bernard remarks, is a metallurgist, and his theory is purely a 
one, Bernard had, prior to the date of Chenot’s communication? 
fact as early as 1842, observed that animals, asphyxiated by the oX' 
of carbon, had their venous blood made red like arterial blood, a , 
Troja had observed .this same thing before Bernard. The last-nan1 
authority, Claude Bernard, and we have no better on the subject, insll 
upon this change of color of the blood, the peculiar reddening ot . 
blood corpuscles, and a reduction of the temperature, as pathognonio 
effects of carbonic oxide, as contrasted with those of carbonic acidity 
cation of the blood, where on the contrary the color of the blood is b 
and the temperature increased. The haemoglobin which constitutes 
1 Chenot, Note sur I’Oxide de Carbon, Comptes Eendus de I’Academic des ScieuC 
t. xxxviii. p. 735 et seq. ANALGESIC EFFECTS OF RAPID BREATHING. 
655 
? ol'\ng substance of the blood corpuscles, plays in them a purely 
erLieal part, and we are no longer allowed to believe that the cor- 
t soles act mechanically, dissolving the oxygen; on the contrary, we 
<ve the best proof that this substance (haemoglobin) forms a true 
with the oxygen. Furthermore we now know that this 
p )stßnee will combine likewise with other gases. The distinguished 
r?\an physiological chemist, Hoppe-Seyler, has studied such crystalline 
filiations of it with carbonic oxide, nitrous oxide, bromide of nitro- 
Glb the vapors of ether, chloroform, and the like, as well as those with 
Jxgeii; and has shown that they can all displace the oxygen in its 
When we have ether used, it has been proved to act in 
v,ls.Way likewise, and as promptly whether the haemoglobin has been 
eviously in combination with oxygen, carbonic acid, or carbonic oxide 
***. , The combination of hsernoglobin with oxygen is less stable than 
Jat. with carbonic oxide, and the latter less so than that with bromide 
otmti-°gen. ■ 
Pense of its oxygen, are, Bernard remarks,1 attended by symptoms 
in their character, and the first with them all is loss of sensi- 
tii i is so marked where carbonic oxide is the combining agent, 
ol f Glabriel Tourdes,2 of Strasbourg, has compared its action to that of 
°i'otorm and proposed it as an amesthetic agent. Speaking of this 
P*°Posal of Mons. Tourdes, Bernard says “it is true that carbonic oxide 
11 lje an anaesthetic, but in this way carbonic acid can also be one. But 
(pm Word anaesthetic, thus generalized, could be applied to a crowd of 
t f rent articles.” “ Indeed,” he adds, “ hemorrhage is thus an anaes- 
j- et3c’ since its first effect is to destroy sensibility. But I believe,” he 
Aether says, “we ought to reserve the name for substances which pro- 
anaesthesia without causing any great danger to existence.”3 In 
8 study of asphyxia from the fumes of charcoal, this same eminent 
. Perinientalist (Bernard), besides pointing out the phenomena character- 
] ffie action of carbonic oxide and carbonic acid, has shown that the 
is pl' *8 destruction of the blood corpuscles as the former is, that it 
] lsplaced in them bj7 oxygen, and that the last-named gas converts the 
°r w^e corpuscles into red corpuscles, in the lungs, by this very 
th 1011 haemoglobin to which we have been referring. By means of 
0 ? spectroscope, Bernard has been able to follow the action of carbonic 
Se lc e in all its stages, and has shown that it is only when the blood 
wf1118 ?ornpietely imbued by this gas that death takes place, and that, 
(j if is gradually introduced, it produces an anaemic state by this 
o Blftion of the corpuscles being more rapid than their removal by the 
3gen of the air through the lungs. Death occurs from the damage 
Wfile directly to the heart. Death from carbonic acid can ensue only 
the supply of oxygen has been entirely cut oft’, 
th f Such facts before us, we can have no difficulty in recognizing 
ad agents which produce insensibility to pain, when applied through 
CQe V}ll^8’ a<d essentially as before declared in the same way ; and though 
stat? eto ana3Sthesia is not a state of asphyxia, we can see how the two 
m lnay occur together; how the latter, occurring in attempts to in- 
ie former, may bring about a fatal result ; and how the former, 
lled to an extreme point of saturation, may in itself cause death. We 
Cinquikme LeQon 
°P- cit. p. 420. 
2 Gazette M6dicale de Strasbourg, 1857. 656 
HEWSOJST, 
have also no difficulty in comprehending how the state of analgesia aj' 
ways occurs from all these agents 'prior to any interference by them vvn] 
reflex actions. 
There is therefore no impropriety in turning our attention to the moCl, 
in which rapid breathing can bring about this state of analgesia, although 
the process is an extreme novelty. From what.l have related as to tfl) 
own experiences of the facilities for inducing this state, it would see'11 
that it is not a condition produced by increasing the essential respiratory 
function, viz., that of introducing oxygen into the blood and 
carbonic acid from it. The position in which I have found the patieo 
most readily to be affected, that of reclining and resting on one side 0 
the chest, and the best manner for him to breathe, that by exaggeration 
his efforts at expiration, are against such an idea. These rather imitat® 
the conditions consequent on a pleurisy or pneumonia, where we have a 
diminution of the oxidation and of the decarbonization of the bloom 
and where we have, to sustain this analogy, not only a diminution 111 
the depth of the inspirations, but an abnormal increase in their relate6 
frequency over that of the pulse, as likewise the peculiar buccal expiration? 
so marked in them, and which the patient readily lapses into when vre 
urge him on in his rapid breathing. Starting out to blow fast, each 
spiration gets less and less in depth, and the patient while increasing 1}) 
his will that part of the action called supracostal, and which is so chat' 
acteristic of woman’s breathing, involuntarily diminishes that of tn 
lower part of the chest. The greater familiarity of females with tn 
essentials of this mode of breathing no doubt, in part at least, will ex- 
plain their greater facility in being inducted into the state of analgeSia 
by the process. 
We have also as evidence against any increase properly of the respip1' 
tory function occurring, that the blood is positively cyanosed. This lS 
not only readily appreciated in the patient’s hue of surface, but can ah 
ways, according to my experience, be detected in the venous hue of fb 
blood which may escape in operations under this state, and also in tha 
of a new-born child when the process has been used in the birth. In a 
instances where I have been able to test the point, I have likewise de' 
tected a positive reduction of temperature occurring in patients wbds 
in this analgesic state. 
Again, we have the most definite proof that increase of frequency 0 
respiration positively diminishes the amount of carbonic acid thrown 
out. Thus Yierodt1 found that, if he respired only six times in a rainll^6’ 
the quantity of carbonic acid was 5.5 per cent, of the whole air exhalery 
with twelve respirations, it was 4.2 ; with twenty-four, it was 3.2; xvd 1 
forty-eight, it was 3.0, and with ninety-six, it was 2,6 per cent.2 , 
cording to experiments of Letellier, quoted by Kirkes,3 about 100 p® 
cent, more of carbonic acid is exhaled by warm-blooded animals at u 
than at 104° Fahr., and, if we take the mean results of Crawford an 
Lavoisier, it may be found by an easy calculation that 20 per cent. m°r 
of oxygen is consumed at 50° than at 82° Fahr. Such facts as these ten 
very clearly to explain the difference I have noticed, as stated before, 
temperature and humidity as favoring the induction of this state on tn 
idea that it is rather from a diminution in the respiratory function, a cU 
1 Physiologie des Athmens, p. 102. 2 Carpenter’s Physiology, p. 524. 
3 Physiology, p. 135. ANALGESIC EFFECTS OF RAPID BREATHING. 
657 
Jlng off of the normal supply of oxygen and retaining the carbonic acid in 
ol°°d to be sent to the nerve centres, 
-Lhe variations which have been noted by numerous observers in the 
of carbonic acid by the lungs as produced by age, sex, devel- 
opment of states of repose, sleep, and watchfulness, likewise eor- 
tfspond with the effects of those considerations whenever I have noted 
Tllem in my cases. 
hvery circumstance would therefore seem to indicate that this process 
lnducing insensibility to pain is one essentially of diminished oxida- 
i’0'1 and decarbonization of the blood, and recognizing such a state as 
elonging to the initiation stage of all anaesthetics, when insensibility to 
Vr'ln is positively marked, we have no necessity for begging airy special 
le°ry for this process, as in its action it readily comes under the eate- 
ry °f such agents, and is thus not either an absurdity or an impossibility 
0111 a scientific point of view. 658 
OBSERVATIONS ON THE TEMPERATURE OF 
OSTEOSARCOMA. 
BY 
PROF. J. A. ESTLAKDER, 
Among the many different species in the great group of diseases ca^eC 
tumors, the sarcoma has always attracted special attention. During 
time that it was considered a form of cancer, it differed from the otm, 
forms of this disease by its appearance in younger persons, and, since 1 
has received its'present name, it has continued to make itself conspicue1 
by its not very rare occurrence, the rapidity of its growth, and particulaßf 
by the most awful speed with which it often destroys the organism. 
history is therefore comparatively well elaborated, but, in the systems 0 
surgery which 1 have had occasion* to consult, I have not found MR 
attention paid to one of its symptoms which seems to me to be very 
stant, and to offer a considerable interest on account of its being 1,1 
mately connected with the nature of the growth ; I refer to the high teM 
perature which it shows when it has attained a certain size, and is rapm j 
increasing. The following accounts of some cases will furnish a m°‘ 
complete description of this symptom. 
OF HELSINGFORS, FINLAND. 
Case I.—Matilda Holm, a workingman’s wife, 28 years old, had always ell 
joyed good health until towards the end other last pregnancy, when she beg‘ 
to feel pain in her right hip when walking. Three months previous to her adn3 
sion she was confined, and afterwards this pain became very severe, and, bll 
weeks prior to her entering the hospital, she began to feel a continuous M 3 
intense aching which she sometimes felt down to the knee and foot, 
the same time she also observed a swelling around the crista ilii, and vfc 
troubled with a sensation alternately of heat and cold in the bod}7. In ot ’ j 
respects her state of health was normal. When the pain by degrees increa 
more and more, she sought and obtained admittance at the Surgical Climh 
on Feb. 20, 1813. 
At the time of her admission, her condition was as follows : Body well bn* ’ 
strong, and not lean ; the internal organs normal. Around the whole cllS 
ilii on the right side, as well towards the inside of the belly as 
large immobile tumor with lobnlated surface, solid consistency, but indistm 
limits. The skin over the tumor was free, movable, and not tight, but A. 
versed by large subcutaneous veins. The tumor itself, but not the surround'\ a 
parts, very tender to the touch. Crista ilii, not only the parts covered by 
tumor, but also the parts adjacent to it, easily permeable to the 
needle. A thermometer placed on the tumor and covered with cotton 8 '.°^ie 
37.8° centigrade, while the same instrument on the corresponding place 
left side, and on the inner side of the thigh, shows only 36.8°, and in the aS-1 
37.2°, a result which reiterated measurings on the following days showe 
be constant. r<lS 
As there could naturally be no question of any operation, the treatment' 
only symptomatic. The tumor increased rapidly, and the patient’s streiir 
sank in the same proportion. On May 11, the right leg and foot began 
get oedematous, and shortly afterwards also the other. May 24, a severe c u TEMPERATURE OF OSTEOSARCOMA. 
659 
Hu, a aPPeare6, and the patient died on the 28th of the same month. On post- 
Sac'.tem examination5 the sarcoma was found to extend backwards to the os 
il- Uu», and downwards to a little below Poupart’s ligament. Half of the 
M.«.|ln-as destroyed, and the rest rarefied and friable; metastatic nodules 
be jf ;°und in tlle lun»s and kidneys. The microscope showed the growth to 
q r°und-celled sarcoma, 
bef ASE 11—Erland Engstrdm, a farmer’s son, 19 years old, had two years 
tlie01'6-’ noticed a small knob, hard as bone, on the right tibia somewhere about 
f0„ In the succeeding spring it was as large as a hen’s egg, and the 
o-roOVVin§ Christmas as large as a man’s fist, but after that time it began to 
L* lllore rapidly, and moreover began to be painful. The movements of the 
thy ere.not much impaired, for on May 11, 1815, the day he was received at 
Surgical Clinique, he had walked a distance of nearly seven English miles. 
in 11 bis admission, the following was his condition : The patient, otherwise 
eou°.lnPle*'e health, had on his right leg a tumor with lobulated surface, and a 
le B,stency at some places more soft, at others more solid. The tumor ex- 
-ocedededed from within an inch below the patella, close to the ankle-joint, and 
,n "P,ed nearly the whole circumference of the leg, in such a way that it was 
WhL,d.e7eloPed 111I11 fronti ancl behind had pressed the muscles f rom the bone to 
fi eU it was solidly attached. Prom above downwards it measured twenty- 
Se Centimetres, from before backwards eighteen, and the circumference was 
,Tl( enty-five. The skin was very highly distended, but everywhere free and 
cedo^0, rl'he mobility in the ankle-joint considerably diminished, the foot 
blaeinat°US, t*ie inSu'nai glands on this side slightly swollen. A thermometer 
of °n tumor showed 31.2° centigrade, but on the corresponding part 
Wdle left leg’ 
or on the thigh, only 36°. Reiterated observations on the fol- 
lng days gave nearly the same results. 
u,i May 21, I amputated the thigh, and the patient left the hospital on 
gust 16, with the swelling of the inguinal glands considerably diminished. 
sat-**6 Umor consisted of a compound mixture of osteoma, enchondroraa, and 
c°tUa, with here and there some small cysts. These three tissues were 
])( erally so distributed that the first was in connection with and close to the 
ai the third more on the surface, and the second, which showed an exquisite 
f0 oar structure, seemed to follow no rule, and had probably in the beginning 
the whole substance of the tumor. The muscles of the leg, in form of 
T,1 y distended thick fasciae, covered the surface of the growth. 
y„ Hi.—Johan Kujola, a farmer’s son, 32 years old, had noticed about two 
hist S that his right knee began to swell and get stiff, and. as during the 
ln°nths this swelling had rapidly increased, he applied and was admitted 
16 Surgical Clinique on Feb. 22, 18*76. 
I'atl Pat^eilt’s condition at that time was as follows: His constitution was 
j0- *ei' —eak, but all the internal organs were healthy. Over the right knee- 
ls ' 0,1 the anterior and inner side, was a tumor closely connected with the 
hac|0’as large a,s a child’s head, and with no well-defined limits. In front it 
bon a l°bulated surface, but on the inner side was covered with a lamella of 
Wa§0 80 thin that it broke into two pieces, on the first examination. The tumor 
neit I>ulSating, but the circumference of the bone, together with the tumor, could 
tha lGl* Manual compression nor by Esmarch’s bandage be reduced more 
I>estr'al1>estr'al)°U*' one centimetre. The movements of the knee, although somewhat 
fleeted, were not accompanied with any pain, and there was no collection of 
B*oll Ul 10 i°int* I’bo glands beneath Poupart’s ligament were somewhat 
88 go011, I'be thermometer on the same day showed 39° centigrade in the axilla, 
tlie 011 Ibe tumor, and 37° on the corresponding part of the other thigh ; and 
da}b in the axilla 38°, on the tumor 38°, and on the corresponding 
of the other thigh 36.5°. _ & 
sa 8 H’ere could be no doubt of the diagnosis of strongly vascularized osteo- 
-ollla, a»d as the swollen glands could easily have been extirpated, I pro- 660 
ESTLANDER, 
posed amputation of the thigh, but the patient refused to submit to the ope'a 
tion, and left the hospital on March 3. 
Case IY.—Fredrika Petterson, a sailot’s widow, 60 years old, had seVep 
or eight years before noticed, on the front side of the right leg, a small kn° 
which wai immovably fixed to the bones. As she felt no inconvenie* 
she paid no attention to this growth until last September, when it bega11 
pain her. She then went to a physician, who found the tumor as large as 
small apple, with a scarcely perceptible swelling of the inguinal'glands. 
Feb. 10, of this year, she came to the Surgical Polyclinique, and as I f°ull 
the size of the tumor as last mentioned, but the glands considerably 1110 
swollen, I proposed to extirpate both. The patient did not consent, but rvke. 
the tumor shortly afterwards increased with great rapidity, the skin ulcerate ’ 
and the pains became much worse, she returned and was admitted to the h°s 
pital on May 11, 1876. f 
On her entrance, she presented a tumor firmly attached to the front pal'*' 
the right tibia, as large as a child’s head; its consistence was soft, and at <‘el 
tain points nearly fluctuating. The skin over the base of the tumor was tig‘y 
stretched, and had on the top begun to ulcerate. Beneath Poupart’s 
ment there was a solid tumour as large as an egg, and, around, several I}1*1 
phatic glands considerably swollen. The thermometer on the tumor con staid 
showed 38.1° ; on the corresponding part of the other leg 37° ; and in the a*1 
37-1° centigrade. g 
As I supposed that the tibia was so much involved that an extirpation 
no longer advisable, on the 15th of the same month I performed Gritti’s exa1 
dilation at the knee-joint, and, besides, extirpation of the inguinal glands; j 
when I left home, on August 14, the patient was ready to leave the hospb‘l. 
By examination of the tumor 1 found it to be a spindle-celled sarcoma wm 
had destroyed the front part of the bone and entered into the medullary cam 
Between the skin and the glands there was no trace of suppuration. 
Case V.—Anders Makiavtitala, farmer, thirty-nine years old, had when 
child of two years been burnt by hot water on the right side of the front 
of the chest. At the age of twenty and some years, the cicatrix began to gl° . 
out in the form of a red knob, which increased so slowly that by last 
it had only attained the size of a walnut. From that time onward it had bc£ 
to grow more rapidly, and, after the top of it had sloughed off, the pat'e 
had repeatedly had bleedings from it. 
On his admission, on June 21, 1876, the state of the patient was as foll°vV 
He was strongly built and well fed. The entire right pectoral region was °c° 
pied by a cylindric tumor, nine and a half centimetres high; its sides Ye 
covered with a distended, red, and thin skin, and its top formed an ulcer 
teen centimetres in diameter. The tumor was movable and not connected 'v , 
the pectoral muscle, and felt at some points very soft, at others more so 
No swollen glands were to be found either in the axilla or the supraclavic*11 Y 
region. A thermometer on the ulceration at the top of the tumor Q 
38.8° centigrade; on the corresponding part of the left side of the chest, 3 | 
and in the axilla, 38.7°. After extirpation, on June 23, the tumor was f°Ujy. 
to be a round-celled sarcoma. By means of skin-grafting the wound was neal 
healed when I left home on August 14. 
The temperature was measured in the following manner: The T 
silver bulb of the thermometer was fastened to the skin with strip8 £ 
sticking-plaster, and afterwards the instrument and the whole part 
the body covered with a thick layer of cotton. This manner of ‘0 
suring could not, of course, pretend to be very exact, if the question . e 
to ascertain the absolute temperature of any part of the body, but as 
sole question here is about the difference between two parts measured 
the same instrument and in the same manner, the result ought to be v 
nearly true. The above related records show, then, that the ternperatd TEMPERATURE OF OSTEOSARCOMA. 
661 
j rapidly-increasing sarcoma is commonly one and often one and a 
a : degrees of Celsius’s scale, higher than that of the corresponding 
0n the other side of the body. 
a high temperature in the tumor might, perhaps, be supposed to be 
, ymptom of inflammation in the distended skin, but Case Y., where 
1)]!° S^'lu to a large extent had ulcerated away and the thermometer was 
t aced on this spot, showed that it depended on the tumor itself, and in 
0 ther cases, if there had been any inflammation in the skin, there 
P Sllt to have been perceived, somewhere under it, an abscess; which, 
°Wever, was not the case with any of the patients, although special atten- 
°o was paid to this point. 
• tbe above-described cases show that all the tumors were rapidly 
Creasing, and, as it may generally be considered a rule that a tumor 
in the same proportion the more arterial blood the more rapidly 
grows, it might, therefore, be supposed that the high temperature in 
fese eases depended only on their rich supply of blood, particularly 
llCe the case of pulsating tumor presented the highest temperature 
s*°ag. them. Without wishing to deny the importance of the arterial 
°°d in this respect, I think we can, perhaps, show the probable pre- 
G,'ce of yet another source of this temperature. When we consider that 
Jen the best thermometers always show the temperature several tenths 
a degree lower than it really is, and when we add this difference to 
c 10 resulting temperature found with the tumors, we get as result a sum 
°nsiderably higher than the temperature of the arterial blood. This 
.ut lorizes the conclusion that this surplus is produced in the tumor 
f? and that thus the high temperature of a sarcoma is the effect not only 
0 richness in bloodvessels, but likewise of the active processes going 
gll 111 the elements of its tissues. It may be that this demonstration, as 
JTported only by a few observations, has not much more value than a 
r°n.Jnion hypothesis; but at all events it explains the relation between the 
‘T'd growth of the tumor and its high temperature more completely than 
c 1(i Presence of a great quantity of arterial blood does. A teleangiectasis 
Retains relatively more arterial blood than any other tumor, and never- 
SpBB it sometimes disappears by itself. 
tf / following the most recent opinions, consider the fungus hsema- 
)(di Case 111. (which was not operated upon) as a sarcoma and not as 
°aucer, then all thenarrated cases have that feature in common that 
were all sarcomatous growths, for even the tumor in Case 11. con- 
-1 Tl}ed this form of growth, although the greater part consisted ot carti- 
and osseous tissue. But naturally this is not yet a proof that 
s / fde round, or spindle, or giant-cells possess this peculiarity, tor the 
evc°nd of the reported cases seemingly leads to hint that on the contrary 
I I'fe cartilaginous tissue has the same; and it seems probable that it 
j 0,1g8 to every tumor whose elements are capable of a rapid increase in 
Of1' development. 
Pp *aU the different parts of surgery which, during the last decade, have 
'eu the object of scientific investigations, perhaps none has been so 
J- eat]y developed and changed as that which deals with tumors. For at 
ijqll6B- it consisted only of a confusion of special observations, but 
ino-V,lt *S a weh-arranged field, where every growth, no matter how vary- 
Us form may be, has its given place. But this change tor the better 
igostly regards their patho-anatomical structure, tor their clinical history 
Co frptty nearly the same as before. I hope, therefore, that this small 
in the latter respect will not be entirely wanting in interest. 662 
ON STONE IN THE BLADDER IN FINLAND, 
BY 
PROF. J. A. ESTLANDER, 
To facilitate the explanation of the peculiar conditions, with respeH 
to stone in the bladder, w'hich exist in my native country, Finland, * 
will divide all cases of this disease with respect to their etiology i®t<? 
two groups. The first where there is no disease in the urinary, orgalls, 
and the stone seems to be of constitutional origin, and the second wl>el’e 
the calculus clearly depends on a local disorder. When cases of sto»0 
belonging to the first group frequently occur in one country, and are, 011 
the other hand, very rare or altogether wanting in another country» 
then the endemic causes are clearly perceptible. But when the calculi 
originates in diseases of the kidneys or in the many causes which p1’0' 
vent the bladder from completely emptying its contents—as for install6 
paresis of the muscles of the bladder, or obstruction of any kind in tbe 
urethra, etc.—then the question arises, in what relation do these caso3 
stand to the general endemic causes? Are they absolutely independen 
of them or not? For my part lam inclined to answer this question to 
a certain extent in the negative. It is true that the rich or so-call 
upper classes of the different countries all over the world live pretty 
nearly in the same manner, and are precisely by their manner of living 
on one side more exposed to calculus, and on the other side more ino!o' 
pendent of the endemic causes of the disorder, than the lower class03' 
But still, as the influence of climate, water, temperature, etc., is nevd 
completely to be avoided, the rich must, at least to a certain degree, b0 
subject to the same epidemic laws as the other classes of the population- 
If I then suppose a country where no endemic causes of stone in tbe 
bladder exist, there we should, as a general rule, entirely miss all tbo 
cases of constitutional origin, and find the cases of local origin princi- 
pally amongst the upper classes, and that less frequently than elsewhei’0- 
This is just the case with Finland. _ , 
Some statistical figures, collected from the Case Book of the SurgicjJ 
Clinique, at the University of Finland, for the last forty-four years, wd 
show the truth of this in respect to the first group of calculous caso3' 
During this time of nearly half a century, only one case has presented 
itself, that being in a farmer of forty-one years, whom, in 1868,1 operate0 
upon for a phosphatic stone in the bladder. This isolated fact is the 
more remarkable, as several such operations have been performed in tbo 
Clinique, but the patients always belonged to the Russian nation, parti- 
cularly from the province of Jaroslaw. As Finland, with a populatin’1’ 
on December 81, 1875, of 1,829,919, has a surface of not less than 67“ 
Swedish square miles (Lapland included), and the means of communica- 
tion between the different parts of the country have to within the lol® 
ten years remained undeveloped, it might be supposed that cases ot tin3 
disease had occurred in any of the eight provinces into which the Gran‘s 
Duchy is divided, without presenting themselves at the Surgical Cliniqllo 
OF HELSINGFORS, FINLAND. CALCULUS IN FINLAND. 
663 
In o o nivei'sity, although it is the only special hospital in the country, 
dote*- •*'-t0 a decided conviction that this circumstance had no 
ffiteiT difluence, I communicated by letter with the doctors super- 
vit]c dlng the hospitals erected by the government in each of those pro- 
ten i the 7 each and all returned the same answer: that in the last 
had°r afteen years during which they had been at the hospitals, they 
never met with a case of stone in the bladder. 
i'are<l.Seß belonging to the second group of calculus have been exceedingly 
alu{ )lmong8t that part of the population which frequents the hospitals, 
the 1116 been principally limited to stones depending on paralysis of 
Case t* er‘ -^ot one single case of renal calculus is recorded in the 
grent °ok- Hut in m 7 private practice I have had occasion to treat a 
caSg n,!any. patients of that kind ; all from the richer classes. Among 
fro vesical calculus, most of them depending on hypertrophy of the 
hav te’ ah°nt twelve may have occurred among my countrymen. I 
el.iS! Precise to judge of the frequency of stone in the upper 
eor !568’ ut seems to me that this number is remarkably small to 
bee'nesfP°nd with a practice of seventeen years, during which time I have 
p, Ihe only ex-professo surgeon in the country, 
elu b°nile hacts I have just now stated, I think lam justified in con- 
an ‘ lnS that stone in the bladder occurs in Finland almost exclusively 
the le uPPer classes, and originates most frequently in disorders of 
iiit Unnai'y organs. It seems as if the causes of so pronounced an immu- 
t}1€y _ ‘°r a whole country ought to be easily discovered, but such is not 
eti iCaSe‘ Here just as well as anywhere, where we have to do with the 
°g.y of diseases, the facts we observe are the result of many co-oper- 
inp* circumstances. As it would be out of time and place here to enter 
be °an 7 l°ng discussion of the different influences which c uld possibly 
eC°! as contributing to this immunity, I will only point out 
re C 1 which seem to me to merit special attention in this 
and e<A fiuality of the water is generally considered very important, 
pril t.° Hdß matter we ought to assign the first place. The land consists 
vas-ClPally granite mountains (ground even during the glacial period), 
barren heaths, which the vegetation of many thousand 
Hv IS, las covere(l with a scanty crust of earth. The water of springs, 
]jllers’ and lakes, therefore, contains only a very small quantity of alka- 
Chvflts. As an instance I will quote an analysis made by Prof. J. 
wJi "ius of the water in the Wanda River, which supplies the water- 
Vo|'ks of Helsingfors. 
grammes contained 7 grammes of solid substance, whereof— 
Chloride of sodium 
. 0.63 grammes. 
Carbonate of lime 
. 1.88 
Carbonate of magnesia ...... 
. 0.81 
Silicic acid .... 
. 0.48 
Crganic humus-like substance .... 
. 2.55 
the *US le Pui’lty of the water is very remarkable, and, as water forms 
Bide.An-Cipal Part °t the nourishment of a people, we certainly must con- 
be fg , .quality as the main cause of immunity. Another cause might 
Cei’e‘plllC. u the hood of the Finnish people, which generally consists of 
meat -S’- Sf1’ Putatoes, and milk (nearly always sour), and very seldom 
acid \n a°t h not think any other people consumes so much lactic 
least 80 meat. It would not perhaps be difficult to find out at 
the , relation between meat as food and the uric acid which forms 
greater part of the calculi of constitutional origin, but I content 664 
ESTLANDER, CALCULUS IN FINLAND. 
myself with simply pointing out the most striking features of the Finnish 
people’s manner of living, hoping that a comparison with that of otber 
peoples enjoying the same immunity will, better than any hypothesis? 
show whether those characteristic points exercise any influence in that 
respect or not. There would yet remain some circumstances worthy 
notice, as for instance the habit of taking once a week a bath in a roo#1 
tilled with hot steam—a habit which is as old as the people itself, and s° 
common that the poorest man never neglects it—but that I think I haVe 
already too long claimed your attention for this subject. 665 
SECTION on dermatology and 
SYPHILOGRAPHY. 
PRESIDENT. 
JAMES 0. WHITE, M.D., 
OF BOSTON. 
S. engelsted, m.u. 
VICE-PRESIDENTS. 
EDAVARD SHIPPEN, M.D., 
OF COPENHAGEN. 
SECRETARY. 
V. S. NAVi’. 
ARTHUR YAN HARLINGEN, M.D., 
OF PHILADELPHIA. 
' ARIATIONS in type and in prevalence of diseases 
•Op THE skin in different countries of equal 
civilization. 
BY 
JAMES C. WHITE, M.D., 
op )T as 0n» been well known that some diseases of the skin are more 
di f6B-8 strictly confined to certain distinct geographical or anthropological 
co nc^S’ anc that ethers assume marked variations of type in different 
Pr 1. es* The number of such affections, however, is small. The im- 
in?1011 as heen gradually taking form, of late, that similar variations 
fha prevalence exist much more generally among skin diseases 
■f n. has been hitherto recognized, nor is it strange that such a fact, if 
of should have remained so long undetermined. The slow growth 
ernwtoiogy prior to the last quarter of a century; the babel-like 
Wr'fUS*°n *n nomcuclature which still hampers its various schools and 
Pri G-rS ’ lack of competent observers, except in a few of the 
centres of the most civilized populations, have prevented the 
Wn ntion comparison of the necessary data from all parts of the 
A intention to consider this subject now under as broad a scope as the 
h't t?1*8 PaPer would suggest, but rather to present my views and the 
th° 8 WM°h I have been able to gather relating to the differences between 
a^Se Sections, as they occur here at home and in the countries which 
oul means of comparative observation. In this narrower compass we 
c A, perhaps, wisely essay the first step towards the complete solution of 
ne question. 
Un^S Bta^ this question of variation has only slowly forced itself 
Am ,■ 6 Perception of dermatologists. Owing to the entire absence in 
erica of any regular instruction in dermatology in our medical 
PROFESSOR OF DERMATOLOGY IN HARVARD UNIVERSITY. 666 
J. C. WHITE, 
schools, and of opportunity of clinical observation of skin diseases in 0111 
hospitals and dispensaries, until within the last few years, those of u3 
here who have labored to supply such deficiencies, and have devoted oui' 
selves specially or exclusively to the study of dermatology, got our fir® 
systematic and practical conceptions of skin diseases in the schools oj 
Europe ; conceptions no doubt often tinged over-strongly in this or tba 
direction by the individual opinions and theories of some eminent teach61? 
and which we have slowly more or less modified since then by more eX- 
tended and broader personal observation; still it was in foreign school3 
that we first familiarized ourselves with the types of cutaneous diseaB®’8®’ 
and the impressions there gained we have retained as permanent stand' 
ards for comparison with the results of our later and more practical eX' 
perience at home. Gradually, perhaps too slowly in the case of those 0 
us whose reverence for a master’s precepts has been strongly inherent, n’e 
have become aware of differences of various kinds in some of the dig' 
eases here and the same aftections as seen abroad, differences in course? 
in severity, in prevalence, in behavior under treatment, etc. These latel 
impressions have been almost wholly the growth of individual observa- 
tion, and with the exception of a limited mutual interchange of opimoll 
on the subject in conversation or correspondence, and brief allusioiy 1° 
some of the more noticeable variations in occasional papers, the question 
of such differences has not been presented or discussed in a general wa> 
by any of our dermatologists. E’er is this strange : we have been nioi® 
wisely spending our time, first, in creating opportunities of study, t°0 
often in the face of indifference or positive opposition, until we nia/ 
justly claim to have established dermatology upon a firm basis; and? 
secondly, in faithful observation, rather than in the preparation of crude 
publications, so that we have been largely ignorant of each other’s oplll' 
ions upon the subject. But now that the mature results of careful auc 
extensive home observation are, of late, more generally given to th 
world; now that we have in our American Archives a special channel o 
publication, such as only one other country can boast of; and now tha 
original and independent works on general dermatology, of which r0 
may justly be proud, have been written by members of this Section; 
is it for the first time possible to compare the results of our enlighten6 
and independent observers with those of our foreign brethren, and t° 
learn how far our previous vague and individual impressions are sup' 
ported by facts drawn from wide fields of observation. And yet ve 
should not over-estimate the opportunities we even now possess for th 
study of this question. It is to be regretted that they exist only in a 
few centres of observation, separated but a short distance, and in th 
midst of large cities with mixed populations; nor until trained derm;1' 
tologists are more widely and uniformly distributed than at present, wi 
it be possible to form a reliable estimate of the prevalence and charactei 
of skin diseases throughout our vast and varied country, or to study ]h 
a satisfactory way the variations which these affections manifest 
the many races which inhabit it. , 
If any one of us who has had much to do with skin diseases in hot 
hospital and private practice in our larger cities, were now asked, wfm 
are the most marked differences between these affections here and in t°, 
eign countries, he would probably reply that we miss altogether certain 
diseases which are either very commonly, or occasionally, met with *u 
some parts of Europe, while others are far less prevalent here than there- 
Moreover, we rarely or never see here such grave forms of some affection  IN TYPE AND PREVALENCE OF SKIN DISEASES. 
667 
8 are of frequent occurrence in the old world. Again, certain diseases 
•^e 111 ore common at home than abroad, or present certain modifications 
u Ape which may be regarded as indigenous. Such, I venture to think, 
°u*(l be tpe reply of all of us, as the result of entirely independent ob- 
-1 Ration; and yet if we were asked for the data upon which such con- 
• llsi°ns were based, we should have to answer that they were largely 
Rpi’essions, but impressions which would prove to be in the main cor- 
ect, when tested by statistics. It is to determine, therefore, how reliable 
e our opinions upon these points, as far at least as the test is applicable, 
.A1*" I have brought together as many statistical reports bearing upon 
16 Prevalence of cutaneous diseases amongst us as are available, "for the 
Purpose of comparing them with well-known foreign tables. In making 
tlj>s home standard, I have preferred to use materials which are the 
seßu]ts of the observations of those of us who have had essentially the 
Rie training in dermatology, and whose nomenclature and deductions 
therefore, interchangeable, and if faulty uniformly so. They are drawn, 
a°0’ trom similar sources in the large cities ot Philadelphia, Hew York, 
Boston, and are therefore homogeneous in character. The figures 
ple from the published reports of free skin dispensaries prepared 
■A.Br. Duhring, in Philadelphia, by Dr. Bulkley, in Hew York, by Dr. 
g Aglesworth, in Boston, and by the They represent ten thou- 
Y . consecutive cases of diseases of the skin, affording thus an oppor- 
of contrasting the peculiarities ot these affections, it such exist, 
p1 Aese cities, and of forming a collection as numerous, I believe, as 
been tabulated for similar purposes by any one writer hitherto in other 
lai’ts of the world. I have not attempted to give the complete lists pub- 
-Blod by these gentlemen, but have put down in the table only such 
r ecti°ns as bear possibly upon the subject before us, those of most com- 
-0,1 occurrence, and the rarer forms of greatest interest. It is to be re- 
* ctted that we have not the published observations of dermatologists 
{ h'otn our southern and western cities, so that a more completely 
A 'A/d representation might be offered ; but until our special branch of 
cdieiue attains a more independent position in these parts of our coun- 
'Ve Racist accept this restricted report as the only one at present practi- 
‘l*A possible. 
an U exarwining this table for the purpose of ascertaining if there are 
in differences in the relative occurrence of the affections therein 
b enti°ned in the cities, of Philadelphia, Hew York, and Boston, it must 
that we cannot generalize too boldly from the results of 
analysis. The element of variableness in the customs of their 
aii/,ective populations, in professional etiquette even, and other non- 
-1 Parent circumstances, which all influence the attendance upon dis- 
practice, must make no little difference in the character of the 
te clSes treated in these cities, in addition to the more noticeable mat- 
8 race, manner of living, location, climate, etc., to which wTe should 
tf Ura.By refer such variations. On the whole, it will be observed that 
reeAuctions do not vary greatly in prevalence; and some of the appa- 
pi! discrepancies may be easily explained. For instance, in Philadel- 
no cases of dermatitis calorica, or dermatitis venenata, are recorded,. 
Riu there can be no question that of the first variety, at least, cases* 
f °ccur; of dermatitis venenata, Boston has more than its share, 
dr< laB8 because the skin clinic of the Massachusetts General Hospital 
Riid"n Pa^Teivts from a wider rural area than those of her large sisters,, 
that her encircling flora abounds more than theirs in the poisonous 668 
J. C. WHITE, 
Table T. Showing the comparative frequency of the 
the. skin in 10,000 consecutive cases in American 
more common diseases of 
dispensary practice. 
Diseases. 
New York. 
Dr. 
Bnlkley. 
1617 cases. 
Philadel- 
phia. Dr. 
Duhring. 
1267 cases. 
Boston. 
Dr.Wiggles- 
worth. 
1862 cases. 
Boston. 
Dr. 
White. 
525-1 cases. 
Total. 
Percent age- 
Acne 
154 
116 
246 
378 
894 
8.9 
Alopecia .... 
3 
19 
14 
36 
.36 
Alopecia areata . 
1 
2 
6 
17 
26 
.26 
Chloasma .... 
6 
6 
22 
16 
50 
.5 
Dermatitis calorica 
9 
5 
26 
40 
.4 
Dermatitis venenata . 
7 
73 
80 
.8 
Ecthyma .... 
7 
3 
3 
58 
71 
.7 
Eczema .... 
520 
535 
447 
2372 
3874 
38.7 
Epithelioma 
18 
17 
25 
60 
.6 
.95 
Erysipelas .... 
32 
3 
5 
55 
95 
Erythemata .... 
39 
4 
24 
86 
153 
1.5 
Furunculosis 
36 
11 
23 
65 
135 
1.35 
Herpes .... 
16 
2 
20 
29 
67 
.67 
Herpes zoster 
22 
7 
6 
77 
112 
1.12 
Ichthyosis .... 
3 
12 
1 
5 
21 
.2 
Impetigo .... 
18 
19 
37 
.37 
.34 
Lupus ..... 
10 
3 
10 
11 
34 
Lupus erythematosus . 
2 
8 
12 
6 
28 
.28 
Pemphigus .... 
3 
1 
2 
15 
21 
.2 
Phthiriasis capitis 
69 
] f 
32 
240 
341 
3.4 
Phthiriasis vestiment. . 
32 
1 25 < 
38 
50 
120 
1.2 
Phthiriasis pubis . 
Prurigo .... 
1 
1 1 
11 
7 
19 
.19 
Pruritus .... 
43 
42 
36 
51 
172 
1.7 
Psoriasis .... 
70 
75 
71 
157 
373 
3.7 
Purpura .... 
9 
5 
5 
20 
39 
.39 
Scabies .... 
62 
9 
17 
145 
233 
2.3 
Scrofuloderma 
11 
6 
31 
30 
78 
.78 
Seborrhcea .... 
54 
48 
56 
158 
1.58 
Syphiloderma 
137 
136 
100 
340 
713 
7.1 
Tinea tonsurans . 
47 
28 
86 
185 
346 
3.46 
Tinea versicolor . 
14 
33 
27 
81 
155 
1.55 
Tinea favosa 
7 
1 
6 
17 
31 
.31 
Ulcers 
25 
23 
33 
317 
398 
3.98 
Urticaria .... 
59 
33 
37 
136 
265 
2.6*> 
Xeroderma .... 
1 
11 
13 
25 
.25 
species of rhus. Epithelioma is apparently unknown in Xew York aS 
skin disease, because the large surgical hospitals no doubt attract 1 
wholly to themselves. So, too, the table fails, without doubt, to repl(3 
sent the actual or proportionate occurrence of lupus, because it \s b.° 
commonly regarded as a so-called surgical disease. Again, ichthyosis 13 
apparently much more common in Philadelphia, perhaps because I*' 
Duhring may regard the cases placed apart by the other observers uime _ 
the title Xeroderma, as merely a variety of the former disease. Oth*- 
differences, however, cannot thus be accounted for. The 
for example, must he less prevalent in Philadelphia, for some inexpbcA 
ble reason, than in the northern cities, for but 4 cases out of the 1 
were there observed. Some small part of this great variation may 
owing to difference of opinion in classification regarding some ot Jv 
varieties of the affection, but a small part only. Erysipelas, too, b v 
these other acute hyperaemic processes, seems to be of less common °ccUt, 
renee in Philadelphia. It is in the parasitic affections, however, th& Variations in tape and prevalence of skin diseases. 
669 
*j.!e greatest differences are to be observed. That scabies forms but 
y ber cent, of the Philadelphia cases against nearly 4 per cent, in New 
orfo and 2 per cent, in Boston ; and phthiriasis only 2 per cent, in the 
I. against 6 per cent, and 5 per cent, respectively in the two latter 
, les? can be easily explained on the supposition, which is thus demon- 
aated to be a fact, that the former’s clinic derives its material from a 
1 rerent class than the immigrant populations which make up so largely 
le patients of the two seaboard cities; but this does not explain the 
i n^rkable predominance of one of the vegetable parasites over the others 
I b hiladelphia. Tinea tonsurans is elsewhere in America far more 
crnnion than the other vegetable parasitic affections, yet the table shows 
_uit in Philadelphia tinea versicolor is of more frequent occurrence than 
°thers collectively. In the New York column there are 47 cases of 
o!Pea tonsurans, 14 of tinea versicolor, and 7of tinea favosa; in Boston, 
/b °f tinea tonsurans, 108 of tinea versicolor, and 48 of tinea favosa; 
V bi Philadelphia there are 28 of tinea tonsurans, 83 of tinea versi- 
i° °r? and lof tinea favosa. We are less acquainted with the natural 
'story of the fungus of tinea versicolor than with those of the other 
• °getable parasitic affections, and it may be that peculiarities of this sort 
II its geographical distribution may throw important light upon its 
nature. 
I Inasmuch as the statistics of dispensary and hospital practice afford 
a partial representation of the prevalence of cutaneous affections in 
16 whole community, I have prepared a table (Table II.) which presents 
nore fairly their distribution amongst all classes. It shows the relative 
ccurrence of 5000 consecutive cases at the out-patient department for 
Ain1 c^seases the Massachusetts General Hospital in Boston, and of 
. b0 consecutive cases in my private practice there, and illustrates the 
f extrerae classes of patients, those on the one hand mostly poor and 
* foreign derivation, with the characteristic affections of poverty and 
’leglect of personal care; and, on the other hand, those who have the 
ans and leisure to seek professional advice for troubles which more 
e°t the looks than the health of the individual. These extremes largely 
therefore, the affections of squalor and of luxury; but, even 
JyGn the two classes are placed together, they fail to show fairly the 
faience of cutaneous diseases amongst all classes. Most infantile 
a eetions of the skin among the middle and upper classes, for instance, 
under the care of the family physician, and only in exceptional 
are seen by the specialist. This is true, too, with many of the 
1 Alal an(b self-limited diseases among them. 
e, might be inferred, it is mainly with regard to the affections which 
the two extremes of the classes which make up. this table, 
'at we find the most striking differences. Those diseases which affect 
personal appearance of the patient, and do not interfere with health 
'll( labor, are naturally in far greater proportion in private than in dis- 
lensary practice. Thus we see that acne forms 18 per cent, of the former, 
j 6.9 of the latter; the various forms of loss of hair, included under 
i °Pecia, over 10 per cent, in the former, and less than one-fourth of 
per cent, in the latter; all the varieties of seborrhcealO per cent, of the 
G'vate cases,and only 1 per cent, of the hospital cases; and yet there are 
a° g°°d reasons for believing that these affections are even as prevalent 
Qln°ag the rich and well-cared for as among the poor and less cleanly. 
11,II, the other hand, it is in the latter class that we find the animal para- 
lc affections positively more abundant, as likewise those which are 670 
J. C. WHITE, 
Table II. Showing the relative occurrence of the more common 
skin disease 
in dispensary and in private practice 
in Boston. 
. 
5000 consecutive 
2000 consecutive 
Diseases. 
cases at Mass. 
Per cent. 
cases in private 
Per cent. 
Gen. Hosp. 
practice. 
Acne ..... 
348 
6.9 
360 
18. 
Alopecia .... 
13 
.26 
205 ‘ 
10.2 
Alopecia areata . 
17 
.34 
27 
1.3 
Chloasma .... 
16 
.32 
38 
1.9 
Dermatitis calorica 
26 
.52 
4 
.2 
Dermatitis venenata 
73 
1.4 
18 
.9 
Ecthyma .... 
55 
1.1 
5 
.25 
Eczema .... 
2242 
44.8 
507 
25.3 
Epithelioma 
25 
.5 
5 
.25 
Erysipelas .... 
52 
1. 
Erythemata .... 
81 
1.6 
33 
1.65 
Furunculosis 
65 
1.3 
9 
.45 
Herpes .... 
28 
.56 
3 
.15 
Herpes zoster 
73 
1.4 
9 
.45 
Ichthyosis .... 
5 
.1 
3 
.15 
Impetigo .... 
19 
.38 
2 
.1 
Lupus ..... 
11 
.22 
6 
.3 
Lupus erythematosus . 
6 
.12 
2 
.1 
Pemphigus .... 
15 
.3 
3 
.15 
Phthiriasis capitis 
216 
4.3 
5 
.25 
Phthiriasis vestiment. . 
48 
.96 
Phthiriasis pubis . 
7 
.14 
1 
.05 
Prurigo .... 
Pruritus .... 
50 
1. 
32 
1.6 
Psoriasis .... 
152 
3. 
78 
3.9 
Purpura .... 
19 
.38 
4 
.2 
Scabies .... 
139 
2.78 
29 
1.4 
Scrofuloderma 
27 
.54 
3 
.15 
Seborrhoea .... 
55 
1.1 
200 
10. 
Syphiloderma 
327 
6.5 
41 
2.05 
Tinea tonsurans . 
180 
3.6 
113 
5.6 
Tinea versicolor . 
81 
1.6 
20 
1. 
Tinea favosa 
17 
.34 
4 
.2 
Ulcers . . .1 
309 
6.18 
15 
.75 
Urticaria .... 
132 
2.6 
17 
.85 
Xeroderma . . . . 
13 
.26 
17 
.85 
caused wholly or in part by the action of external irritation, and th°s 
which are more or less due to poverty of the blood and unhealthy 
of living. Thus disturbances produced by lice form 5.4 per cent, of t*l 
hospital cases, and only ,3 per cent, of those in private practice; 
scabies 2.8 per cent, in the former, and 1.4 in the latter. The vari° 
forms of dermatitis, due to the action of external causes mainly, _^el.g 
twice as common with the former as with the latter. Eczema, which u. 
somewhat under the same exciting influences, formed 44.8 per cent. 
the former, and 25.3 of the latter; but it must be remembered, as abo 
explained, that the latter figures represent less fairly the absolute pr 
lence of eczema among the wealthy classes. Herpes formed 2 per cen 
of the hospital cases, and only .6 per cent, of the private. The variety 
of cutaneous syphilis, both acquired and congenital, were in the form 
6.5 per cent., and in the latter 2.05 per cent. Ulcers 6.18 per cent- 0 
the former, and only .75 per cent, of the latter. Urticaria 2,6 per cen • V ARiAtions I]sr TypE A]sri) PREVALENCE of skin diseases. 
671 
?. le former, and .85 per cent, of the latter. In other orders of affec- 
°us, which are apparently little under the influences of class and cus- 
u 1118 of life, we find a striking equality in prevalence in the two series of 
~sesq The erythemata, mostly forms of E. exudativum multiforme, were 
‘ pvein both, 1.6 per cent.; ichthyosis .1 per cent, in the hospital cases, 
• 0 Per cent, in the private; lupus .34 per cent, in the former, .4 per cent. 
11 loe latter; psoriasis 3 per cent, in the former, 3.9. in the latter; and 
- et even with these affections we cannot accept these comparative results 
£ absolutely their relative prevalence amongst all classes. 
, Eet us now compare the combined results of our American table with 
,|Ose of similar statistics in other countries. The most available raate- 
-I<l 8 for this purpose are Anderson’s 10,000 cases from the Glasgow Dis- 
l'e'isary, Pardon’s 3000 Irish cases, and 24,000 made up from the annual 
sports of Hebra’s Vienna clinic; and the private cases published by 
dson and Anderson, with 2000 of my own; making 47,000 hospital 
o’11 private cases—in all, 60,000. Dr. Anderson’s cases are espe- 
Ja/ly valuable as representing the prevalence of skin diseases in Great 
1 Hain, not only because the number is the same as that in our Ameri- 
,ai| table, but because his nomenclature and classification are also essen- 
identical with those of the American reporters. The statistics of 
dson and Purdon are less valuable, because from want of such har- 
n°Uy it is impossible to make a reliable comparison of affections at all 
*0tttplete. On this account 1 have been obliged, in the following tables, 
T3 group several classes of disease under more general heads than in 
i able I. 
a 111. shows the comparative prevalence of the more common 
eGions of the skin in American and European dispensary and hospital 
D’actice; and Table IV. shows the same in special private practice here 
‘ !'d in Great Britain, as closely as differences in nomenclature and clas- 
will permit the formation of reliable comparisons. 
As will be seen, Acne appears to be three times as common with us in 
practice as in Scotland, and nine times as much as in Vienna, 
I tables are to be believed ;or else our population is more sensitive 
j °ut its “ complexion” than foreign nations, even among the lower 
The former conclusion is sustained in Table IV., which shows 
&cne forms but 7.5 per cent, of private cases in Glasgow, and 5 per 
Ant. in London, against 18 per cent, in Boston, The Vienna statistics, 
, 111 ust be borne in mind, represent more a resident than an ambulatory 
ass of patients. Alopecia, meaning loss of hair in general, forms 36 per 
nl1 °f the dispensary cases in America, .56 per cent, in Scotland, and 
jV per cent, in Ireland, whilst it does not enter at all into the Vienna 
a les, because it is not a sufficiently serious affection for hospital resi- 
e^llce> among private cases it forms 10.2 per cent, of the Boston, 1.8 per 
of the Glasgow, and 4 per cent, of the London cases. Alopecia 
*eata, on the contrary, seems to be of much more common occurrence in 
Gotland than here, for in the dispensary cases it forms .26 per cent, of 
c, 6 -American, and 1.5 per cent, of the Scotch ; and among the private 
i£lfTs 1-3 per cent, in Boston, 4.4 per cent, in Glasgow, and 2.7 per cent. 
Eondon. Of its prevalence in Austria we can form no estimate. Chlo- 
_ n‘a (the local distribution of melanoderma upon the face, moth or liver- 
ch°t, as popularly called) formed .5 per cent, of the dispensary, and 1.9 per 
c °f the private cases here, against .03 per cent, of the former and .3 per 
nit- of the latter in Glasgow. Ecthyma presented no differences of impor- 672 
J. C. WHITE, 
Table III. Showing the comparative prevalence of the more common affectio1lS 
of the akin in American and European dispensary and hospital practice■ 
Diseases. 
Amer’n. 
10,000 
cases. 
Boston, 
Phila., 
N, York. 
Per cent. 
Scotch. 
Ander- 
son, 
10,000 
cases. 
Glasgow 
Hosp. 
Per cent. 
Irish. 
Purdon, 
3000 
cases. 
Belfast 
Hosp, 
Per cent. 
Anstr’n. 
Hebra, 
21,000 
cases. 
Vienna 
Hosp. 
Per c«Dt’ 
Acne .... 
Alopecia .... 
Alopecia areata 
Chloasma 
894 
36 
26 
50 
8.9 
.36 
.26 
.5 
325 
56 
153 
3 
3.25 
.56 
1.5 
.03 
8 
.26 
263 
1. 
Dermatitis 
120 
1.2 
27 
.27 
244 
1. 
.9 
% 
.36 
Ecthyma .... 
71 
f- 
. i 
97 
.97 
6 
.2 
233 
Eczema .... 
3874 
38.7 
2527 
25.27 
800 
26. 
2877 
Epithelioma . • 
60 
.6 
38 
.38 
14 
.46 
33 
Erysipelas 
95 
.95 
10 
.1 
22 
.7 
89 
Erythemata 
153 
1.5 
476 
4.7 
210 
,0 
.7 
JIerpes .... 
179 
1.79 
32 
.3 
20 
.6 
178 
Ichthyosis 
21 
.2 
31 
.3 
1 
.03 
56 
Lupus .... 
62 
.6 
198 
1.98 
738 
Pemphigus 
21 
.2 
13 
.13 
15 
.5 
53 
13- 
Phthiriasis 
480 
4.8 
327 
3.27 
107 
3.5 
3186 
Prurigo .... 
1 
740 
% 
Pruritus .... 
172 
1.7 
39 
.39 
149 
Psoriasis .... 
373 
3.7 
725 
7.25 
75 
2.5 
652 
2.2 
Purpura .... 
39 
.39 
8 
.08 
4 
.13 
95 
.0 
Scabies .... 
Scrofuloderma . 
233 
78 
2.3 
.78 
2527 
27 
25.27 
.27 
497 
16. 
11,284 
48. 
Seborrhcea 
Syphiloderma . 
Tinea tonsurans 
158 
713 
1.58 
7.1 
13 
493 
.13 
4.9 
299 
9.9 
25 
.33 
346 
3.46 
142 
1.4 
53 
1.7 
80 
Tinea versicolor 
155 
1.55 
106 
1.06 
18 
.6 
50 
.li 
.79 
Tinea favosa . 
31 
.3 
156 
1.56 
15 
.5 
105 
Ulcers .... 
398 
3.98 
433 
4.3 
190 
Urticaria 
265 
2.65 
147 
1.47 
43 
1.4 
206 
Xeroderma 
25 
.25 
1 
tance, although the term is too loosely used for close comparative analysl ’ 
Eczema made 88.7 per cent, of the American dispensary cases, 25.57 P6 
cent, of the Scotch, 26 per cent, of the Irish, and 11.9 per cent, of 1 
Austrian ; and of the private cases 25.3 per cent, in Boston, 84.8 per ce# 
in Glasow,and 45 per cent, in London. It does not seem, therefore, W 
there is any marked difference in its prevalence in Great Britain a* 
here at home, if the figures in both Tables (111. and IV.) be considei6 
together; and the inverse ratio established by a comparison of its pr6V j 
lence in the poorer and richer classes here and abroad may be expla#1. 
h}7 simple custom, as governing the relations between general and speC.u 
practice in the respective countries. The low percentage in the Austrn 
column may be partly explained by the fact that those affected with 
milder forms of the disease do not seek hospital residence for relief, an 
that cases of infantile eczema are diverted to the children’s hospital- 
With regard to the next two affections in the tables, Epithelioma 
Erysipelas, trustworthy comparison is impossible on account of varum1 
in local custom of referring such cases to the skin or surgical depart#l6l 
of hospitals. The various forms of Erythema would seem to be less P 
lent in America than in Europe, for here it occurred in the 
1.5 per cent, in dispensary, and 1.6 per cent, in private practice, to 4. i i!t VaRIATIONS in type and prevalence of skin diseases. 
673 
able iv. Showing the 
comparative prevalence of the more common skin 
diseases in American 
and European private practice. 
Boston. 
Glasgow. 
London. 
Diseases. 
2000 
1000 
10 000 
consecutive 
cases. 
Per cent. 
consecutive 
cases. 
Per cent. 
consecutive 
cases. 
Per cent. 
Acne 
AW ’.*••• 
360 
18. 
75 
7.5 
508 
5. 
A °Pe«a . 
205 
10.2 
18 
1.8 
414 
4. 
ni.?Pecia areata . 
tlloasma . 
&atitiS. ; ; ; 
Jcthyma . 
5Czetna 
lpithelioma .* ! ! 
elaS * • • * 
<rata • • • 
. 
wPus 
R^nasis.... 
j,ruriRo 
27 
1.3 
44 
4.4 
276 
2.7 
38 
22 
5 
1.9 
1.1 
.25 
3 
.3 
15 
42 
.15 
.4 
507 
25.3 
348 
34.8 
4500 
45. 
5 
33 
12 
3 
.25 
1.6 
.6 
.15 
9 
99 
1 
7 
.9 
9.9 
.1 
.7 
12 
219 
108 
46 
.12 
2.19 
1. 
.46 
8 
3 
.4 
.15 
25 
3 
2.5 
.3 
155 
19 
1.55 
.19 
6 
.3 
7 
2 
.7 
.2 
23 
.23 
32 
1.6 
11 
1.1 
61 
.61 
■pSoriasis 
78 
3.9 
106 
10.6 
628 
6.28 
dUrP«ra 
sCahies 
4 
29 
.2 
1.4 
1 
44 
.1 
4.4 
308 
3. 
SehifUi?^erma • 
8v .... 
3 
.15 
6 
.6 
200 
10. 
41 
2. 
57 
5.7 
350 
3.5 
Tin a 0nsui’ans 
Twa Tricolor 
113 
5.6 
36 
3.6 
252 
2.5 
20 
1. 
15 
1.5 
131 
1.3 
\J> f»osa . . . 
TVcers 
Yrticaria ’ 
4 
15 
17 
.2 
.75 
.85 
4 
7 
5 
.4 
.7 
.5 
3 
88 
.03 
.88 
Aer°derma ] | | 
17 
.85 
o jc* bi Scotland in the former, and 9.9 per cent, in the latter, and of 
f0 Per cent, of Mr. Wilson’s cases. In Austria, on the other hand, it 
ah] onlJ -8 per cent, of the cases in the hospital. Herpes is consider- 
fot/-rnore prevalent in America than in foreign dispensary practice, 
Ce ,*llng 1.8 per cent, of the cases here to .3 per cent, of the Scotch, .6 per 
tice ’ le lrish> an(l *1 Per cent, of the Austrian ; but in private prac- 
eeiu aS w'th eczema, an inverse ratio prevails, at least in London, the per- 
sPo =e being in Boston .6, in Glasgow .1, and in London 1. Ichthyosis 
est -n° rernarkable variations in the tables, .7 per cent, being the high- 
rjla’{lri° presented by any country. Lupus, on the other hand, shows a 
difference in relative occurrence, being much less common here 
L abroad, a fact which is strongly impressed upon an American in 
pW°Pf .by the chronic nature of the disease and the heroic means era- 
treatment. Of the dispensary cases it forms in America 
Vato hercent.,in Scotland 2percent.,in Austria 3 percent.; and in pri- 
-1.5 Practice here .4 per cent., in Scotland 2.5 per cent., and in London 
dc®nh The reports do not allow a proper subdivision into its two 
anf|Ulct l°i'nis. Pemphigus shows itself about alike in both classes of eases 
siVeiln countries. Phthiriasis is naturally everywhere almost exclu- 
ladar Co?bned to the lower classes, and marks clearly the degree of deg- 
lon in habits of cleanliness of a nation. It will be easily understood, 
43 674 
J, C, WHITE, 
therefore, why Austria with her dirty Slavonic races should presents 
excessive a percentage of cases, 13 per cent, to 4,8 per cent, in Amer'c ’ 
8.3 per cent, in Scotland, and 3.5 per cent, in Ireland, although the Viellll 
figures comprise also the excoriations produced by fleas and hugs. Scam ’ 
too, affords of course another and much stronger illustration of the sap 
law. Of dispensary cases it forms amongst us only 2.3 per cent., in _ 
land 25 per cent., in Ireland 16 per cent., and in Austria 48 per cen.* ’ 
and in private practice in Boston 1.4 per cent., in Glasgow 4.4 per cen *’ 
and in London 3 per cent. Prurigo may be set down as an affect1 , 
almost wholly absent from this country, and in fact virtually connlie, 
exclusively to certain parts of Europe. Not a single instance is record 
among the dispensary cases in America, only a single one in Scotia11 ’ 
whilst it forms 3 per cent, of the Austrian. In my private practice I 
not sure that I have seen a single case, whilst Anderson puts down 
instances in his list. Mr. Wilson’s statistics cannot be considered, 
confounds the disease with simple pruritus. This latter affection &ee . 
to he somewhat more prevalent here than in Europe, forming 1.7 perce1 
to .4 per cent, of the Scotch, and .6 per cent, of the Austrian dispen 
cases; and of the private cases 1.6 per cent, here, to 1.1 per cent, of 1 
Scotch, and .6 per cent, of the English. 
Psoriasis is much more common in Scotland than elsewhere, accord1 o 
to the tables, in both classes of patients ; in the dispensary cases sho"’ 
7.25 per cent, to 3,7 per cent. American, 2.5 per cent. Irish, and 2.2 P 
cent. Austrian ; and in the private cases 10.6 per cent, to 3.9 per ceG. 
American, and 6.3 English. Purpura, if the small number of y 
recorded permits comparison, seems to be rather more common here ttJ 
in Great Britain, both in dispensary and private practice. Scrofulodei 
is a term so indefinitely used by different writers that no legitimate c[ 
elusions can be drawn from the statistics presented. Seborrhcea, 
acne, appears to be much more common amongst us than elsewhere, 
term being used to include that scaly condition of the scalp so intinia 
connected with alopecia. Of the American dispensary cases it forms ■. 
per cent., of the Scotch .13 per cent., and of the Austrian .1 per 
whilst in private practice it forms 10 per cent, of all cases. With recW 
to the syphilodermata, it is clearly impossible to draw any inferences i> 
the figures presented in the tables as to the comparative 
this disease, because the existence of special departments and of eh jtl 
tising quacks draws the cases almost wholly away from skin clinics. 
the Vienna column, for instance, the space is not filled, because the 11 
ber of cases which find their way into the cutaneous wards is so tn'i 
compared with the immense number in the adjoining clinic of Signl qeg 
In the skin department of the Massachusetts General Hospital, the 
(Table I.) are almost wholly those of the wives and children of 
men. The Vegetable parasitic affections present some rather surpl 
results: Tinea tonsurans is more common here than in other coim 1 
forming 3.46 per cent, against 1.4 per cent, of the Scotch, 1.7 per cen • . 
the Irish, and .33 per cent, of the Austrian dispensary cases; and 111 
vate practice 5.6 per cent, against 3.6 per cent, of Anderson’s, and 0 0f 
per cent, of Wilson’s, llebra’s cases hardly represent the frequency, 
its actual occurrence, because he did not recognize, when they were P 
lished, the parasitic character of eczema marginatum, and a p°l’tlrp-I)en 
his cases of sycosis should possibly be included in the same class. 
versicolor does not vary so greatly, but is less common in Ireland e 
Austria than elsewhere. Tinea favosa is somewhat less comm°u VaRIATIONS IN TYPE AND PREVALENCE of skin diseases. 
e^au hi Europe, and noticeably so than in Scotland. It is in Italy, how- 
p eib that it especially flourishes. The ratio which these three affections 
, ea.r one another in Scotland in dispensary practice is singular by com- 
-3 4rBoll °Eier countries, for whereas with us tinea tonsurans forms 
n per tinea versicolor 1.55 per cent., and tinea favosa .8 per cent., 
g Ul Ireland 1.7 per cent., .6 per cent., and .5 per cent., respectively ;in 
d£«and the percentages are 1.4, 1.06, and 1.56, or nearly equal. In An- 
p ISOn’B private cases, however, their relative occurrence is more like 
j.u‘d observed elsewhere. Urticaria is somewhat in excess in America, 
gaming 2.65 per cent, of the dispensary cases against 1.47 per cent, in 
v 1.4 per cent, in Ireland,and .8 per cent, in Austria; but in pri- 
ii? n l,ractice the difference is not so marked, the percentage being .85 
Eoston, .5 in Glasgow, and .88 in London. 
Ta 
ble y. Showing the relative prevalence of certain rare forms of skin 
disease in both dispensary and private practice in America and Europe. 
675 
Diseases. 
Amer’n. 
10,000 
dispen- 
sary 
cases. 
Per cent. 
Scotch. 
10,000 
dispen- 
sary 
cases. 
Per cent. 
Irish. 
3000 
dispen- 
sary 
cases. 
Per cent. 
Austr’n. 
23,941 
hospital 
cases. 
Per cent 
DDtaneum 
VipP, atltiasi8 Arab. 
1 
.01 
2 
.02 
1 
.03 
5 
.05 
7 
.07 
2 
.06 
36 
.15 
ntiaSiS Grsec- 
2 
15 
.02 
.15 
1 
5 
.01 
.05 
3 
1 
.01 
jJ?ucoderrna 
Ltlen exudat. rub. 
T; ,lei1 Snrofulosorum 
Hlen Planus . . 
2® fsma.... 
Mf!l|USCUm c°ntag. . 
Morni!CUtn fibrosum 
to^Pnaea 
, eHagra 
vcleroderma .* .* 
Xanthoma ! ! 
1 
■2 
1 
.01 
.02 
.01 
4 
3 
.04 
.03 
7 
67 
.02 
.23 
3 
13 
3 
.03 
.13 
.03 
1 
6 
1 
.01 
.06 
.01 
5 
.15 
5 
.02 
1 
.03 
7 
.07 
1 
.01 
4 
.04 
Scotch. 
English. 
Per cent. 
Diseases. 
2000 pri- 
Per cent. 
1000 pri- 
Per cent. 
10,000 pri- 
vate cases. 
vate cases. 
vate cases. 
ftw.1 catatleam 
JSlSu ntiasis Arab. . 
Gr.ec. . . 
* ‘ * 
l5en exudat. rub. . . 
LipV,etl Scr°fulosorum . 
It'?6" Planus . . . 
\lnfSma ‘ 
kn USCUm contag. . 
kol \SCum fibrosSm . . 
2 
2 
1 
.1 
.1 
.05 
1 
1 
.1 
.1 
3 
20 
34 
.03 
.2 
.34 
1 
.1 
2 
.2 
2 
5 
2 
2 
.1 
.25 
.1 
.1 
6 
5 
.06 
.05 
&hae'a . 
sellagra . 
vcleroderma ’ * * 
3 
1 
.15 
.05 
1 
.1 
11 
1 
2 
.11 
.01 
.02 
authonra .... 
4 
.2 
8 
.08 
now turn to Table V. we may learn the relative prevalence of 
IXI6 of the rarest forms of disease of the skin in both dispensary and 676 
J. C. WHITE, 
private practice in America and Europe. The results are interesting 
mainly because they show on the one hand how extremely rare are cel' 
tain affections of the most marked type, and on the other hand how very 
infrequent are other diseases in the countries thus represented compel’0! 
with their well-known prevalence elsewhere. We have here tabulated 
it will be remembered, 60,000 cases of skin disease. Among them in tn 
first category we find only 4 cases of cutaneous horns; 82 cases of mol' 
luscum contagiosum, 16 of molluscum fibrosurn, 15 of raorphsea, 12° 
scleroderma, and 16 of xanthoma. In the second class above specify 
the most notable instances are those affections which assume in certain 
parts of the globe an endemic character; elephantiasis Arab urn occU>.s 
but 56 times, 36 of which are found in the Austrian column; elephant1' 
asis Graecorum (leprosy) 27 times, of which 2 were American, 3 Scot611’ 
and 3 Austrian, and the remainder (Mr. Wilson’s) nearly all import6 
cases from colonial leprous districts. Pellagra occurred but in a singl' 
instance. Two other affections, outside these two classes, should, pelr 
haps, be referred to specially, inasmuch as they have been so sharp J 
defined as distinct types by Professor Hebra; these are lichen exudativu 
ruber and lichen scrofulosorum. Of the former not an instance is record6' 
outside the seven Austrian, except one amongst Anderson’s private cas63' 
Lichen scrofulosorum occurs only twice in the American 12,000, and hv 
times in the Scotch 11,000 cases ; while 67 instances are recorded in W 
Austrian statistics. 
The conclusions to be drawn from the above brief analysis of th 
tables, which have a direct bearing upon the question immediately bein’ 
us, may, perhaps be best arranged as answers to questions, as follows- 
(1) What skin diseases of well-established character and recoglllze 
occurrence in Europe are wholly absent in the United States? ? 
(2) What affections are noticeably less prevalent here than in Euro}16' 
(3) What affections are more prevalent amongst us than in Europe 
(4) What modifications from the European types are observed in skl 
diseases in the United States? 
(1) Wholly absent.—The most notable example in this class is Prurig0' 
I mean by this term of course the affection which one sees so freqn6llt{, 
in the Vienna clinic, and which is marked by such pronounced feat111'!, 
that its individuality is unquestionable. Ido not mean that jumble 
cutaneous disorders so frequently called by this name, secondary chapgp 
in the tissues of the skin as the result of simple pruritus, animal parasff 
etc. One feels its absence from his practice after foreign study 
positive void long after his return, but may even come in time to do 1) 
the truthfulness of his recollections and the very existence of the a • 
tion. Hot a single case is recorded among the 10,000 American case9 1 
Table lIP, and but a single one among the same number in Scotia11 
and lam giving here the results of the observations of those only £ 
have had ample opportunity of studying it in Vienna. In the tain6 
statistics of private practice, Anderson records two more cases. 111 n 
own, none are set down ; yet I have seen one or two patients, wb° 
cases in Vienna might perhaps have passed for doubtful, ill-den 
examples of the disease, but none who presented all its 
manifestations. I)r. Wigglesworth, of Boston, has reported a case wm 
he thought must be prurigo. On the other hand, we find in the ien.j3 
column of the table 740 cases, forming in fact 3 percent, of all 
diseases treated in Ilebra’s wards. llow can we account for this strik” Variations in type and prevalence of skin diseases. 
677 
Rriation in the prevalence of so well-defined an affection ; for its entire 
< JSence from this country? lean offer no explanation. There is no- 
j 11J1S in its pathology, or known etiology, to assist us in this direction. 
s prevalence is greatest in the country which, of all Europe, presents 
le greatest diversity in races. We can only blindly congratulate our- 
on the absence of this life-long and well-nigh incurable disease. 
Among the rarer affections of the skin which are tabulated as to their 
preparative prevalence in Table Y., there are two which find no 
rp.clCejn the American columns, lichen exudativus ruber, and pellagra. 
first named is one of the rarest diseases even in the country where 
8 individuality was first recognized and announced, only about twenty 
<lses in all having fallen under Prof. Hebra’s observation, seven of which 
, nc* place in the Austrian column. Anderson records a single instance 
toong his private cases, making, with Hebra’s, only eight among the 
' IQIe 60,000. We know nothing of the causes, and but little of the 
■pure, of an affection which proved uniformly fatal until brought under 
pEjection by arsenic, but more extended observation may yet give it a 
P ace upon our native list. 
cl m^a§ra, granting still its specific individuality, follows such sharply 
renned geographical laws of distribution, that it is not surprising that 
P’T a single case is recorded in the table and that under Mr. Wilson’s 
Nervation. It is improbable, with the marked contrast in respect to 
• IG abundance and variety of food which our country offers to the regions 
I dec ted by this disease, that it should develop amongst us, but not impos- 
P J*e that emigrants from its haunts may bring it to our shores. It 
. °uld scarcely establish itself here, however, as it has been slowly retreat- 
from some of its oldest footholds in Europe during the last half cen- 
i(2) Less'prevalent—Our analysis shows that the following affections 
ave more or less claim to be considered in this class: Erythemata, 
leri scrofulosorum, lupus, leprosy, phthiriasis, scabies, tinea favosa, 
d alopeeia, areata. 
g Ihe various forms of erythema seem to prevail less in the United 
a than in Great Britain, at least. The causes of such disturbances 
tp S° Var^ous and so often of extraneous character, that it is not strange 
t.lclt considerable diversity in their prevalence, corresponding to varia- 
g to modes of living among different nations, should exist. Of lichen 
{ofuloaorum we know so little that it would be useless to conjecture 
P A the skins of strumous patients should be less liable to such disorder 
Gto and apparently elsewhere than among the nations of the Austrian 
ta??lre’ but such is notably the fact. Lupus, it will be seen by the 
tiv eS’ orms one °f fbe most striking examples of variation in compara- 
? occurrence upon this list. It is an affection, moreover, about 
8ollc 1 false conclusions in this respect are least liable to exist; for it is 
, gtove in character, so enduring in course, and so imperative in its 
piUlancf for heroic means of cure, that scarcely a case is liable to escape 
G observation of the dermatologist. Lupus is a rare disease in America, 
ough if our figures were drawn from hospital records the statistics 
dc\u f° support this opinion, because most chronic ulcerative and 
P 8 lUctive processes, especially those seated upon the face, are regarded 
jl'W?l,Se°us as lupus. It is not only rare but, as we shall see below, 
0))-( • m fype also from that so commonly observed in Europe. The 
vu,;;ion held, lam aware, by some American dermatologists that lupus 
<garis is even less common than.lupus erythematosus amongst us. Dr. 678 
J. C. WHITE, 
Duhring has found it to be so here, in Philadelphia, and Dr. GeddingP 
of Aiken, whose valuable studies of this affection are so well know11’ 
writes me that it is “ much more common at the south than genuin 
lupus.” Yet Tables I. and 11. show that whatever be the case in the moi 
southern parts of the United States, such is not the fact when the figll1’03 
drawn from the three cities, Philadelphia, Yew York, and Boston, 
combined, for of the seventy cases forty were lupus vulgaris and thb’U 
lupus erythematosus. 
Leprosy (elephantiasis Grsecorum) according to Table Y. would seen1 
to fall almost within the class of affections which do not occur amongßl 
us, two cases only being recorded therein, both of which, however, we'e 
observed in native Americans. Yet we know that in the neighboring 
province to the northeast there has long been a community of lepe1B’ 
and that in our western States among the Norwegian immigrants tn 
disease exists. In our southern States, too, lam informed that it p1'6' 
vails to some extent, and am indebted to my friend Dr. W. IT. Gedding3 
for the following notes concerning its occurrence in his native cit)’ 
Charleston, S. C. The first case of the disease came under the observe' 
tion of his brother in that city some time between 1846 and 1849, na 
he is unable to say whether it had occurred before that time. Sixteen 
well-established cases have come to his knowledge since then, five 
them within the last ten years. In none of them was any hereditaO 
taint to be traced, no progenitor having been affected as far as know11’ 
except that mother and daughter in one instance were attacked sinndG' 
neously and died about the same time. In two other instances also tw° 
members of the same family were affected. These certainly are veDr 
important data, and worthy of further careful investigation in connecti°*J 
with the question of infection, which can be nowhere so favorably 
as in an isolated region where hereditary taint is excluded. With regal 
to the race and color of the lepers, four were Jews, eight were whJ0 
Christians, three were mulattos, and one a full negro. The wide-sppea 
occurrence of the disease outside our limits to the south, in troplC!l 
America and its islands, and westward in the Pacific isles, is well know11’ 
With such foci of foreign origin all around us, and even within °u 
borders, it is not improbable that the disease may some time becon10 
endemic in the United States. 
Phthiriasis and Scabies.—ln the former, an affection almost wholy 
confined to the lower classes, we somewhat lead Great Britain, accordnG 
to the Tables, but as compared with Austria, our cases are only one t 
three. It is in connection with scabies, however, that the most remnW 
able difference is to be observed. Since the close of our late war, dui’HG 
which it attained a wonderful growth, it has again dwindled until it 
become a somewhat rare affection, even in our seaboard cities where 1111 
migration is constantly bringing fresh supplies to sustain it. While "rg 
us, as Table 111. shows, it forms only 2.3 percent, of dispensary cases, 11 
Scotland it constitutes 25 per cent., and in Vienna 48 per cent, of t1 
same class, and in the Ospedale di S. Gallicano at Pome, one-half t1 
cases under treatment in 1873 were of scabies. The disease seems to 1 
diminishing also steadily in Austria, for, whereas in the Vienna ohll 
in the year 1857, that of the first report included in our statistics, fi’ol 
were 1695 cases, in 1873 there were only 322, a diminution due in VIXX 
to the fact that the various trades in Vienna are employing each its 
physician, instead of sending the infected to the general hospital. T11(31  ATIO Ng xjf TYPE ANT) PREVALENCE OF SKIN DISEASES. 
679 
n° reason, however, why, with habits of cleanliness like our own, the 
Se should not become as rare everywhere as amongst ourselves. 
, tinea favosa, as stated in the analysis, is somewhat less common here 
aR in Europe, especially in Scotland, but it is in Italy that it finds 
.Pparently its most favorable conditions of development. In the skin 
°spital at Rome, above mentioned, Dr. Schilling reports 145 cases in 
le year 1878, 98 in 1874, and 63 in 1875, or nearly 12 per cent, of all 
16 cases there treated. Such extraordinary preponderance implies either 
'e existence there in proportionate abundance of the extraneous sources 
contagion, or wonderful carelessness or ignorance concerning its com- 
. Tinea tonsurans and tinea versicolor, on the other hand, 
uiay be stated, seem to he almost wholly unknown there. Such local 
familiarities in the prevalence of the vegetable parasites, may yet lead 
0 important discoveries in relation to their non-parasitic phases of de- 
Vel»Praent. 
Alopecia areata.—With no intention of entering upon the disputed 
Action of the nature of this mysterious affection, it is to be noted that 
18 of less frequent occurrence here than in any of the European 
°'mtries from which we have drawn our reliable data. 
. (v) More 'prevalent.—The affections which are shown by the tables to be 
1 aRy marked degree more prevalent here than in Europe are, seborrhoea, 
urticaria, pruritus, the peculiar forms of efflorescence due to the 
imsons of rhus and mosquitos, heat rashes, herpes, alopecia, and tinea 
to'pUrans (sycosis). The affections of the sebaceous glands seem really 
more common with us in all classes than among European nations. 
P Rave no explanation of the fact to offer, but I am aware that it will 
t e Used as an argument by those who hold the opinion that acne is con- 
‘ected with derangements of the digestive system, inasmuch as Arneri- 
Riis are supposed to be more “dyspeptic” than other people. However 
• J'B may be, for my part I have never been able to find any fault of the 
fflternal economy which I could regard as an important primary factor 
1 the etiology of this disease in any general way. No more can I 
xplain the somewhat increased prevalence of seborrhoea of the scalp in 
D'vate practice here, over its occurrence in the same classes of society 
ruad, in places where our statistics allow a direct comparison. The 
qore frequent occurrence of alopecia, as shown in Table lE, is, perhaps 
1 Jfmportion to, and in direct consequence of, this latter affection. 
Urticaria and pruritus are both slightly more prevalent in the United 
‘des than in Europe. Both are more or less intimately dependent upon 
o*°hi float ions of innervation, and it may be that our drier atmosphere 
. Skater extremes of temperature may account for such excess ; cer- 
‘Uuly the latter affection in some of its forms is closely connected with 
ilO winter season. Summer, too, with our intenser heat, it may here 
6 mentioned, produces far more frequently direct disturbances of the 
Ameral integument than in more temperate Europe. Prickly heat, heat 
kl. i or folliculitis dependent upon overwork of the sweat glands, is 
. fflversally prevalent, leading up to acute eczematous and furuncular 
’Animations of the cutaneous tissues, which form no small share of our 
during such a season as the summer just passed. Herpes zoster, 
al°’ aPPears to be more common among dispensary patients here than 
fo*°ad, possibly through climatic influences, as there are good reasons 
1 1 believing that in some cases it is directly caused by impressions 
eeived through the skin itself. Other forms of dermatitis occur 
mougSt us, which as the result of purely local excitants, in both senses 680 
J, C. WHITE, 
lit 
of the word, are not met with in Europe, but which on this very accom 
need only have mention here. They are the peculiar eczematous inff*11* 
mation produced by the poisonous species of rhus, so widely diflnse, 
throughout the United States, and the multiform efflorescences provok6 
by the stings of mosquitos in persons not previously inoculated 
their virus. 
The vegetable parasitic affections present, as we have seen, 
unexpected variations in comparative prevalence in the countries include 
in our tables. It is tinea tonsurans which seems to find its most fov° 
able conditions of growth amongst us; and in its various manifestation® 
of ringworm of the scalp, beard, and general surface, of parasitic sycos1 » 
and so-called eczema marginatum, is quite a common affection. Amolb 
domestic animals, too, it is not unfrequently observed. Were the 
of such unequal distribution of cutaneous affections more fully recojf , 
nized, we should not witness controversies between dermatologists 0 
different countries concerning the prevalence or even the very existen® 
of certain diseases, nor have the authority of so eminent a master 
Hebra categorically expressed in denial of the occurrence of affectm" 
which are almost daily met with here, because they are rarely met Wlf 
in Vienna. Of such character are his assertions in relation to tin®*1 
sycosis, which may well be extremely rare in Vienna, and yet from di#0 
rent habits of barbers in shaving, perhaps, or from other causes, 
occur very frequently elsewhere, as it certainly does at least in Bosto'1' 
It is especially in connection with the vegetable parasitic affecti011 
that one’s point of view should be very broad before venturing up°u 
such statements. .. 
(4) Modifications.—Before discussing this division of our subject,1 
should be distinctly stated that we have now left our tables, impert 
as they are, behind us, and that our opinions in connection with it re , 
almost wholly and necessarily upon impressions alone. As individu 
observers we may naturally differ widely from one another, therefor®’ 
upon such points. My own opinions will be stated, briefly and it 
be uncertainly, although I doubt not that others will have much mOl 
decided and definite views upon the subject to express. lam aware, 
example, that some of our best observers believe that many affections 0 
the skin assume a more acute or inflammatory type amongst us tml 
elsewhere, and that others are of the opinion that cutaneous diseases 
less tolerant of exciting and severe local medication than in Europe, flll 
that therefore what may be the best methods of treatment there may f? 
injurious even, if strictly followed here. lam not prepared to conce >g 
these propositions; at least I do not think that I have sufficient 
to warrant the statement of any such convictions in this paper, even 
they were doubtingly entertained by me. That my judgment 'vl 
regard to the choice of remedies in skin diseases may differ someth' 
from that of some foreign writers and teachers, is indeed true, but 1 c 
not on this account feel authorized to infer that the therapeutical 
physiological reaction of the American skin differs materially from I*l 
of the European, for I know that I differ quite as widely from some of IJv 
colleagues here at home upon important matters of treatment, and I niafp 
confess too that, now that I come to record formally my opinions regnf 
ing this part of our subject, lam not prepared to state my belief in the i 1 
quency or degree of such changes of type in these affections as strong J 
or generally as I thought I might do before considering the question 
immediately.  IN TYPE AND PREVALENCE OF SKIN DISEASES. 
681 
The number of diseases that I can specify as exhibiting such modifica- 
-0118 to any noticeable extent is therefore extremely limited. They are, 
oreover, diseases characterized by varied and extreme structural changes 
tlie cutaneous tissues, so that a comparison of the appearances pre- 
-11 ted as the}' occur here and elsewhere, is easy. The most conspicuous 
Sample of such is undoubtedly lupus vulgaris. We have already seen 
lat it occurs far less commonly here than in Europe, and it may be that 
? sarne law governs its course as well as prevalence. At all events,. I 
lllk there can be no question that we do not see cases here which 
Pproach those so frequently met with in foreign clinics in severity of the 
estructive process, or in extent of the surface affected. Such at least is 
‘}T own experience, and I have no reason to offer in explanation of the 
act. It might seem that it required several generations of accumu- 
awd malnutrition or more positive constitutional evils to effect such 
Eventual disorders of cutaneous structure, and that on this account lupus 
l,evailed more abundantly and in its worst forms where poverty and 
t]0(lily misery were more common than with us ; but Ido not think that 
Ae history of individual cases amongst us warrants any such conclusion, 
'vish I could add that I have found a corresponding benignity of type 
? disposition to yield more readily to treatment, but corresponding 
asses of cases have in my experience exhibited the same obduracy to 
here as in Europe, and perhaps the same tendency to relapse. 
The same statements may be made with truth, too, in my opinion, of 
6 cutaneous syphilides, especially their later manifestations. We 
rp/'ely, if ever, see here cases of so grave a type as in European hospitals, 
j-here seems to be a resistance to the destructive force of the disease, on 
j1® part of the skin, which tends to prevent the formation of the worst 
esi°us within its tissues, 
.-Leprosy, too, seems to feel the mitigating effect of some local influence 
'Vlthiu our borders. In Trecadie it has kept up a lingering existence for 
uiany years. With regard to its character among our Norwegian immi- 
grants at the West, at present, I regret that I have no definite intorraa- 
to impart; Prof. Boeck expressed the opinion, after his visit to them 
a few years ago, that the disease seemed to be partially controlled ; its 
retarded to some extent by their change of residence. Whether 
, ie interesting observations made by him while amongst them are 
e.sf interpreted under the theory of contagion or hereditability, is not 
Whin the province of this paper to consider. As to the character of the 
as it occurs in our southern States, I am not informed. 
, Indeed, the best use that I can make of my conspicuous want of know- 
edge upon this and other points which should be considered under this 
Wsion of our subject, is to exhibit it frankly as an illustration of what, 
fear, may be a too common state of ignorance on our part, and to indi- 
?afe how much definite information is yet to be acquired before we can 
utelligently discuss it. Finally, I may add that no one can be so fully 
iVVare as myself of the incompleteness of this paper in all respects, and to 
Jow unsatisfactory an extent iffails to answer the questions it proposes, 
offer it merely as an introductory sketch, or skeleton chart, to show in 
Jat directions we may best carry out the investigations which may 
Mutually lead to the full solution of the subject. 
The following conclusions seem to be warranted by the data above 
Rented :~ 
T Certain obscure affections, the etiology of which is little, if at all, 
nderstood, even in those parts of Europe to which they are mostly con- 682 
J. C. WHITE, 
fined, may be regarded as practically non-existent amongst us. Such are 
prurigo, pellagra, and lichen exudativus ruber. 
11. Certain diseases, directly connected with and dependent up°n 
poverty and habits of personal uncleanliness, are less prevalent in tbe 
United States than in those parts of Europe of which we have sufficient 
statistical information for comparison. Examples of this class are tbe 
animal parasitic affections especially. 
111. Some cutaneous affections of grave character, which are dependent 
upon or a part of serious constitutional disorders, are of less frequent 
occurrence and of milder type amongst us than in Europe in general, °l 
those parts of it where they are endemic. Lupus, the syphilodermata (•)’ 
and leprosy are the most marked instances of this class. 
IY. Certain disorders of the skin, especially those of its glandule 
systems, and those connected more immediately with its nervous system? 
are apparently more prevalent with us than in Europe. The most notable 
examples of the former are sehorrhcea, acne, and possibly the heat rashes? 
of the latter, herpes, urticaria, and pruritus. 
Discussion on Dr. James C. White’s Paper. 
After the reading of the preceding paper, Dr. Lours A. Duhring, of Phil*1' 
delphia, said:—The subject treated of in the paper just read is one of greff 
interest, and the statistics contained in it show that there is a marked d’s' 
crepancy in the prevalence of skin diseases in the three great eastern cities o 
this country, Philadelphia, New York, and Boston. How to account for these 
differences is a difficult problem, and, on account of these differences, Pl' 
White’s conclusions should, it seems to me, be taken with reserve. The p1’6' 
cise meaning of some of the terms employed should also be given with rnm’e 
particularity; for instance, m orphan a is a name susceptible of several meaning 3' 
Dr. L. Duncan Bulkley, of New York, said:—American statistics are not 
as complete as could be desired. Morphaea is undoubtedly more frequent than 
it is represented to be in the tables of Dr. White’s paper. I have myself see11 
it in a number of cases. I observe that no cases of prurigo are mentioned m 
the paper. Heretofore, I have only reported cases observed at hospitals and 
dispensaries, and have not reported those of ray private practice. I have ha( 
two cases of prurigo under my own observation in this country. I also belief® 
that, in the types of diseases of a congestive character, there is a marked dd' 
ference between this country and Europe. I have in New York repeatedly 
tried Hebra’s treatment for this class of cases, without success. I am 0 
opinion that in these diseases, as met with in the United States, there is the 
general characteristic of nervousness, so peculiar to the American peopl6’ 
which requires a treatment very different from that taught in the schools 0 
Europe. American physicians are discovering this everyday; they are be- 
coming more familiar with American characteristics as they grow older, all 
are finding it profitable to forget much that they learned in the old world. 
Dr. Duhring said :—I have brought up the subject of morplnea in order to 
ascertain the views of Dr. White on that disease. Dr. White and Dr. Bulkle} 
evidently understand it as Mr. Wilson has described it; whereas I think tha 
Mr. Wilson has so confounded it that no one could recognize it from hl3 
definition as a distinctive disease. Mr. Wilson confounds the old morphrea 0 
leprosy with the modern morph sea. I have discarded the definition of Wilsom 
and also that of Kaposi, and have from experience adopted the view to whm 
Dr. Eox has inclined. Morplnea should be entirely disconnected from lepros.' - 
I have seen three cases of it, at a clinic in London, and five in this count!,'- 
As I understand the disease, its manifestations are of two kinds; the flj’s 
being the large or small yellowish circumscribed patch upon the skin, aRIATIONS in type and prevalence of skin diseases. 
683 
fo!'ece fat or lard, in appearance resembling the well-known macular 
. °f leprosy, with which, however, it has no connection. Another form 
Aiv 6d the name of morphsea is the keloid so accurately described by Dr. 
(IISOIL I have seen four cases of this disease in this country. It is an 
cle ,'emely complex affection, requiring great detail and particularity in its 
seripti°n. I have seen all the symptoms encountered in both forms of the 
I ' L>ase in one patient; I have seen the macular patches from the size of a pin’s 
a a(. to that of a hand with those numerous symptoms of the so-called keloid of 
dison. I have also seen the macular manifestations, accompanied by reddish 
j Purplish streaks and striae atrophicse, and, moreover, band-like cicatriform 
In a paper recently prepared by me, I have tried to give an accurate 
®eviption of the disease, but to attempt it here would occupy too much time. 
I t)*'- Bulki.ey said:—l would designate as morphsea just what Dr. Duhring 
described, and, with due deference to Dr. Duhring, would say that Wilson 
* 'es a similar description. 
Duhring said :—Partial atrophy of the face should not be confounded 
r.,1 1 niorpluea, though it closely resembles the cicatriform form of the disease, 
j. le object is a very complicated one, and the clearest distinctions should be 
ade between the old morphsea of leprosy, the macular and cicatriform varie- 
e® °f the disease now designated raorphaea, and unilateral atrophy of the face. 
,r* White said :—I had a case which began with the round form of mor- 
'sea. Jt was sent to England where Mr. Wilson saw it and called it morphaea; 
Xq6'1 I'0 V ienna where Hebra called it Addison’s keloid ; and, finally, returned 
® this country and resulted in time in atrophy of the skin. In the paper 
j.O ol’e the Section the word has been used in all the looseness of meaning 
ecffiiaite to cover the variety of forms assumed by the disease. 
w Duhring said :—I have seen the case referred to by Dr. White, and I 
°uld call it unilateral atrophy of the face. The lesions are not confined to 
‘e skin, but extend deeper and affect even the muscular tissues and bone sub- 
aBce. In one case of unilateral atrophy of the face which I have observed 
eight years, the tongue and roof of the mouth have dwindled upon one side 
half the normal size. 
l* Dulkley said:—l have seen two such cases, in which the patches, or 
felfS^s °f development, resembled very much morphaea. I have also within a 
tl V%s seen a patient who has been put under galvanic treatment and is two- 
-1lf*s °r three-fourths cured. 
r. Duhring said :—ln the reported cases of unilateral atrophy of the face, 
j^e disease has tended to increase from year to year, while in those cases of 
olphsea which have come under ray observation, the disease has tended to 
evillta.neous recovery; one young lady who has been the subject ot a most 
Rn fnsiVe morphaea, is now nearly cured, the patches upon her body having 
the £ ®oue spontaneous involution ; this never occurs in unilateral atrophy of 
jj Pl’- White said :—With regard to prurigo, lam well aware that many Eng- 
ca 1 Wl’iters do not concede that there is such a disease, maintaining that the 
Seeu W Vienna are but poorly developed diseases of a secondary charac- 
!111 which the cutaneous lesions follow, and do not antedate, the subjective 
Matures. 
Dulkley said:—l have seen two well-defined cases of prurigo in native 
One occurred in a man who, after terrible suffering, died of the 
ase- The other was the case of a child. 
o-ei ** Engelsted, of Copenhagen, said:—Prurigo is very rare in Copenha- 
H *s sometimes met with. It sometimes commences in childhood, and 
j *en incurable. It occurs only in the lowest grades of the population. 
Ih 1 I)UHLIING said :—I agree with Dr. White, that this is a very rare disease. 
Rio-aVe Been kut one case in this country (at Boston), that I thought was pru- 
p*°.’ could not positively say that it was so, for I saw the case only once, 
Will • asked to name it I could call it nothing else. I was forcibly struck 
IBs resemblance to the Austrian prurigo. The whole surface was involved. 684 
J. C. WHITE, VARIATIONS IN SKIN DISEASES. 
"While attending the clinic at the Hopital St. Louis, at Paris, I one clay sav 
boy who had prurigo. Hardy said that he called the disease “ strophl1* 
prurigineuse,” but it was undoubtedly the prurigo of Hebra. Hardy said 1 
was obstinate but curable. Evidently it did not, in Paris,take on that agg'a 
vated form which is commonly seen in Austria. There is at present, in 
Philadelphia Hospital, a case very much resembling prurigo, but I would n° 
so call it. I doubt whether lichen ruber is more common abroad than hel6' 
Lichen planus and lichen ruber I regard as one and the same disease, \] 
latter being the more advanced stage of the process; I would ask Dr. Wnl 
whether, in his experience, he has ever known lichen planus to run into lichell 
ruber ? 
Dr. White said :—I have not. 
Dr. Duhring said :—I would ask Dr. Engelsted whether he has ever seen 1 
Copenhagen Hebra’s lichen ruber? 
Dr. Engelsted said;—l have not, but I have seen there lupus vulgaris. 
Dr. Duhring said:—Lichen ruber is as rare in Europe as here. I have see 
in this city a case of lichen planus which passed into what might be cabe 
lichen ruber; it was not so severe as the cases I have seen abroad. Prurg? 
is a common disease in Austria, but lichen ruber is rare. I must also dine 
from Dr. White as to the severity of the syphilodermata, which I consider 1 
be as severe in type in this country as in Europe. 
Dr. White said:—Upon this point 1 have written only from my own ol>ser 
vations in Boston of the severity of the disease, and have made no comparison 
with other cities. 
Dr. Arthur Yan Harlingen, of Philadelphia, said :—I agree with Dr. Hu 
ring that Philadelphia has a pretty fair share of these cases, and that many 0 
them are of a severe type. There are no syphilitic clinics in this city; 1)U ’ 
judging from the tables of skin diseases, the proportion of the syphilodernW 1 
is large. 
Dr. Bulkley said;—T coincide with Dr. Duhring’s opinion that the disea8 
is not less severe here than in Europe. 
Dr. Duhring said:—Many cases have come to my notice undiagnosed all 
consequently untreated. I can recall half a dozen frightful cases which ha' 
come from the country districts untreated. In Vienna the disease is, as arm ’ 
recognized at once and treated, and hence it is checked before it reaches 1 
worst stage. One case which I can recall had been diagnosed as cancer, a'l 
so treated for fifteen years. 
Dr. Bulkley said;—l have known five cases of elephantiasis Grascorun1’ 
two died within four or five years; another has been progressing eight or nlll 
years, and another four or five years. Two of these cases came from 1 
southern part of this continent. Those which occurred in native America11 
were very severe. 
Dr. Duhring said ;—4 was not aware that leprosy occurred in this countif 
at all unless it was imported. Before being convinced that it exists 
cally, I should like to see a case thoroughly studied by a competent observe 
and have it carefully reported. The disease occurs in Central America a’1 
Mexico, in the Sandwich Islands, and also in California; but not, I thin M 
endemically. I have seen but one case in this country, and that was a CuDh-H? 
who acquired it probably in Spain. 
Dr, White said:—Prof. Boeck thought that the disease, as found in 
Norwegian settlement in this country, had been checked by the change of >’e® 
dence. I have known of one other case, one of the tubercular form of t1 
disease, which resulted fatally in Boston. 
Dr. Van Harlingen said :—As to lupus, I think that statistics here sh°" 
larger proportion of cases of lupus erythematosus than of lupus vulgaris ; 
fact, the former may be considered a common disease, whereas the latte* 
not so frequent. 
Dr. Duhring said ;—The American type of lupus vulgaris is much mih L 
than the European. 685 
VERRUGAS, A DISEASE PECULIAR TO PERU. 
BY 
GEORGE A. WARD, M.D., 
MEDICAL DIRECTOR OF THE OROYA RAILWAY. 
T . 
iseT 18,1 believe, pretty generally know throughout the world that Peru 
then®aSe(lin the gigantic enterprise of building a series of railways across 
the v,n°Wy PeaLsof the Andes, in order to connect the Pacific ports with 
con *ead. waters of the Amazon ; and by this means to establish a shorter 
Ho Unu 11 Nation with Europe, thus avoiding the inconveniences which 
w result from a long and tiresome sea-voyage, as well as throwing 
t° the w°rhl the untold wealth which exists on the Amazon and 
en J;rihutaries. This wonderful undertaking, conceded to be the greatest 
gnieering triumph of the century, is due to the energy, skill, and per- 
|®rance of Don Enrique Meiggs. 
q~n °ae of these routes, starting from the Pacific Ocean at the port of 
of if0’ Pass^ng through Lima, the capital of Peru ; thence up the valley 
the laver Plniac; and finally crossing the summit of the Andes by 
0i ans °f a tunnel, at an altitude of 15,645 feet above the sea-level, vast 
iave been encountered, not only in the way of the many natural 
of jU.^es to be overcome, but also from many and strange diseases, one 
So WhvlG.h R R the purpose of this paper to describe; but before doing 
y a brief geographical description of the district in which this disease 
p,«vailß will bl proper. 
his district lies between altitudes of 3000 and 6500 feet, cases of the 
j S®ase occasionally originating a few hundred feet higher, though rarely. 
a^ ®an Pedi’o Mamma, 3000 feet above the sea-level, we find 
p (*ry rocks; but on the river banks, wherever water has access, fine 
e 1 .Urage for animals. The banana here grows luxuriantly wherever 
IVated ;as we gain altitude, we encounter fine groves of oranges, 
cherimoyer, peaches, guavas, and in fact every variety of tropical 
except the cocoanut; as well as vegetables familiar to our northern 
UeT’ as o,iion, lettuce, cabbage, etc. At an elevation of 5280 
Va],’ ar*d 46 miles from the sea, the character of the soil changes, as the 
the becomes more narrow, the soil sandy and intermixed with granite, 
Ca Bu|es °f the mountains steep and producing abundantly a variety of 
cai i’ susceptible to a high degree of cultivation wherever water 
in e.cai’rßd. At an elevation of about 6000 feet, we find the granite 
‘ finable, decomposing condition. 
(]e a,lalng through this valley is a rapid mountain stream varying in 
of tV *lom two to s'x *’eet, hy sPl’lnos an(l the melting snows 
and 10 Bunimif* The temperature at the altitude of 3000 feet is mild 
an . ,e(IUahle; as we gain 4000 feet the temperature is increased, and at 
j’ai*1 of 5280 feet we frequently encounter a temperature of 110° 
oiem'i ln s^iacß’ the middle of the day, and at night find it suffi- 
ltly co°l to require a couple of blankets on our beds, the range of 
[Communicated by the Secretary.] 686 
WARD, 
12 
temperature frequently being as great as forty degrees Fahr. between 
M. and 12 P.M. Approaching an altitude of 6000 feet, the temperate1*6 
again becomes more equable, and at an altitude of 8000 feet it rarely 
varies ten degrees the year round. 
The name popularly applied to the disease of which I am about f° 
speak is Verrugas. It is a disease usually preceded by an initial teyel 
of varying intensity, lasting from ten to thirty days, and accompam6 
by excruciating pains of a rheumatic character, finally culminating in 0,11 
eruption of warts over the body; these occasionally proceed to suppll' 
ration and ulceration, accompanied at times by profuse hemorrhage. .. 
It is a disease confined to certain valleys in Peru ; it has well-define 
limits, and is not found outside of those limits. Its range of altitude lS 
between 3000 and 6500 feet, and it is found in the valleys of the Rin'iaC’ 
Pacasmayo, Chimbote, and some of the valleys on the eastern slope 0 
the Andes, and was probably the disease which struck terror into tj10 
adventurous hearts of Pizarro’s troops on their march into the interi0 
of Peru through the valley of Turnbez. lam informed that this diseu80 
prevails on the eastern slope of the Andes, but always under the sa^10 
conditions of altitude, soil, climate, and natural productions. 
It is a disease which affects animals as well as men ; it is a disea90 
which recurs, one attack not exempting from a second, a third, or eyel 
a fourth, if the person is exposed to the same influences. The 6ruptK>1 ■> 
however, in the subsequent attacks, is not as profuse, nor the warts as 
large as in the first, although no general rule is observed in this resp© 
The disease obeys none of the known laws of the exanthemata, althoug 
it is in many respects closely allied to them. Retrocession of the erup' 
tion always produces very grave, and often fatal, symptoms, and usualv 
takes the form of congestion of the liver or lungs. In like maun01’ 
should the eruption not make its appearance on the skin, or niucou9 
membrane of the mouth or nose, a fatal termination of the case may V 
expected. Many have supposed the disease to be allied to syphilis, but 
do not so regard it. The disease cannot be communicated by inoculati©11’ 
for I have repeatedly tried on my own person, as well as on others, t1 
insertion of pus from an ulcerating verruga, but. without avail. 
only analogy with syphilis is in the nocturnal pains and the occasion 
persistence of a copper-colored spot on the skin after a large verruga baS 
proceeded to ulceration and cicatrization. The ulcers lack, howeV1’ 
entirely the geometrical forms so characteristic of syphilitic ulcerating 
and these copper-colored spots are only left on the parts of the both 
which are covered by the clothing; no matter how large a crop 0 
verrugas one may have had on the face, scars or discolorations rare ) 
remain. 
In those cases in which the disease is heralded by an initial fever, t" 
types are presented; the acute rheumatic, and the low typhoid, olt© 
combined with an intermittent element which prevails extensively 1 
the verruga district. Patients thus affected require careful watchuk 
from their extreme liability to succumb to the violence of the feV<31’ 
before the eruption makes its appearance. . 
In the excruciating pains, particularly affecting the joints, this a 
tion is closely allied to dengue, a disease which occasionally occurs 
the Southern States of North America. In contradistinction to 
however, one attack does not prevent another ; the fever has a l°n&. 
duration ; the eruption is of a different character; hemorrhage 0)11 J VERRUGAS. 
687 
l0ClTrs from the verruga itself; the duration of the disease is much 
fatin’ *s not eP^ern^c J and it is an extremely distressing and often 
A a disease. It occurs as well among the strong and healthy as among 
who are weakened by previous disease, or who are of feeble habit 
ur body 
T J 
J-n regard to the cause, nothing is known. Many have supposed the 
sease to be caused by the water of the valley ; this cannot he the case, 
h niany Pe°pte have simply passed through the infected district on 
P°rseback, or in the train, without drinking one drop of water, and have 
een as severely affected as those who have passed weeks and months in 
® valley. Others, in their fear of having the disease, have drunk 
othing but wine or brandy during their entire period of residence, even 
coffee and tea; and have suffered just as severely as others who 
f ave followed their ordinary mode of life. Some suppose that it may arise 
r°m the turning up the ground along the line of railway, thus bringing 
cei'tain telluric influences to bear; this, however, cannot be the entire 
ause, as the disease existed before the ground was ever disturbed. I 
inclined to the opinion that the friable, decomposed, and decompos- 
es granite, has an influence in producing this disease as well as the 
dermittents which here prevail to so great an extent. I have known 
biirsmg infant pass one night in the affected district, and in three 
' eeks break out over the entire body with verrugas. The disease may 
'ot show itself for weeks or months after exposure, though a change of 
a lrdate, and particularly a sea-voyage, is very liable to bring out the 
eruption. 
f remember particularly the case of an Italian, who had made some 
loney on a small contract in the infected district, and, returning to his 
, ?nie in Italy, on the voyage, broke out with verrugas; on arriving at 
18 home he was immediately ordered into quarantine as a leper, and was 
j1()t allowed to enter the city until he had been pronounced cured by the 
Proper authorities. Many of the gentlemen connected with the railroad, 
' 1611 home on visits to Hew York, California, or other parts of the 
have been looked upon with very grave suspicion, not only by 
e'r friends, but by physicians and surgeons whose word is law in regard 
0 rnedical matters, 
Ihe treatment of the disease is entirely palliative, and will be more 
Particularly illustrated in the typical cases presented. The bowels should 
.e hept open by mild laxatives, of which none are better than the tarna- 
s taken freely in the form of a drink; the infusion has a grateful, 
abacid flavor, particularly agreeable in the semi-febrile condition ot the 
latients, and the addition of one of the alcoholic stimulants will usually 
advisable. Should there be indications of liver trouble, nothing is 
than blue mass or podophyllin. Hot vapor baths, or a resort to 
°P the various hot springs, will have the effect of accelerating the 
Ppearance of the eruption. I have sometimes found good effects from 
e iodide of potassium, in ten grain doses three times daily, taken in 
“.fusion of sarsaparilla, or, more agreeably still, in the compound 
dVUP sarsaparilla of the U. S. Pharmacopoeia. Should the pain be so 
|eat as to prevent sleep, morphia or chloral must be resorted to. The 
is thinned, and deficient in heematin ; hence the necessity for the 
8e ot iron, and, of all the preparations of this metal, I have found none 
Y .equal the muriated tincture, given in ten drop doses, three times 
Ivb Pi a glass of port wine. This course of treatment, with a full 
heoerous diet, and a proper allowance of alcoholic stimulants, will usually 688 
WARD, 
in time bring out the much desired crop of verrugas. Exercise in tb® 
open air, although exceedingly painful and at times impossible, is oI 
very great importance. 
A great variety of native remedies has been used in this disease. *■ 
have tried them all and found them all wanting. Of these remedies, tb® 
best is an infusion of the Indian corn, taken in large quantity with tb® 
native sweet wine of the country. This “agua mote,” as it is called, b®s 
a diaphoretic and diuretic action, as have in a greater or less degree tb® 
other native remedies, “ una de gato,” maguey,” u norvillo,” etc. 
of these remedies are taken in infusion, and with an equal quantity oI 
sweet wine. 
Should none of these measures avail to bring out the eruption, a chang® 
of climate or a sea-voyage, or a resort to some of the famous warm baths 
of Chili, will probably have the desired effect. 
The literature of this disease is very scanty. Prescott, in his ConqU®st 
of Peru, mentions it as one of the diseases encountered by the Spaniards* 
Yon Tschudi, in his work published in 1749, mentions it, and tb® 
same author is said to have written an article on the subject in son1® 
medical journal of Germany; these, with an article in a Lima newspap®I’’ 
and an article by Dr. J. M. Browne, U. S. IST., in the Contributions t° 
Medical Science, U. S. ISTavy Department, vol. i., 1872, constitute, X b®' 
lieve, the entire literature of the disease. An idea of verrugas can bes 
be formed by the study of illustrative cases, of which I cite a numb®1/ 
and, as will be obser.ved, the symptoms in the various cases are diarnetri' 
cally opposed to each other, scarcely any two cases presenting the sain® 
features. 
Case I.—The first case of verrugas which I ever saw was in the northern 
part of Peru, on a sugar hacienda. The patient presented himself to me wd 
what I supposed to be a node, just on the point of ulceration. I immediate 
placed the man upon a course of iodide of potassium and iron, advising rest? 
and poultices to the tumour which was situated upon the edge of the tihin* 
This, however, did no good, and the tumour, after ten days’ treatment, show® 
no signs of ulceration or pus. One day the superintendent happened to s®e 
it, and without ceremony plunged in a lancet, making a gash about an in®, 
long, and then sent immediately for me to control the hemorrhage which bIS 
unlucky thrust had caused. 1 succeeded in this bj' using pressure and th® 
perchloride of iron; rapid ulceration then took place, and the man left tb® 
hacienda and went to a hospital in Lima. About a year afterwards he can1® 
under my observation in one of the hospitals of the line, suffering from cai’i®® 
of the tibia and continued fever, of which he died. Upon questioning him?1 
learned that before going to the hacienda he had been at work on the Or°yft 
Hoad, and that lie had thus contracted the disease there. 
Case II.—A Chinese had received an injury of the spine, causing paral.V81® 
of the lower extremities, and had been in the hospital for a period of abo11 
five months, slowly but steadily gaining the use of his legs. One morning 11 
called my attention to some lumps on his legs, about as large as peas. Th®s® 
lumps gradually increased in size and number, without pain, heat, or redness? 
until many of them reached the size of hens’ eggs, and till they were fo®ll 
not only on the legs but on the arms and chest. The patient in the mean tm1 
did not suffer the slightest inconvenience whatever, not one of the verruga® 
proceeding to ulceration, but gradually subsiding as they appeared. His ;lP 
petite remained good, his urine was free and of natural color, and his b°w® 
acted daily and naturally. The only remedies given were the tinctura 
chloridi, ten drops three times daily, and a daily subcutaneous injection 
the fiftieth part of a grain of strychnia, which remedies were given for t1 VERRUGAS. 
689 
Paralysis. I saw the patient frequently for two years afterwards; he was in 
th^ASE —This was the case of a Chinese who entered the hospital with all 
Woe S^mPtoms of rheumatic fever, complaining of pain in the joints, which 
ho*6 Sw°^en and tender, his tongue being covered with a dirty-white fur, his 
th 'e 8 onstipated, and his urine scanty and high colored, at times not more 
an half an ounce being secreted in the twenty-four hours, and that soon be- 
m nearly solid from the contained urates. The fever was constant, the 
ranging from 110 to 120 in the minute, and the temperature from 102° 
fO, Fahr, The patient was placed upon the alkaline course of treatment 
ti(. 1 leurnatic fever, with some slight improvement to the symptoms. Diure- 
jj s’ however, produced but little effect upon the urine, and after having ex- 
tj lsfed. all the means at my command, and, at the end of two weeks, the pa- 
O't s condition continuing much the same, I resorted to a native remedy, 
leo,lch consisted of an infusion of the legs of the common cricket. Four of the 
the cricket were bruised and infused in half a pint of hot water, and 
cold half an ounce of the infusion was given every four hours. This 
an?] Ced immediate relief to the symptoms ; the urine began to flow freely, 
vj was an immediate abatement of the febrile movement, followed by a 
p °.LISe eruption of verrugas which proceeded rapidly to ulceration accom- 
Rted by free hemorrhage. The ulcers finally healed kindly under the use of 
e carbolated cerate and powdered matico. Iron and alcoholic stimulants 
U'eely use(l f° recuperate the patient’s strength, which was much ex- 
118ted by his long and painful illness which had extended over a period of 
months. 
ofT*as led to the use of the infusion of cricket legs by the recommendation 
as *• H. Kinne3r, former Medical Director of the line, who highly extolled it 
f a 'Paretic. I have used the remedy a number of times since, and with uni- 
good results. Ido not pretend to explain its modus operand!, but pre- 
ITle P to be analogous to that of cantharides, as in one case I observed some 
mency to stranguiy. 
bor|ASE —-^3r °wn case. I was attacked with wandering pains about the 
otf8e pains particularly affected the joints, sometimes one and sometimes 
pains simulating those of muscular and articular rheumatism, but 
Bhifv le ißflamraatory symptoms. These pains were of an intermittent,. 
finc/"g character; for instance, they would affect one joint, say of the little 
kn^?1’ *u le Rooming, and by noon would be located in the opposite hand,. 
or arm, and as rapidly change to other parts of the body, affecting, 
Cvf\eVe.I’’ Particularly the legs below the knees. Suddenly all the pain left the 
e.v.letlVties an 6 located itself in the right testicle, which became enlarged and 
painful, though without any inflammatory symptoms being devel- 
op ,C ‘ All the ordinary remedies useful in swelled testicle, excepting leeches,, 
the6 lISeP to mitigate the pain and reduce the swelling, but without avail; but 
8(ll felling, which had come on rapidly, after continuing for nearly two weeks,. 
ho within twenty-four hours, leaving no ill effects behind. Immediately, 
the right arm began to swell, and continued to do so until I thought 
fr s V'R would burst, so great was the tension; the tumefaction extending 
? t.*le pßgers to the shoulder, and lasting for about ten days, then subsiding 
apidly as it had come on. 
ha(.i UllnS Fliis time I was in perfect health, being able to ride about on horse- 
°ut ’ eat well, and drink well, wandering pains, however, being felt through- 
the 16 PpPji as well as the steady pain in the arm. After the subsidence of 
onl SVV.elling iR the arm, there was a let-up to all the symptoms, but this was 
°f U i 6 Calßi before the storm. Suddenly I was prostrated by congestion 
ki'o l6| Ver’ flowed by jaundice and the discharge of a large gall-stone, which 
ugkt me so near death’s door that my coffin was actually prepared.. Fol- 
-44 690 
WARD, VERRUGAS. 
lowing this, appeared the eruption of verrugas over the entire body, and a sea- 
voyage restored me to health. The first pains were felt on the first of Marc11’ 
and the first verrugas showed themselves about the first of August, when they 
continued coming and going until December, many of them ulcerating an 
being the source of free hemorrhage. 
The course of treatment which I adopted was simply palliative, treating 
each symptom as it arose. My diet was of the most generous description, aC" 
companied by the free use of brandy and wine, and I continued to go abou 
and attend to my professional duties, though at times the effort was most ag° 
nizing from the intense pain. I gave a thorough trial to the corn-water wit 
sweet wine, but did not perceive that it had much more effect than worn 
naturally be induced by the ingestion of a large amount of fluid. , 
I have since that time had three other attacks of the disease. In the secon 
attack I suffered no pain ; two or three verrugas made their appearance 0,1 
the skin, and a severe wetting caused their retrocession, producing extrcin6 
irritation of the stomach, which was only relieved by a residence at the sea 
side and a careful use of iced champagne. In ray third attack, three verrugaB’ 
the size of pigeons’ eggs, made their appearance without any premonitcbf 
symptoms, causing no pain or inconvenience. Business compelling me 
make a long and tiresome journey on a hard-trotting horse, which, considering 
that I had been out of the saddle for three months, was anything but agl’e<j 
able, a violent congestion of the liver and lower portion of the lungs resulted 
and was followed by the retrocession of the verrugas and a narrow escape A 0*1 
death. In my fourth attack I suffered but slight pain, the eruption making 
its appearance over the entire body, but none of the verrugas being largel 
than a pin’s head. lam now in the most perfect state of health imaginable- 
This disease is particularly liable to attack the mucous membrane9 ’ 
I have repeatedly seen verrugas coughed from the throat and lungs, 
have found them in the intestines after death. Should a verruga loca^3 
itself upon the eye, it should by no means be disturbed, and only fll 
simplest remedies should be used to combat any sympathetic irritatr00’ 
allowing nature to take her own way to cure the disease. Troublesoin6 
cases occur occasionally in which the verruga locates itself in the ul® 
thra, causing mechanical obstruction to the passage of urine. The trea 
merit is obvious; the patient must urinate, and hence a catheter muS 
be passed, and retained if necessary, with a bandage upon the catheter 
restrain hemorrhage. 691 
ARE ECZEMA AND PSORIASIS LOCAL DISEASES OP THE 
SKIN, OR ARE THEY MANIFESTATIONS OF 
CONSTITUTIONAL DISORDERS ? 
BY 
L. DUNCAN BULKLEY, A.M., M.D., 
PHYSICIAN TO THE SKIN DEPARTMENT, DEMILT DISPENSARY, NEW YORK, ETC. 
suggestion of a local pathology of diseases of the skin is of com- 
L'at!vely recent date, and stands in bold contrast to the older humo- 
doctrine, which ascribed all these diseases to a morbid entity, a 
morbi, seeking exit from the system, and whose escape is bene- 
j laC* and the positive demonstration within the present century of a 
aft* .cause several cutaneous maladies (as dermatitis, the parasitic 
Btetc«onß, etc.) which had, for ages, been regarded as expressions of blood 
is an achievement of which modern medicine may justly be proud, 
-‘-his discovery of a local origin of certain skin lesions, and the fact of 
j. e resemblance between some of the forms of dermatitis and the erup- 
f °f impetigo, lichen, eczema, etc., have led some to claim, still 
ther, that most, if not all, of the diseases affecting the skin are either 
j(|-e results of local external causes, or are local diseases originating in 
'°pathically deranged action of the elements of the skin; a view, the 
j>r °Pl'lon of which has undoubtedly been promoted by a natural reaction 
the too exclusive, humoral doctrines previously entertained, 
t need hardly be said that in arguing a constitutional origin and 
olcjUre of eczema and psoriasis, Ido not desire at all to return to the 
thVT kUmoralistic doctrine of disease, but seek to keep entirely within 
8 bounds of recent chemical physiology and pathology, while at the 
Mu!]6 lrne bj no means ignore the importance of local cell-action, as 
e aPPear later. Nor does the recognition of a constitutional nature of 
and psoriasis, by any means necessitate a belief that it is danger- 
Pas t0 c^ or rer°oye these diseases by local measures, for experience 
im PloVed the contrary; it does, however, demand an investigation of 
gi erilai causes, and a removal, as far as possible, of systemic disorders, 
p CG thereby elements of disease are removed and the general system 
ctited, while the eczema and psoriasis are cured. 
Ec 11 the further presentation of the subject of the nature and origin of 
mo^a and psoriasis, it will be advisable to separate the two diseases 
and n°r BSS J therefore, in each instance speak first of eczema, 
Sg 1i 0n ®a^e the application to psoriasis; because, although they re- 
0j- J e each other in many important particulars, and have many points 
in g°ntac.t’ their dissimilarities are such as to cause confusion if they are 
instance spoken of together. 
le^ pathology of eczema and psoriasis has rested largely on three 
anfiUn v : ret» on the results obtained in the local treatment of these 
not< P^ler diseases of the skin, especially in the larger hospitals in Europe, 
tolo y those in Vienna; second, upon microscopical researches in his- 
Sy; and, third, as far as relates to eczema, on a clinical and micro- 692 
scopic study of the artificial eruptions produced on the skin by irritating 
substances, idiopathically and experimentally. We will dispose of the 
last of these first. 
Now, while there is as yet no absolute proof that the 
process excited artificially in the skin differs essentially from that tak- 
ing place in acute eczema, we need not conclude that eczema is of local 
origin because its eruption resembles artificial dermatitis. If we accept 
one artificial eruption as eczema, we must accept all as such, from the 
large blisters following cantharides, heat, and cold, to the discrete, pustu- 
lar eruption caused by croton oil or tartar emetic, or the slight erythema 
of the mildest irritant. Moreover, many of these artificial erupting 
resemble erysipelas even more than they do eczema, and yet there wm 
be few who will hold that true erysipelas is a local disease of the skin ? 
again, the eruptions of croton oil and tartar emetic resemble those ot 
smallpox and syphilis, without this being any argument against tbe 
constitutional nature of these latter, while the eruptions produced by the 
insect in scabies and by lice are frequently confounded with eczema- 
These lesions are all purely local, there is simply a local response 
the cells and capillaries of the over-stimulated part; they are all bm 
forms and varieties of inflammation of the skin, and are properly termed 
dermatitis, and bear no more relation to eczema than does the inflamma' 
tion of a sprained joint to true rheumatism. In a very small proportion 
of persons, such irritations may become the starting point of true eczema? 
but in them I believe that the elements of the eczematous diathesi3 
may always be discovered. A demonstration of the essential difference 
between these artificial eruptions and eczema is shown b}7 the fact tha 
it is not uncommon to induce dermatitis, as by a blister, for the cure 0 
chronic eczema, as also of psoriasis. 
It is necessary, therefore, in the present study to remember the dlS' 
tinction between eczema and dermatitis, for undoubtedly much that ha3 
been treated for the former is but the latter, and of course no argunien 
can be drawn from therapeutical results obtained in dermatitis as to tfi 
local nature of eczema. In regard to psoriasis also, we have to clearly 
exclude, not only the scaly syphiloderm, but also all syphilitic influence ? 
true psoriasis, the lepra of Willan, has nothing to do with syphilis, i]Cj 
even in the way of a later hereditary transmission, as has been suggested? 
nor must it be in any way confounded with the dry, scaly forms 0 
eczema, or with the true leprosy, the elephantiasis of the Greeks. , 
Before proceeding systematically to examine the several points regard' 
ing the local or constitutional natures of these diseases, let us consider 
for a moment, the question of the possibility of a double origin of 
diseases under consideration, whether they can own two natures, beU|& 
sometimes local and sometimes constitutional. In regard to the skid 
lesions in the contagious exanthemata and syphilis, no question exists tlia 
their origin is solely and always due to the introduction of a p°i 
which acts through the system, and that the cutaneous manifestations &r 
but one exhibition of their effect. Passing now to such general disease 
as gout and rheumatism, whose etiology is more deeply hidden, we do n 
doubt that the local phenomena observed in each are always the result o 
the same constitutional condition, some of the earlier links in the chain o 
cause and effect being recognized in functional derangement of certa 
organs, and a consequent sub-oxidation or imperfect elaboration of t 
elements of food, and an absence of healthy disintegration of tissue; ad 
BULKLEY, ECZEMA AND PSORIASIS. 
693 
we speak of cold or external injury as being the cause of gouty or 
. aeUniatic inflammatory action in a part, we understand readily that it 
is only intended to signify that it was the exciting cause, which determined 
hat that particular spot should be affected, or that the disease should 
ev®lop at that particular time. The same line of thought might be 
to other diseases, showing that it is irrational to deny the con- 
.ktutional orison of a disease unless its local nature can be established 
,! a manner answering every requirement, as is the case in the parasitic 
c peases of the skin; quite as impossible is it to exclude local causation, 
vuen the constitutional nature fails to account for every condition. 
jbreat error has, therefore, been made, I believe, by those who look 
°nly 0r mainly at the local causes, and argue therefrom a local nature of 
eezeina, they forgetting the established principles in general medicine in 
|egard to predisposing and exciting causes of disease. This is verified 
the fact of the difficulty of producing a true eczema artificially, at 
in a person not subject thereto either in self or family (if indeed 
eau ever be done), and the impossibility of inducing a psoriasis by any 
iocal means. 
, Our conclusions then, thus far, are that eczema and psoriasis cannot 
6 both local and constitutional diseases, that is, either exclusively, ac- 
c°rding to the case; and that the eruptions resembling eczema, artificially 
produced, are either ordinary dermatitis, with a strong tendency to 
spontaneous recovery, or are true eczema in eczematous subjects, in whom 
mo exciting cause, instead of occurring in the ordinary way, has been 
ai'fjficially supplied, just as a gouty person might, by measures volun- 
nrily applied, induce a true gouty inflammation of a joint. As before 
stated, we know of no claim to the production of psoriasis by local mea- 
SUres alone. 
bn the present study of the question as to whether eczema and psoriasis 
aie local diseases of the skin or manifestations of constitutional disorders, 
1 Pr°pose to develop the following points:— 
(1) The nature of the eruption in disorders of the skin which are 
meognized to be constitutional, as the contagious fevers, syphilis, etc., 
•awing a comparison between eczema and psoriasis and these affections, 
and showing their points of difference. 
v-P The nature of local diseases of the skin. 
(3) The microscopic anatomy of eczema and psoriasis, with a view of 
C°.mparison with that of the local skin diseases on the one hand, and 
VV]th that of the constitutional on the other, 
(b) The clinical history of eczema and psoriasis, in so far as they bear 
°a the question, the points considered being (a) age, (b) sex, (c) location 
mmption, (d) relapses, (e) hereditary transmission, (/) gouty and 
®umatic symptoms, (y) urinary disturbances, (Ji) bronchitis, etc. 
. (5) The clinical history of some local diseases, to show the differen- 
mting elements between constitutional disorders and those believed to be 
°Ca], as epithelioma, verruca, keloid, parasitic and mechanical diseases 
01 skin, etc. 
(6) The effect of local treatment, and how far the success of local mea- 
-111 es necessitates a belief in the purely local nature of the disease. 
r V‘) The effect of constitutional treatment, and the internal and general 
Measures of service in eczema and psoriasis, to show how far their effect 
P1 °vea that the diseases which they remove are constitutional. 694 
BULKLEY, 
(1) In comparing eczema and psoriasis to the acknowledged constitd' 
tional disorders atfecting the skin, contagious fevers, syphilis, etc., 
must not, of course, press the similarity too far. We find, however 
certain resemblances, as in the symmetry of development of the lesiod3? 
for eczema, if uninfluenced by local causes, will, when carefully studied’ 
be found to exhibit this almost as clearly as psoriasis, whose bilatera 
disposition is so striking; the peripheral mode of spreading of eczend1 
resembles much that of erysipelas, and the scattered eruption of psoriasiß 
corresponds much to the mode of development of other exanthematous 
diseases, including syphilis. Eczema also is not infrequently attended 
with fever, in its more acute and general forms, and on the full, recen 
development of psoriasis there is more or less of malaise and prostration 
and probably fever. The characters of the lesions in eczema and psoria31® 
are not entirely unlike those of constitutional diseases, which are marked 
by, first, congestion; second, exudation; and, third, if these former haV® 
been sufficiently severe, desquamation. The lesions of eczema and 
psoriasis are also superficial, and rarely, if ever, do they leave cicatrice3? 
when uncomplicated. * 
(2) In contrast with these stand the characteristics of local diseases oi 
the skin, marked by their utter want of symmetry (unless accidental)’ 
their extension depending either on a recognized cause, or being une2C' 
plainable, as in keloid, epithelioma, etc.; local diseases very rare!) 
affect the whole integument, or even large portions, unless ichthyosis, o* 
whose true nature, however, we know very little, be granted as sued- 
Local diseases, moreover, acknowledge no constitutional connections not 
fever; while, finally, the congestive element of eczema and psoriasi3 
stands in striking contrast to its absence in local diseases, except, 01 
course, where it is called forth by local stimulation. I am well awal’e 
that many cases of eczema present a number of the features of local^i3' 
ease, and that psoriasis occasionally is seen quite localized; but this i® 
the exception, whereas it is rare to find exceptions in regard to the 1 oca 
diseases exhibiting any constitutional features; and, as we have cod' 
eluded that eczema and psoriasis cannot be at one time local and at another 
constitutional, the wreight of evidence, in this comparison, is decided!) 
in favor of the latter. _ . 
(3) The study of the microscopic anatomy of eczema and psoriasis lS 
as yet in its infancy, and throws but little light on the etiology of the 36 
diseases; but, for a comprehensive view of the subject, we will bried) 
recall the main points in their histology, which will be seen to favor tn® 
constitutional rather than the local nature of the affections. The firS. 
anatomical change in eczema (reasoning from what is observed in arid 
ficial eruptions) is capillary congestion, resulting in capillary stasis ad 
exudation in the tissue of the skin, producing more or less oedema. k 
some instances, not rare with us, the process stops here, or is arrested b) 
treatment, and we have only the erythematous state, followed by mod®' 
rate desquamation, the result of the impaired nutrition of the out®1 
layers of the skin, a state very similar to the epithelial shedding in seal' 
latina, erysipelas, or measles. 
If the exudation is too great to allow of absorption, it seeks egi’e® 
through the external layers of the skin, or becomes organized as chrodi 
infiltration. Biesiadecki believes that the fluid of eczema gains 
through certain spindle-shaped cells, which lie between the round an 
polygonal cells of the rete, these becoming so altered as to convey td 
fluid, as through direct channels. When the outer surface is still intac > ECZEMA AND PSORIASIS. 
695 
ie hard, horny epidermis resists further progress and a vesicle forms; 
" hen the epidermal layer has been dissolved off or ruptured, the fluid 
°zes from the surface. Charpy1 gives a somewhat different account of 
. le genesis of eczema; still regarding the beginning of the disease as being 
}} the coriura, and consisting in a congestion of the layer just beneath 
® papillae, he believes that the exuded fluid is absorbed by the deeper 
of the rete, in the intervals between the papillae; that these cells 
sconie engorged until they rupture, whereby alveoles are formed ; and 
iat the increase of these alveoles terminates in the production of vesicles, 
Ton the rupture of which cul-de-sacs are formed, whose walls furnish the 
Ul'ther secretion. 
chronic eczema, the exuded plasma has become organized, and is seen 
tlB cell infiltration of the corium; the papillae are much enlarged ; the 
fniphatics, both in the papillae and corium, are increased in size and 
dated (Neumann); the bloodvessels are sometimes obliterated (Rind- 
cisch); and even the deepest parts of the skin are involved. 
|he anatomical and other relations of eczema have suggested to some 
a hkeness between this and catarrh of the mucous membranes, and it 
Iffy be well here to consider for a moment the nature of the mucous 
Section called catarrh, in reference to the bearing of this resemblance 
i P°n the nature of the diseases now under consideration. First, it must 
Je remembered that it is no more proper to call all inflammations of the 
Fucous membranes catarrh, than it is to name all those of the external 
fl1 tegument eczema, or even dermatitis ; the term catarrh but signifies 
rke exudative feature, and the word eczema implies much the same. 
e have already separated and clearly differentiated many diseases of the 
lueous membranes, and it is highly probable that future study will show 
'at there are many very different processes included in what is yet 
Called catarrh, and ultimately their nature and origin will, we suspect, be 
as clearly defined as are now those of cutaneous diseases, or, it is hoped, 
]Ur more clearly. That this is true may be judged from our present 
knowledge; thus, we have simple intestinal catarrh caused by the direct 
1 station of indigestible substances, a mechanical affair corresponding 
0 ordinary dermatitis; we have an incontrollable diarrhoea, or catarrh, 
h°m the irritation caused by the circulation of effete substances in renal 
lsease ; there is also a mechanical catarrh from portal congestion in 
rfhosis ; we have also gouty affections of the various raucous surfaces ; 
Jbevvise catarrhal complications of measles, those of syphilitic origin, 
eo aud I have long believed that much of the ordinary bronchial 
was truly eczema of that surface. Therefore, in likening eczema 
•0 Catarrh of the raucous membranes, we by no means simplify matters 
1 regard to its local or constitutional nature. Moreover, the common 
c| Bervation of catarrhal affections following a chilling of the surface, 
£°es not indicate necessarily their local nature, due wholly to the cold, 
01 We see great differences in the results produced, dependent evidently 
t P°ri constitutional states, the congestion due to the action of cold on 
integument being only the exciting cause, 
v e will now consider for a moment some views in regard to the local 
ure of eczema propounded by Dr. Tilbury Fox, in the Lettsomian 
e<ffures for 1869 and 1870.2 He suggests that the capillary congestion 
a consequence of cell-activity, arguing that mere capillary excitement 
1 Annales de Dermatologie et de Syphiligraphie, t. iii. p. 100. 
2 Eczema, its Nature and Treatment; London, 1870, 696 
BULKLEY, 
cannot give rise to eczema, because otherwise the ery themata would coH' 
stantly overstep their limits. The element of the influence of the nervofl® 
system is largely considered by Dr. Fox, who believes that this abnorma 
state of the cells may be in response to “perverted innervation,” as su£' 
gested by Hebra some time since; but while Hebra limited the action of t*l 
nerve influence to the production of “congestion and other disturbance 
of the circulation,” Fox considers its influence in inducing cell prolifer? 
tion a very necessary point to be admitted in eczema. That the latter 1 
very true is shown by alterations of tissue plainly following and due t 
nerve lesions, and the same might be expected from the distribution 0 
the nerve fibres even to the cells of the rete and epidermis. 
But while a step in advance is made in recognizing the direct agency 0 
the cell elements of the skin in the production of eczema (and independe' 
cell activity can be no longer denied, as is shown in leucocytes), an 
while the influence of the nervous system in the production of °c 
changes is acknowledged, there is no proof that this cell change is real*; 
primary in eczema and psoriasis, and independent of constitutional pon' 
ditions, and that it exists as a local affair; and this view finds I'd . 
support beyond theory. It is a field, however, in which research ]S 
needed, and may perhaps be carried on with advantage, namely, 
microscopical investigation of the apparently healthy skin of marked*) 
eczematous subjects, both before and after local disease, as also a stud) 
of its nervous relations, both clinically and histologically. ShoU* 
repeated, careful, and well verified microscopic studies demonstrate ee 
change in the earliest erythematous stages of eczema, and possibly 
in the elements of the skin of eczematous patients before or afff 
disease, it would do much to enlighten what otherwise must rem^11 
uncertain, namely, the part that the diseased tissues take in 
how far they are primary and how far secondary. The skin is the 
favorable, if not the only, portion of the body on which very earv 
pathological changes can be observed and followed, and research in tn1 
line may throw light upon the pathological histology of other organs. 
That independent cell-action has much to do with inflammatory 
other changes in the skin, is evident from the results of mechanical 
chemical irritation, where, as in the case of the ordinary blister, 
intervention of any blood influence cannot be suggested with reason ; iID 
that the cells are under very direct control of the nervous system is a* 
very plain from the lesions in zoster, elephantiasis Grsecorum, those occU1 
ring after nerve injuries, etc. ; here the cells which under normal nervr 
control absorb just enough nutriment to maintain their proper relatioIlSj 
under perverted nerve control take on morbid action. Anatom 
studies of the nerve trunks and branches in eczema might perhaps assi 
in our knowledge of its nature. _ , 
Psoriasis has been less studied microscopically than eczema, and 
or nothing has yet been published of its genesis. The most strikflk 
histological changes in sections from older patches, as is known, cofl®1 
in a great papillary enlargement, with thickening of the rete Malpighi 
a corresponding extent, or nearly so. The papillae are crowded with 
cells, disposed mostly about the bloodvessels, with some infiltration 0 
the corium; but the infiltration is not nearly as extensive as in chron 
eczema, as might be judged from the clinical appearances. , 
Wertheim, from a microscopical study of psoriasis, concluded thatt* 
patches were due to some peculiar change in the capillaries of a circling 
scribed spot. Neumann considers that what Wertheim thought ECZEMA AND PSORIASIS. 
697 
JarSe<i and blocked-up capillaries were cell groups around them, but 
ers no suggestion as to the mode of origin of the patches. By the 
ad ness of my friend Br. A. R. Robinson, of Yew York City, I have 
au the opportunity of examining microscopically some sections from 
psoriasis, which confirm Wertheim’s views, and throw some light on the 
I tliological histology of this disease. The earliest specimen was taken 
i 0111 a papule of psoriasis but two weeks old, in which there had been 
Dut Uttle scaling. The bloodvessels in the papillae were very distinctly 
ea to be greatly enlarged, and in some places appeared to approach the 
Race of the epidermis very closely; in quite a number of places the 
°qclvesselß had ruptured, and microscopic ecchymoses were plainly 
Slble. In specimens from rather older patches the bloodvessels showed 
distinct budding processes, and some of the vessels appeared corn- 
el etely blocked up; there was little or none of the new deposit of cells 
by Yeumann, and there was no possibility of mistaking the 
•barged bloodvessels for cell heaps around them. 
B will be thus seen that the microscopic changes in eczema and 
PoHasis do not differ so very much from those observed microscopically 
j?1 sonie other chronic skin diseases, and that histology contributes but 
to show the local nature of these diseases, except so far as relates 
0 the studies of Wertheim, further verified by those of Dr. Robinson; 
11 o yet here no one can show that even those changes in the bloodvessels 
primary. Fox, however, believes that psoriasis “consists primarily 
essentially in a misbehavior of the cell-elements themselves—a per- 
. ersion of the ordinary cell-life of the epidermis—a true tissue disease, 
II 'vbich the trophic nerves probably play the chief part,” but, unfortu- 
gives no reasons for his interesting supposition. 
A hile this latter view finds little or no support in anything that has 
",et been reported of the pathological histology of psoriasis, there is a very 
, ’Silt foundation for it in a certain resemblance which can be made out 
psoriasis and a disease of well-recognized local nature, namely, 
Pbdielioma, to which we would venture to devote a few words, 
i. Ibe elements which have suggested the comparison between the 
•leases are; a similarity in some of their clinical features and modes of 
oevel°pment, their anatomical disposition, the transformation of patches 
the tongue, called psoriatic, into epithelioma, the asserted family 
Rations of the two affections, and the occurrence of epitheliomatous 
t(!°'Vt.h8 °n the faces of young persons affected with psoriasis. In regard 
0 a similarity in their mode of development, the increase in both is by 
»«al extension, to the extent often of forming a ring, with healing 
1 bin. Anatomically, epithelioma is an outgrowth, or rather an in- 
S ovvth of epithelial elements, whether the more external ones of the 
Clr> or those lining glands; we have, as yet, no studies with which I 
e3 acquainted to prove it, but the true pathology of psoriasis may be an 
helial hyperplasy of somewhat similar nature, and the lengthened 
.Poke seen in it may be the result of the ingrowth of the rete. We 
eY? same shedding of the outer epithelial layers in psoriasis as in 
ou lelsoma 5 on scraping both, by no means forcibly, not only are the 
rie Gl' dried layers removed, but the softer and more succulent portion 
the papillae is also separated, and we have in both the 
preec lllg, familiar to all. The presence of the fibrous papillae in psoriasis 
ti^'e^8.further progress in the scraping, or we might induce a destruc- 
’• similar to that in epithelioma. 
be only real histological support I have to offer to sustain this 698 
BULKLEY, 
theory of the ingrowth of the epithelial layer in psoriasis, other tba 
the well-known increase of the inter-papillary portion of the rete>1 
found in some of Dr. Robinson’s sections, in which, in addition to 
capillary change already alluded to, the sheaths of all the hairs show® 
outgrowths at their lower portions similar to those which have b®®11 
observed in lichen ruber. I 
The transformation of what has been called lingual and bu®®a 
psoriasis into true epithelioma is now proven beyond doubt; of the tra 
nature of the former affection, and its relations to ordinary psoriaslj 
however, we have little reliable information; it is certainly rare to b'1 
these mouth lesions in psoriatic patients, and many who have them 
never had ordinary cutaneous psoriasis, and it is highly questionable 1 
there is the slightest relationship between them. _ . 
Gaskoin affirms very confidently the hereditary relations of psorD8 
and epithelioma. I have occasionally found both diseases in the sa#1 
families, in intelligent private patients, but have never been able 
satisfy myself of any relationship; the cases, however, have been far 
few, and the time which has elapsed since I first investigated the ®Oll 
nection, far too short, to form any conclusions therefrom. Iha 
recently treated a young man with well-marked psoriasis, who 
perfectly developed epithelioma in front of the left ear. I would sugg’Gi 
this relationship between psoriasis and epithelioma as a profitable fi® 
for research, clinically and microscopically. If a relationship can 0 
established, the local nature of the former maybe demonstrated; * 
the present, however, this is not proven, and the constitutional relati°! 
of this disease, as well as of eczema, are so abundant and conclusive to 
we must here grant them the weight of argument and fact. , 9 
(4) We will now turn to a consideration of the constitutional relate , 
of eczema and psoriasis, as exhibited in their clinical history. In rega; 
to the age at which they occur, eczema affects all, from the cradle to t 
grave ; none are too young, none too old to suffer from it. This is ni° g 
the character of constitutional than of local disease; cancerous affect10 
seldom, if ever, are seen in the young; warts (of the ordinary van®™' 
seldom in the old; keloid very generally in middle life, both extreflO 
being spared. The vegetable parasitic diseases rarely occur in the olt ’ 
whereas in them are found changes in the skin, and diseases therefr0 ’ 
not seen in young life. Psoriasis may be also said to prevail at all ag® ’ 
though less frequently very early or very late in life. 
Eczema and psoriasis both occur about as frequently in the inal® ‘ 
in the female. In location, eczema spares no part of the surface, 
I believe, may affect every portion of the mucous membrane as r® 
while its development is very commonly symmetrical; these features a 
true also of psoriasis, and are those of general and constitutional disea8 
rather than of those of local nature. The tendency to recurrence in 
same parts might be claimed as a local feature, but, in regard to ecz® 
the same exciting cause may be present again and again; and it must 
conceded that tissues are undoubtedly weakened by disease, and nl° i 
likely to be affected the second time than sound tissues; this is obsei’V 
in gout and rheumatism, as also in affections of the mucous membra11 
But relapses in eczema and psoriasis furnish more indications 0 
constitutional than of a local nature, for fresh attacks of eczema are v® 
commonly found to follow a depression of vitality; and I believe 
this is true of psoriasis far more commonly than is generally cone®®1 
Moreover, these eruptions by no means occupy the same locations ®a ECZEMA AND PSORIASIS. 
699 
ifiiot P bave frequently observed that the spots of psoriasis fall almost 
rp, 9hite as often on new tissue as on the sites of a former disease, 
asis no d°uht as f° the hereditary character of eczema and psori- 
°r w) Aether the heredity consists in any general, constitutional habit, 
be , ether it is simply a transmitted tendency to tissue-change, cannot 
at fjie present time; in favor of the latter may be cited the 
Hth S-81°n °? mental and physical characteristics, cancerous disease, and 
gout 'yoSuß ’aS hlßtances °f tiie former, we have the inheritance of syphilis, 
obit ' i rbeumatisnh and the history of the occurrence of gouty, bron- 
pSori°V* lepat-i<3’ an? uriuaiT troubles in the family of eczematous and 
j~at'c patients, in such a way as to show a connection. 
estaVp \e claim ot’ an inherited, perverted tendency of tissue could be 
oalle 1 • led in eczema and psoriasis, which tendency lies dormant until 
aloiip n?to activitJ bJ some exciting cause, it would still fail to explain 
°eea • by a cause which is at one time inefficacious, will, on another 
‘sion, even in a much less degree, be sufficient to produce the disease. 
Urim!18 bj'jngs us to the study of the gouty and rheumatic symptoms, the 
pat-ary disturbances, and the bronchitis of eczema and psoriasis. That 
der entS w*th these affections are the frequent subjects of the systemic 
as angeruents connected with or tending toward gout and rheumatism, 
tai 6 as f° complete manifestations of these diseases, is very cer- 
teee ’ tP’B observation is of ancient date, and is strikingly confirmed by 
Uap Sdence- bt is not very uncommon to find attacks of gout alter- 
VarlnS with those of eczema and psoriasis, and clinical study shows that 
tie lOiUB disorders which may properly be classed under the name of func- 
tp Ul derangements of the liver are very common in the subjects of 
rp,e vvo diseases of the skin, 
fin , • e BJstemic disorders are shown in the urine, which undergoes 
pSo . lo.nal derangement in a large proportion of the cases of eczema and 
W .'aSlS‘ In a recent contribution to and study of the subject by the 
doi Gr’1 following conclusions were reached: “Eczemic patients sel- 
Jilii1 PaBB ar»e umounts of urine, the tendency being to scanty secretion, 
aor°S*i alvvays unnaturally acid, with a specific gravity averaging above 
tirnrna'* Eree uric acid, the urates, and oxalate of lime, abound; some- 
°xa^uiaa is very persistent. Albumen is rarely seen. The urea 
be iUI lc are often below the normal standard, although they may 
bag? excess when a large portion of the integument is affected; indican 
hio-i G-en f°und in pathological quantities. When the specific gravity is 
dium may be due to an increase in the sulphates. The chlorides are 
del/"-18 . • Psoriasis sometimes alternates with phosphatic urinary 
spiffs in gouty subjects. The fixed salts are increased. The urine 
oXap8 generally a hyper-acidity, with deposits of uric acid, urates, and 
is |-aAe °f lime, the contrary being the exception. The specific gravity 
j.a le to great and unaccountable variations.” 
algo be claimed that these urinary changes are observed in persons 
beuvWltb no cutaneous disease, and that therefore there is no connection 
chaneen fbe two. lam not yet in a position to prove exactly what 
inentpS ni tbc urine necessarily accompany eczema and psoriasis, but 
,vita;n those that have been actually observed to show that patients 
and ) fße diseases are not in the perfect health often claimed for them, 
°l'hetj ough a casual examination will often fail to detect any disease5 
ban that of the outer integument,! assert that searching investiga- 
1 Archives of Dermatology, October, 1875, p. 1. 700 
BULKLEY, 
tion will seldom fail to demonstrate elements of disordered health, 
commonly shown in the condition of the urine. And as these 
removed by appropriate remedies, the eczema and psoriasis improve, all 
vice versd. 
JSTot less striking, as indicative of the constitutional relations of ecZ 
and psoriasis, is the occurrence of bronchitis and asthma, conjointly 0 
alternately, in the patient, or in his immediate family ; the truth of f*l 
is well attested by many writers. , 
The neurotic relations of eczema and psoriasis are also very interesti'V 
and indicate other than a local nature of the disease; but the subject 
yet too recent and unsettled for more than a mention in this place - 
have elsewhere1 given a fuller study of it. Recorded facts, based on lalS 
clinical experience, are needed greatly for the full and satisfactory detel 
mination of many of the points here alluded to. _ . i 
(5) Enough has perhaps already been said in reference to the eli* 
history of local diseases, but a few points may be again alluded to i 
advantage in connection with what has just preceded, Ro 
relations have been recognized, to my knowledge, in any of these ; c° j 
stitutional remedies have no effect upon them. Their unsymmeti’ 
character and irregular development have been mentioned, as also the , 
removal solely by local measures. Local diseases of the skin of extern 
origin are represented by the parasitic affections and dermatitis; lClj, 
pathic misbehavior of cells is exemplified by epithelioma and kelo1 ’ 
herpes zoster may be taken as a type of an acute local disease ot " 
skin dependent on nerve elements; and ichthyosis of a chronic, local d 
turbance of general cell nutrition ; the clinical history of each of these 
familiar to all, and quite different from those of eczema and psoriasis- 
Hebra, as is well known, has always stood as the representative 
local pathology and therapeutics, and it may not be uninteresting ~ 
unprofitable to refer briefly to his present views in regard to the pl|rf-g 
local nature of eczema, as found in the recent, second edition of ffjj 
work.2 That I may not be charged with misunderstanding him, I 
quote a section from the close of the long chapter on the Etiology 
Eczema (p. 462). After repeating what had been said in the fprrl?-g, 
edition to show the local nature of the disease, and after stating his c 
belief in any diathetic cause, he says: “While, therefore, we can 
accede to any peculiar or proper dyscrasia, we must, on the other ha’1’ 
confirm the fact that certain conditions of the human organism, pal. L 
transient, partly permanent, at one time increase, and at another ti 
diminish its susceptibility to agencies producing eczema. These physl A 
conditions are called a disposition, or predisposing cause, momentum , . 
poiiens, to distinguish them from the direct exciting cause of irrita*1 
agencies, and we are obliged to recognize these elements in the etiof 
of eczema, because experience confirms it.” 
“ For example, we see an eczema on the hands and forearms of a y 7 
girl who has been engaged in washing soiled linen, and we declare 1 
the origin of the eczema is in the action of the lye, soap, hot wa 
and friction. Row, at the same time with this girl, there are wia 
other females washing in the same lye, using the same soap, and IIV .-3 
under the same circumstances, without acquiring eczema. Indeed, t 
* 
1 Archives of Electrology and Neurology, November, 1874, and May, 1875. Bepll 
by G. P. Putnam’s Sons. New York, 1875. 
2 Lehrbuch der Hautkrankheiten, Zweite Aufl. ; Erlangen, 1874. ECZEMA AND PSORIASIS. 
701 
Previ^11 V now *iaß eczema> has been exposed to the same influences 
sußce°rSr ,wlthout becoming affected. What is the cause of her present 
Ability! careful examination of her general condition will 
re(rU],t le. explanation. The girl who before was healthy, robust, and 
ano f1’ ln ber menses, has now lost her appetite, has become sluggish 
pf0f anguid, her appearance is pale and bloated, her menstruation is 
The S8; in.a word, she has become chlorotic, and thereby eczematous, 
and remec^es suitable for the chlorosis are now employed; the appetite 
disan°Wer pf work return, the menses become regular, and the eczema 
it. >r?arß 111 BPlte °h tbe continued influences of the agencies causing 
° Bame.observation is made in reference to pregnant and nursing 
latt; 6I1’ a^SO 111 tb°se suffering from chronic sexual disturbances. The 
dis* must always be looked" upon as favoring elements (a momentum 
and iT5’or PredlßPoßjng cause) which induce a status minoris resistentice, 
Ca all°w an otherwise ordinary skin irritant to become an exciting 
se, a momentum excitans.” 
Hel ter again claiming that we need no blood explanation of eczema, 
>a adds: “In order not to be misunderstood, we will, however, here 
itT.1U Btate that every eczema is not caused by a local irritation, but that 
ay be occasioned by diseases of the rest of the system.” 
an^Ucb clear and unqualified statements as to the constitutional nature 
cot °ri?ln °h eczema are unexpected from one so prominently known in 
Un ]llec^on with local pathology, and show that his opinions have latterly 
at (~ergcne considerable change. It must be remembered, however, that 
tio 16 tlrne °f tbe first edition of llebra’s work, upon which his reputa- 
pa 1 as a local pathologist greatly rests, many of the crude theories of the 
exr • not Jet been completely overthrown; and also that within his 
tio ieQce many diseases which had formerly been considered constitu- 
pa a:’ba,d been demonstrated to be purely local, as scabies, the vegetable 
8 asitic diseases, plica polonica, etc., and that the success of local mea- 
ke fs s®emed to demonstrate to him that other affections were also local; 
fp\aS\ k°weveib the candor to acknowledge his mistake. 
Hiq I v e come now to one of the most interesting and at the same time 
of i disputed portions of our investigation, namely the relative effects 
aiul°Ca and constitutional treatment as indicating the nature of eczema 
that^S°T*as*s’ Tlebra and Neumann declare, in the most positive terms, 
dig 18 quite unnecessary to regard the constitutional relations of these 
Yi ases5 except when they are striking, and those who have followed the 
i(je ?a School for any length of time can testify how completely this 
ahn 18 Cariaed out there. External remedies and measures are used there 
asp°8t.exclusively, it being the greatest exception to have any questions 
111 regard to the general health ; and internal medication, it may 
eC2 y de asserted, is very rarely, if ever, employed in the hospital, in 
tion^a and psoriasis, except by way of experiment; and yet these erup- 
pro are removed in a very satisfactory manner. Does this, however, 
but 6 le l°ca,l nature of the disease? In negation of this I need 
j^a^Suggest how the stiffness resulting from gouty and rheumatic inflam- 
wpij°u 18 benefited by external counter-irritants and passive motion, 
cocr,p origin of the serous inflammation and fibrous thickening is re- 
atro/- as conßtitutional origin. Syphilitic iritis may be subdued by 
calf, 0 a^one? and tubercular laryngitis receive great benefit from topi- 
of le|eatment; the ulcers of dysentery may be cured, and the discharge 
festnrC°rrk°?a arrested, by local measures; and yet these diseases be mani- 
-10118 °f constitutional states. 702 
BULKLEY, 
But there is not the slightest influence exerted by local treatment 111 
preventing the return of eczema and psoriasis, whereas we know f'l? 
constitutional measures have considerable power to prevent relapses; tlJlj 
is, as is well known, less true of psoriasis than of eczema, but mainly? 
believe, because of the neglect to carry out faithfully the proper measu1’6 
for a sufficient length of time after the disappearance of the erupti^0' 
Again, in this country at least, local measures often fail to accomp*19 
the desired end until constitutional measures are resorted to in additi011' 
In considering the effect of local treatment as an argument for the l°c.fl 
O O 11 tl 
nature of eczema, it is well to bear in mind the distinction drawn early 1 
this paper between dermatitis and eczema, for many cases treated as 
latter disease are entirely local in character, the result of local irrita 
possessing in themselves a strong tendency to heal when the irritat 
cause is removed and the inflamed surfaces protected, that is, are case 
of dermatitis and not of eczema. 
I believe true eczema and psoriasis to be constitutional states where111 
ordinary irritants give rise to inflammatory changes in the skin, whlC 
form an important element of the disease, but which are no more its so 
element than are the cutaneous phenomena of the exanthemata, leprosy? 
syphilis, etc. I believe also that single attacks of eczema, and of psollg 
asis, too, correspond in nature very much to those of such diseases a 
gout and rheumatism, in which the local changes have a greater or I®3” 
tendency to self-limitation, although the effects of the disease may loll*’, 
remain. That is, as arthritic, pulmonary, or cerebral symptoms app 
to be the culmination of blood-processes which we know as gout 11,1 
rheumatism, so eczema and psoriasis are directly dependent upon so#1*3 
what similar, although as yet little defined, blood changes, the acU 
symptoms corresponding to those of rheumatism and gout, while 
chronic local alterations in the skin answer to the gouty concretion8 0 
and in the synovial membranes, and to the rheumatic thickening of 
valves of the heart or around joints long inflamed ; and, as in gout 
rheumatism, there is a tendency for the attacks to recur again and ag 
the health in the mean time seeming to be perfect, so in eczema1111 
psoriasis the local phenomena may be manifested from time to ti^6’ 
without any very apparent constitutional disorder between, while 111 
'product of the disease, the cell infiltration, remains.l 
hfow but little can be done to arrest the acute phenomena of ecz®111.1 
by local means, other than soothing applications, and it is very difli®11 
to check a developing psoriasis by outward measures; but the results 
both may be removed by local stimulants, which induce cell acti'n 
within the bounds of health. I speak more especially of these dis®aS i 
in adults, for infantile eczema exhibits more plainly the constitute114 
elements whose great activity renders local measures often very futil6- 
While, therefore, the arguments are against eczema and psoria8 , 
being local diseases of the skin, it must be admitted that they become l°c. 
diseases in their skin lesions, and as such may be amenable very 1 
to local treatment, as far as relates to the single manifestations of 0113 
ease at any one time. , e 
(7) Whatever may be the views of those who hold exclusively to 
value of local treatment in eczema and psoriasis, no doubt whate' 
exists in my own mind, nor, as far as I can learn, in the mind of a ial» 
1 “The Management of Eczema,” by L. Duncan Bulkley. M.D., Trans. Am. Med- >^sS 
ciation, vol. xxv. 1874, p. 121. Reprinted. G. P. Putnam’s Sons, 1875. ECZEMA AND PSORIASIS. 
703 
tionaj°f tilose make skin affections a special study, that constitu- 
of the m®asures are both valuable and necessary to the cure of most cases 
alone 86 dlseases- Alld by constitutional treatment Ido not mean arsenic 
ment’ ,I?or any <?ne specific remedy, for truth demands the acknowledg- 
exeenr at sPecifics tor diseases do not exist, unless it be with the two 
C()nstif0f-S °f mercury for sJl,hilis and quinine for malaria. But by 
*°r tl CUtlonal treatment I understand the employment of every measure 
jj- le eure of disease, which cannot truly be called local treatment. 
With my exPerience has been, as already stated, that most patients 
and -eczema aRd psoriasis present anomalies in their urinary secretion, 
the rV ProPortion as this exists have I found the congestive feature of 
disea el8e t0 be marked, and in the same proportion have I seen the 
sidel-n benefited by cathartic and diuretic remedies. A not incon- 
cotJp e number of patients with eczema and psoriasis are habitually 
Until ha.ted’ and the diseases, with me, resist all local and other measures 
Win i is rernedied. Many are what is called bilious, and nitric acid 
Hot f ° more to cure their skin diseases than any other means. It is 
at ak uncommon, in this countiy, to find eczema and psoriasis in those 
ello, are extremely nervous, and cases are constantly met with where an 
ine/nioUs dental strain is keeping up the disease ; here the constitutional 
tiVgfUl'e of rest, with perhaps change of scene and climate, is impera- 
y demanded, together with nerve tonics of various kinds. In dispen- 
lactice in this city a good portion of all eczematous and psoriatic 
OtS.exhlbit the features known as strumous or scrofulous, and are 
°il tl aild surely cured by the internal administration of cod-liver 
Or r,] n. by any other remedy, local medication either being used not at all, 
c P aynig a very unimportant part. Arsenic also is capable of entirely 
the *bat is, removing, eczema, and that tolerably quickly, without 
°f any local measures whatever, as I have repeatedly witnessed 
Jill *,Bewbere shown,1 and its power over psoriasis is acknowledged on 
riaf C eS* bron is indicated in a large share of our eczematous and pso- 
the1C Pa^ents 5 others require such remedies as rhubarb and soda ; and 
tonics play an important role in our therapeusis, 
to al€d’ hygiene, exercise, and bathing, are all essential in my opinion 
\v})0 , management of these diseases. I claim that patients 
vim iaVe been thus carefully managed not only recover from the indi- 
te ia attack under proper local measures much more quickly than when 
dUioatter0atter a^one are but that they most certainly are in a better con- 
aticl r*° .res' future attacks, and that relapses are far less frequent, 
actio (daatn that the clinical history of the patients shows this. The 
vi^*1 °b these measures is not local, is not directed to the skin; but by 
tbeJL influence exerted on the general economy, as well as on 
ected tissues, they cure the diseases in question. 
11l 
de,.a study I have not referred much to the opinions of writers on 
tiQle at°b)gy, because, with the exceptions which I have mentioned from 
consf f0 the opinion is very general that eczema and psoriasis are 
Btanc} -Utd?nab disorders. By a constitutional disorder, as we now under- 
morhi not meant the existence of some peccant material or materies 
’ Wliich the system endeavors to throw off; nor that the discharge 
i fp 
P. 113 a?f ‘ A.mer- Med, Assoc., vol.xxvii. 1876, p. 163; New York Med. Journ. Aug. 1876. 
y. ePrinb “ The Use and Value of Arsenic in the Treatment of Diseases of the Skin ” 
oric, Appleton, 1876. 704 
BULKLEY, 
is in any way curative or beneficial to the system ; nor that the remove 
of the cutaneous lesion can in any way or manner act prejudicially 
the economy; but the expression, constitutional disorder, is understo0 
in the same sense in which it can be applied to gout, rheumatism, ch|°J 
rosis, leucocythfemia, scorbutus, etc. And it is used here in espoCia 
distinction from local disease—that is a pure and specific disease of fll 
tissues of the skin itself, singly and alone—as the artificial eruptio119’ 
parasitic diseases, epithelioma, verruca, keloid, etc. 
There are several elements of causation in infantile eczema which h<Ae 
not been touched on, partly because of want of time, and partly becap90 
observations are wanting as to their true effects in producing the dl 3' 
ease. One is the occurrence of the exanthematous diseases ; it has beo1* 
observed by some that eczema followed soon upon these affections, 
it has been thought that they left such an impression upon the cell-e‘e' 
merits of the skin that these readily took on eczematous action, sinipv 
on the application of an external irritation. Now if they can have 
causative effect in eczema, the exanthemata can also induce psoria3l9’ 
lichen, urticaria, etc. Whether, however, they act in any other Wa; 
than as depressants, leaving the body and tissues in an enfeebled stat0* 
I cannot tell; it will be remembered that Mr. Hutchinson has recent1; 
claimed that the later lesions of syphilis are but the remains of the earh01’ 
general, dermal phenomena. If the exanthemata had any real power t° 
impress any tissue change on the skin, which should afterwards result 1 
eczema, we could hardly conceive why this should happen in such a snia 
proportion of cases ; for, of the multitudes who go through these inflate 
matory skin affections of childhood, but few suffer from eczema aft 
wards; while many children have eczema long before undergoing ono 0 
the exanthemata. We cannot therefore accept any argument as to tj3 
local nature of these diseases drawn from the previous occurrence of 
exanthemata. 
Vaccination is another process which we not rarely see followed V 
eczema; do we suppose here a local cause (other than exciting), that l3’ 
does it induce any change in the cells of the skin whereby they are flip 
prone to eczema? I believe not, because of the very general adoptlo, 
of vaccination, and the very few cases of eczema immediately follow1 
I need not in this presence state that there can, of course, be no blood-pol 
soning, no contagion of eczema by means of the lymph, even when tak® 
from a vaccinifer suffering from eczema ; we know of no transmission ; 
this means except that of syphilis, unless it be a tendency to carbufl011,1 
inflammation, of which I have observed a number of cases, and wh10 
my friend, Hr. Frank P. Foster, tells me he occasionally meets wd ' 
The only agency which vaccination can exert in calling forth an eczefl1 ’ 
is, I believe, simply that of a local irritant, acting in the same way a 9 
burn or other excessive stimulation. I have seen psoriasis of a 
marked character develop for the first time immediately after vaccfl1 
tion, but the event must of course be looked upon as a coincidence, 
else we must conceive that the local tendency to cell-proliferation 0 
furnished the starting-point, the fire which kindled the train all 
for ignition. The rarity of the observation of psoriasis immediately 1 
lowing vaccination shows the correctness of this view. , y 
Equally useless and uncertain is it, in my judgment, to look upon 0 . 
tition in any other light than as an exciting cause, not acting locally?1 
true, but probably as a reflex irritation, and as such I believe it to bp 
more or less importance; but in view of the small proportion of teetb1 » ECZEMA AND PSORIASIS. 
705 
1 ants who have eczema, and the infinitely smaller ratio of those with 
J,.ol’iasis, other elements must be looked to for the real etiology of these 
in Ses ’ this is shown also by the frequent occurrence of these diseases 
those of older years, and before the teeth begin to appear. 
■j tn’roneous diet, however, I consider as an all-important and un- 
P Notedly prolific cause of eczema in infants, a point which we cannot 
Sfye e.nter upon, except to mention it as of weight in favor of the con- 
Vp i°nal origin of the diseases under consideration. 
P that local causes are of very great importance in the etiology of eczema 
Ql hifants, as well as in adults, is beyond doubt; such causes are the use 
h’ntating diaper-linen, harsh bandages, too frequent and careless 
ashing and drying, incautious exposure of the face to cold air, hot 
faPs °n the head, harsh attempts to remove the dried sebaceous matter 
r°rti the scalp, etc.; but that the disease very frequently does not get 
cVe ' upon the removal of these irritants, and under local measures alone, is 
that a ProPer study and direction of constitutional measures 
PI cure the disease, if proper local treatment is employed, is equally sure, 
t soriasis is observed so rarely in those of very tender years, that no 
can be formed respecting it; if indeed the disease in infants 
P*ers in any way from that of adults. 
I t have said nothing yet in regard to the relations supposed to exist 
between scrofula and eczema and psoriasis. This is a very difficult sub- 
'kct and one which needs clearing up, there being thus far no sufficient 
jda upon which to base a scientific investigation of the matter; for, 
though many authorities state that there is a connection, the evidence 
any causal effect is far from being established. Neumann states that 
L|d°''g 808 eczematous children he found but 30 who were rachitic and 
r vho were scrofulous, while among more than 3000 scrofulous and 
a(rhitic children he found none with eczema. 
P°r the proper study of this relation, we need to have the true position 
scrofula more clearly defined than at present, its causes and symptoms 
ore sharply drawn, and further statistical details, such as those of Neu- 
r atlri, recorded. That quite a share of children with eczema, among the 
s]0-01'’ exhibit some of the features called scrofulous, that is pale, pasty 
*lrißi light hair, eyes, and complexion, enlarged glands, ophthalmia, 
orrhcea, etc., is not to be questioned, but, that this state has any special 
Get in causing eczema, other than its depressing power, cannot now be 
moved. It is certain, however, that eczema and psoriasis exhibit some- 
ltlt different features when occurring in these subjects; the tendency 
0 pus formation is evident in the secretion from eczema, and in psoriasis 
~e scrofulous state is shown by a thickened and more yellowish condition 
r Jhe scales. 
v -Although less commonly thought of, there is probably more connection 
6 Ween what is called a scrofulous state and psoriasis than there is 
„ Ween the former and eczema. Gaskoin thinks that phthisis plays 
part in preparing the way for psoriasis, and I have been 
v ler inclined to think the same; investigations are, however, needed 
h ere. 
he results of this inquiry as to the local or constitutional nature of 
|erTl and psoriasis may be summed up in the following propositions:— 
fo * r‘C2erna and psoriasis are diseases sui generis, and are not to be con- 
Ullded in any way with other states; as, the former with artificial 
45 706 
BULKLEY, 
dermatitis, and the latter with the eruptions of syphilis, scaly eczema 
or leprosy. 
11. Eczema and psoriasis cannot own a double, independent causatff0’ 
or nature, at onetime local, and at another constitutional; hut, 
other diseases, they may have a twofold cause, namely, a predispose 
and an exciting. 
111. Eczema and psoriasis in many of their features resemble tn 
accepted constitutional diseases more than they do those recognized a3 
local. 
IV. The skin lesions of eczema and psoriasis, as also their niff1’0' 
scopical characters, more nearly resemble those of the general and co°' 
stitutional diseases affecting the skin, than they do those of pnreO 
local diseases. 
V. Eczema is very properly likened to catarrh of the mucous men1' 
branes, but no argument as to its local nature can be drawn therefrom > 
it is very probable that some proportion of the mucous attacks caheC 
catarrh are eczema and psoriasis of this tissue. 
VI. Both eczema and psoriasis resemble gout and rheumatism, 111 
certain respects, and are dependent upon a somewhat similar, althoug, 
as yet unknown, constitutional cause; much of the skin lesions, a 
ordinarily observed, must be looked upon as the local results of the dis 
eases, removable by local means. . 
VII. There as yet exists no microscopical or physiological proof 
eczema and psoriasis are the sole result of local cell disorder, either cm1 
genital, acquired, or due to perverted nerve action; although from °u 
present knowledge of independent cell activity, and from the intinff 
connection between nerve elements and the cells composing the skin,1 
is highly probable that cell action and nerve influence are import*10 
factors in eczema and psoriasis. e 
VIII. Local causes play a very important part in the etiology 0 
eczema; they are probably inoperative in psoriasis. r0 
IX. Certain relationships between psoriasis and epithelioma hav(" 
been claimed, which require much further investigation ; at 
they are not established, and are no proof of the local nature of psol 
asis. 
X. The clinical history of eczema and psoriasis furnishes ranch 
deuce of constitutional relations, mainly with states allied to gout 
rheumatism; no direct causal connection has yet been demonstrate 
between the scrofulous state and eczema and psoriasis. . g 
XI. Local treatment alone is often insufficient to remove the lesffl^ 
of eczema and psoriasis, and cannot prevent or delay relapses; its suc<ffs 
does not demonstrate the local nature of these affections. . 
XII. Constitutional treatment, alone and singly, can cure many caS 
of eczema and psoriasis, and prevent or delay relapses in a certain 1° 
portion of cases; by constitutional treatment is intended every age°c' 
not properly placed among local measures. q 
XIII. The total weight of evidence and argument is that eczema a° 
psoriasis are both manifestations of constitutional disorders, and 11 
local diseases of the skin. 
Inclosing this paper, already far exceeding the limits designed,^1 
writer would beg indulgence for its imperfections, of which he of tiff 
aware; some ot these have been necessitated by the vastness nt 
subject and the small amount of space afforded in which to couff1 ECZEMA AND PSORIASIS. 
707 
lem. Many points which had been elaborated much more, have been 
ecessarily condensed or omitted, and many fields, an investigation of 
hich would have further developed the subject, have been left entirely 
; many have been barely alluded to, because of the scantiness 
. pliable data. It is to be hoped that the investigation will be pursued 
p \ further, for the etiology and pathology of these diseases maybe 
?nsi(lered as at the foundation of all dermatology, and the importance 
®°nie of the questions here raised can scarcely be overestimated. 
Hie following are some of the points requiring further study: the 
°de of the formation of vesicles in eczema, and the way in which the 
xuded liquid reaches the surface; the state of the skin, histologically, 
j. y early in eczema and psoriasis, as also after the disappearance of the 
lßease, and likewise of the skin of those subject to eczema and psori- 
. fls in places where no disease has yet appeared; the nerve relations of 
diseases clinically, and the state of the nerves microscopically ; the 
°ndition of the bloodvessels very early and very late in these diseases, 
specially in regard to Wertheim’s view of a capillary change being the 
aUse of psoriasis; the resemblance between psoriasis and epithelioma, 
nhcally and microscopically, as regards also the development of what 
‘le called psoriatic lesions of the mouth into epithelioma, and the true 
'ature of the former and their relation to psoriasis, if any ; also the 
P°ssibility of the origin of psoriasis in hyperplasy of the rete downwards 
etyveen the papillae; the urinary relations of eczema and psoriasis, also 
ieir heredity, as relates to the diseases themselves, and also to other con- 
Putional manifestations; the asserted connection between the eruptions 
, the exanthemata and eczema, especially in infants; the influence of 
*eidition in the production of eczema; the effect of vaccination; and, 
the relations of scrofula to eczema and psoriasis. 708 
THE VIRUS OF VENEREAL SORES, ITS UNITY OR 
DUALITY. 
BY 
FREEMAN J. BEMSTEAD, M.D., 
LATE PROFESSOR OF VENEREAL DISEASES IN THE COLLEGE OF PHYSICIANS AND 
SURGEONS, NEW YORK. 
The question, the discussion of which I have the honor to open to-dkG 
is expressed in the following terms:—“ The Virus of Venereal SoM3’ 
its Unity or Duality.” 
In presenting this question, the first inquiry that suggests itself 
one’s mind is whether it is identical with the question of the “Un 
or Duality of Syphilis,” that, for the last twenty-four years, has exche 
so much interest and discussion in the medical world. I reply that1 
is essentially the same. To ignore this fact, to attempt to assume a 
departure, to consign the question of “ unity or duality” to the tornhs < 
having no bearing upon our present views, would be a fraud upon m®d 
cal history and a source of confusion to the student; since those rvU 
have so earnestly advocated the so-called “ duality of syphilis,” ha 
never for a moment supposed that there existed two kinds of syphi’d 
virus, but merely that there was more than one poison at work in 
etiology of a complex disease known for many years under the nam® j 
syphilis; and he who now recognizes a duality of poisons in venei’®8, 
sores, is a syphilitic “ dualist” in the sense in which that term has be®,, 
employed. It will be seen, however, that the term “ duality of syphd1 
has always been a misnomer, and the form of the question presented 
us to-day is most appropriately substituted for it. 
I take it for granted that the question proposed to us is intended 
include the poison or poisons of every kind productive of venereal ulc® 
and that the term virus is to be used in its broadest sense, viz,, that 
contagious 'principle or poison. When speaking of a special poison sUP 
posed to be incapable of generation de novo, I shall call it a specific viellS'.^ 
Allow me also to add that I shall use the terms chancre and chance0} 
in the sense which is commonly received in this country—chancre as 1 
cheating the initial lesion of syphilis, and chancroid as indicating t 
“soft chancre” of the French school, and the “chancre” of the Gerim1 
school. 
Three views as to the origin of venereal sores have been entertained • 
(1) All venereal sores are due to a single, specific virus, the virus 
syphilis. 
(2) Some venereal sores are due to the syphilitic virus, and others 
a distinct specific virus, known as the chancroidal. 
(8) Some venereal sores are due to the syphilitic virus, and others 
the inoculation of the products of simple inflammation, in which la- 
case no specific virus exists. 
The clinical observations and artificial inoculations, which have u 
brought forward, for and against these several theories, must be farm u UNITY OR DUALITY OF VENEREAL SORES. 
709 
the 1088 ere Present> and I shall therefore limit myself to reviewing 
Ci and drawing my own inferences from them, as a basis for the dis- 
tif- S/?n is to follow. Indeed, any other course would be imprac- 
atue within the limits of this paper. 
sintl ieW firSt ment'fo viz-5 that all venereal sores are due to a 
thr 6 virus’ the virus of syphilis, had been the prevailing one for nearly 
es ee centuries prior to the year 1852. At the same time, it had not 
hyPed the notice of many observers that the results of contagion were 
no means identical; that, in some cases, the persons infected showed 
c symptoms after the healing of their ulcers, while others developed a 
childr°f symPtoms, lasting through years, and even transmissible to their 
I* the year 1852, Bassereau claimed a distinct cause or origin for each 
these two classes of cases. He founded his claim, first,"on the his- 
‘-f of venereal sores, whereby he endeavored to show that' although 
c ndagious ulcers of the genital organs, communicated in sexual inter- 
c|.Urse, had been well known to the ancients, yet that the constitutional 
I Sease which we call syphilis made its first appearance in Europe in the 
4 for part of the fifteenth century. 
j " Pile believing this argument drawn from history to be a valid one, 
'v®uld not insist upon it in a discussion like the present, which should 
Vlied uPon scientific data. I will merely remark that this argument 
dl receive additional support, provided that it can be shown that the 
is due to a poison generated by simple inflammation, and 
that it must have existed at all times and among all nations. 
Bassereau’s second argument was based upon the “ confrontation” of 
lei’sons affected with venereal diseases, and he and others were able to 
pi°ve, in several hundred cases, that when the disease was local in the 
f.IVer it was also local in the recipient, and that when it was constitu- 
*°nal in the giver it was always constitutional in the recipient; in other 
°rds, that the broad line of distinction separating a local disease on 
gl6 °ne hand from a constitutional disease on the other, was constant in 
ccessive generations without limit. 
r wiH be observed that this proof does not involve any differences 
j °r supposed in venereal ulcers themselves; it may be said to rise 
j J°ve such consideration in that it ascends to the source and origin ; and 
o d°_n°t hesitate to say that much of the confusion and contradiction of 
upon this subject has been due to the fact that observers have 
themselves to investigating symptoms, which, though generally 
r nsfont, may yet be poorly marked or even wanting, and which often 
C|yUre practised eyes and fingers for their recognition. 
JNow I maintain that this clinical proof adduced by Bassereau has 
Aver been shaken, for, although local ulcers have been produced by the 
fooculatkm of matter from syphilitic sores, yet this is susceptible of, and 
i(] requires, as we shall see hereafter, another explanation than an 
ejdity of poisons, and, on the other hand, there has never been a, single 
case in which syphilis has been produced by the inoculation of chan- 
°gd,al matter from a person who has had only a chancroid and not syphilis. 
fe. assefeau does not appear to have speculated on the cause of the dif- 
or Ti(ICe veuereal ulcers. Ido not find in his work the words “ Unity 
Uuality of Syphilis,” nor any expression of opinion as to the existence 
a Bpecific virus for the local sore. He simply says that he is obliged 
recognize a different cause {line cause differente) for the local and con- 
ntional diseases. 710 
BUMSTEAD, 
A school of dualists, however, soon sprang up, who departed from tho 
simple faith of their founder in attaching undue importance to to 
characteristics of the sores themselves, and who claimed for the 1 oca 
sore a distinct, special virus of its own. _ , 
One of the tenets of this school was that the secretion of syphilis0 
lesions could not be inoculated with success either upon the person- 
bearing them or upon any other person affected with syphilis, and tin8 
tenet, in the theory of dualism, wras looked upon as vital. , 
It was not long, however, before it was successfully attacked anc 
overthrown. Clerc, of Paris, Melchior Robert, of Marseilles, and others? 
succeeded in inoculating the secretion of syphilitic sores upon the bearer8’ 
with the result of producing ulcers, without incubation, bearing all tn 
characteristics of the chancroid, and inoculable in successive generation8, 
Mr, Henry Lee, of London, and Kobner and Pick, in Germany, also fonj1 
that a true chancre would become auto-inoculable, if it was irritated by 
the application to its surface of powdered savine, or by having a setob 
passed through its base, so as to render its secretion decidedly purulem' 
Again, Boeck and Bidenkap, in Christiania, in their later attempts 
syphilization, took matter exclusively from true chancres, and obtain61 
the same result as when they had inoculated chancroidal pus. In fivo 
cases reported by Bidenkap and Gjdr, of Christiania, matter was tak6° 
from ulcers obtained in the above manner, and inoculated by patients b’6o 
from syphilis upon themselves, and in only one instance did any genera 
symptoms ascribable to syphilis follow, and these were of a doubti11 
character. 
Gentlemen, the import of these successful auto-inoculations of sjP . 
litic lesions as regards the question before us, deserves our serious con81' 
deration. Let us inquire what they apparently proved, and what th6; 
actually did prove. They apparently proved the identity of the 
litic poison with that of the local sore. By their means, it was suppoß6 
that the doctrine of duality was demolished, and the advocates of unit; 
were triumphant. Whether this conclusion was not too hasty, we sha 
presently take occasion to inquire. But these experiments actually dl 
prove the absence of any distinct specific virus in the chancroid, incapah 
of generation de novo; for here were chancroids artificially produced m 
dependency of any descent from chancroids. 
You are well aware of the defence adopted by the dualistic school'''' 
the mixed chancre, a sore combining both the syphilitic and chancroid* 
specific poisons—which, it was asserted, would satisfactorily explain a 
these cases and still leave the tenets of dualism, as at that time unde 
stood, intact. This explanation was for a while regarded as satisfactoij’ 
but it could no longer be upheld when such experiments had b66 
multiplied indefinitely ; when their number was so great that the chan6 
of the commingling of two kinds of specific virus and their simultaneo 
inoculation was reduced to a homoeopathic absurdity; when an m 1 q 
rated syphilitic primary lesion could be taken at random, and, after d 
irritation, its secretion could be successfully inoculated with the efie 
of producing pustules and ulcers bearing every characteristic of 
chancroid ; and when the same result could even be obtained at will J 
the inoculation of the secretion from a purely secondary lesion, as, 
instance, a syphilitic mucous patch! If the chancroid was depend61 
upon a distinct specific virus, its presence in all these cases was 
impossible, and yet not a single shade of difference could be pointed 0 
between the result produced and that from the most emblematic cfia UNITY OR DUALITY OF VENEREAL SORES. 
711 
i‘u''d ever met with in practice. Dualism was indeed henceforth demo- 
lshed, if by “ dualism” be meant that each of the two kinds of venereal 
*°le has a distinct, specific virus of its own. In the face of the expon- 
ents referred to, I cannot believe it possible to defend in future any 
ul|h doctrine of duality. 
, Lut the last word had not been spoken in favor of a distinct origin of 
le chancroid from that of syphilis, nor the last experiment made and 
e°orded which would decide the question before us to-day. Let us ex- 
am*ue more carefully those experiments I have just referred to. What 
as the matter so successfully inoculated? The pure, unmixed^virus of 
Iphilig ? By no means. It was a compound product, taken, to be sure, 
jlortl a syphilitic lesion, but a lesion irritated commonly to suppuration 
T artificial means; containing possibly the germ of syphilis, but con- 
aining also, and in fact chiefly composed of, pus. Which of these two 
clctors was responsible for the effect produced ? The syphilitic virus ? 
that case this virus should have preserved its power of infecting the 
Institution, and matter taken from these ulcers, and inoculated upon 
Jealthy individuals, should invariably have produced syphilis, which has 
®eri shown not to be true. Moreover, if it could be proved that pus 
H °ne, free from all suspicion of syphilitic mixture, ivas capable of pro- 
| llcing the same result, then pus was the guilty factor, and there was no 
, Ueh transformation as supposed by the unitists. Such proof we now 
]ave as will be seen from the following cases:— 
hu 1865, Prof. Pick, at the suggestion of Prof. Zeissl, inoculated sim- 
P'c, non-venereal matter of inflammatory origin upon syphilitic subjects, 
aking the secretion from pemphigus, acne, scabies, and lupus, he inocu- 
l'ted it upon persons affected with syphilis and produced pustules, not 
Preceded by incubation, and the matter of which was further inoculable 
Jhrough several generations. Counter-inoculations upon the persons free 
T2m syphilis who were the bearers of these affections, were without 
Effect. The same result was attained by Kraus and Reder with the pus 
? scabies, and by Henry Lee with pus from a non-syphilitic child. The 
ate Mr. Morgan, of Dublin, also succeeded in producing pustules and 
. cers, identical in appearance with the chancroid and capable - 
e*loculation through a number of generations, by inoculating syphilitic 
emeu with their vaginal secretions. 
It would thus appear that the skin of syphilitic individuals possesses 
'Larked vulnerability, a peculiar aptitude to become inflamed when 
I'ctod upon by irritants; but this is nothing more than is seen in other 
subjects, whose vital powers are impaired by any cause 
Whatever. For instance, it is well known that among medical students 
in the dissecting-room, it is those who are run down by hard 
x. and overwork, who are most likely to become inoculated by fluids 
|orn the dead body. Again, the idea which was entertained by some 
• there must be a syphilitic soil for such inoculations to succeed upon, 
8 disproved by other experiments which I have to relate, 
i 11'e earliest of these experiments, as far as lam aware, have never 
eeii published, and were performed in the winter of 1867-8 by Dr. Ed- 
,ar(l Wigglesworth, Jr., of Boston, upon himself, while pursuing his 
j ,U(lies at Vienna. He has kindly furnished me with the following 
'story; After stating the grounds which led him to the conclusion— 
"ginal, it appears, with himself—that u pus pure and simple might be 
le cause of the chancroid,” Dr. W. says:— 712 
BUMSTEAD, 
“ I would state that I was free from all disease either hereditary or flC' 
quired; that I had never had a sore of any kind or any local or 
lesion of the skin or mucous membranes, and that I was merely a little 
down from overwork in the hospital. I took from an acne pustule upon myßol’ 
pus, which I inoculated upon myself in three places on the anterior radial aspoo 
of my left forearm at the junction of the middle and upper thirds, first prick1*1® 
open the apertures of hair follicles and then rubbing the pus into them. DlO 
result in the course of three or four days was three well-marked pustules. 
each of these I inoculated one new spot upon the same arm nearer the wris • 
The result was three new well-marked pustules. From each of the three ot t1 
second series I again inoculated fresh spots still nearer the wrist, and again th 
result was positive. The second series was hardly as well-marked as the fh’s ’ 
and the third series was slightly inferior in vigor to the second ; still all 
well marked, the nine sores being at the same time present upon my arm. y 
removal of the crusts, perceptible ulceration of the skin was found toexiy * 
Zeissl, with wdiom I was studying at the time (1867-8), happened to be lectin-1*1® 
upon dualism, and requested me to show ray arm to the class to prove tq 
production of ulceration from properly inoculated, simple, healthy pus. The1 
were no buboes in my case, nor did the ulcerations require other treatme11 
than exclusion from the air by means of a simple dressing, and cleanliness- 
The scars remain to the present day. I thus convinced myself and others-y' 
“I. That the products of inflammatory action, if properly introduced hy 
the human integument, may cause local ulcers, closely resembling chancrom 
and re-inoculable in generations. 
“ 11. That this pus need not come from a syphilitic person or be inoculate 
upon a syphilitic person. If taken from, or inoculated upon, a person deb11 
tated by any disease as syphilis, the effect would doubtless be the same thoug 
probably greater in intensity.” 
’th 
Many years subsequent to these experiments of Dr. Wigglesworu ? 
which ought to have been made public at a much earlier date, Kaposi1 pll*3' 
lished the following statement; “My own experiments have taught 111 
that non-specific pus, such as that from acne and scabies-pustules, whell 
inoculated upon the bearers as well as upon other non-syphilitic person9’ 
will produce pustules whose pus proves to be continuously inoculable 1 
generations; that from these pustules losses of substance occur, whlC 
heal with the formation of scar-tissue ; and that as the number ot Pll 
tides produced increases, the inoculability of the pus derived from the111 
diminishes and finally ceases altogether.” 
It is not necessary for me to dwell upon the exact correspondence 0 
the result of such inoculations and that obtained by the inoculation 0 
so-called chancroidal matter. . , 
The idea that the products of inflammation are the source from ivblC 
the chancroid springs, and that the simultaneous inoculation of 
products and of the germs of syphilis will account for the vary* 
degrees of ulcerative and other phenomena met with in varieties 
venereal sores, will strike many of you as novel, and it is easy to foi'eS 
the objections which will naturally arise. It will be asked ; Can if 
possible that the pus from acne, ecthyma, or scabies can give rise to 
sore equal in duration and severity to that produced by matter \ 
typical chancroid? Comparative inoculations upon the same individ*p 
with these two agents may even be adduced to show that this is not t 
case. In replying to such objections, it must be frankly admitted t**‘ 
we do not as yet fully understand all the laws governing the inoculat1 
1 Die Syphilis der Haut, etc., p. 47. UNITY OR DUALITY OF VENEREAL SORES. 
713 
v- septic matter. We cannot, for instance, fully explain why one indi- 
-I(|ual should be more susceptible than another, why different parts of 
- ln tegument, as that of the chest, the arms and the thighs, should 
°velop ulcers so varying in their destructive tendency as is shown in 
of syphilization ; why the secretion from purulent urethritis 
off l)Urulent conjunctivitis should be interchangeable, and yet have no 
, upon the mucous membranes of the mouth, nose, or ear; why a 
Jaucroid of the prepuce should inoculate other points of that membrane, 
I yet commonly spare the glans penis; or why one upon the os uteri 
\°uld allow the walls of the vagina in contact with it to escape; and so 
ny °ther instances that might be brought forward. 
, 1 the effect produced is to a great extent proportionate to the 
1 Gerative action of the source from which the matter is taken, is evi- 
erd to any one who has performed auto-inoculation from indurated chan- 
J>es. pf tpe ciiancre consist of a simple erosion with a watery secretion, 
Gated upon an indurated base, the first two or three, or even more, 
‘ tempts at auto-inoculation will probably fail; but as the surface of the 
‘Ore becomes irritated to suppuration by repeated pricks of the lancet, 
I lese attempts will succeed, first in producing minute pustules and ulcers, 
.’ff subsequently, as the suppuration increases, others larger and better 
eveloped. Taking these facts into consideration, it need not be 
Q tale red at if comparative inoculations upon the same individual 
matter from a simple skin affection and from a chancroid of the 
Guitals, should show greater severity in the latter. But without enter- 
;!'S further into this subject, I claim it to be sufficient to have shown 
the inoculation of the products of inflammation will produce an 
Jueet identical in land, even if not in degree, with that of matter from 
, 16 most typical chancroid; and this is my reply to the objections I 
lave named. 
« f have now, gentlemen, called your attention to the evidence drawn 
*°Ui artificial inoculation in favor of a duality in the poison of venereal 
°lGs, some of them being derived from the virus of syphilis, while others 
i r<r. due to the products of simple inflammation. This view, which I 
elieve to be most consistent with our present knowledge of pathology, 
to be supported both by experience and scientific investigation, has 
bite years found its advocates among medical men. 
f bus Baumler, in his recent able work on syphilis, after quoting ex- 
ho|uniental inoculations like those just given, says;—■“ The necessary con- 
Usion is, that the 'poison of the soft chancre may, under certain circum- 
he produced de novo without the intervention of the syphilitic virus, 
R fide the syphilitic poison propagates itself only in one continuous 
‘Glies. Hence the chancroidal poison, or whatever in these experiments 
the pustules resembling chancroids, cannot even be compared 
cap’ le syiddhtic poison, to say nothing of regarding them as identi- 
I yu the recent and well-known debate upon syphilis before the Patho- 
Society of London, that accomplished surgeon, Mr. Hutchinson, 
cllue within one short step of the truth when he admitted the origin of 
IG local venereal sore to be “the products of syphilitic inflammation, but 
usually containing the germs of syphilis.” It he had omitted the 
VyJefive, “syphilitic,” before the word “ inflammation,” his expression 
anl d bave been consistent with the facts at present in our possession, 
ud he would have found it inconsistent with such facts to proclaim 714 
BUMSTEAD, 
dualism as dead, since, as I have already shown, dualism is nothin 
more than a duality of poisons in the evolution of venereal sores. 
If the view which I advocate be the correct one, it suggests an inter' 
esting analogy with the history of our belief as regards the nature 0 
gonorrhoea, an affection which in the last century was regarded as du® 
to the syphilitic virus. Eicord finally adduced convincing proof 
it had nothing to do with syphilis. It was afterwards supposed * 
depend upon a virus of its own, the gonorrheal virus. We now kno 
that it may he caused by any simple irritant, but more especially 
the pus from the urethral and other inflamed mucous membrane0’ 
whether originating or not in contagion. Such as the history of gon°1' 
rhoea has been, so, I predict, the history of the chancroid will be. 
In the preceding remarks, I have only casually alluded to the evidence 
in favor of a duality of poisons to be found in the symptoms present6 
by venereal sores themselves, and by the lymphatic ganglia in anatom^1 
relation with them. The value of this evidence must always depen 
upon the observer’s knowledge, skill, and experience in venereal disease9* 
How often do we witness the grossest errors in the diagnosis of 
ulcers made by men who are deservedly eminent in general practice • 
Moreover, instances not unfrequently occur in which the symptoms ai6 
ill-defined, and in which the most experienced will wait for furth01 
developments before expressing an opinion. Hence, so long as the symP' 
toms of the sores themselves were alone considered, the question of unit) 
or duality remained undecided. And yet, to my own mind, the evidence 
founded oh these symptoms is not to be despised, for in the great majors 
of cases they are sufficient to enable us to distinguish the syphilitic h’ollll 
the local sore, and the obscurity of some cases is readily explicable 0 
the ground of the simultaneous inoculation of the products of inflanm 
tion and the germs of syphilis, and the well-known immediate action 0 
the one and the incubation of the other. , 
One word as to the form of the question with which we ' 
It may appear to some that as the products of inflammation are varied9’ 
the question should read thus: “The virus of venereal sores, its unn) 
or plurality?” But this is a matter of small moment. If any 013 
prefers the latter reading, I have no doubt it will be accepted as 01 
amendment. The actual point at issue is whether the syphilitic vu’u 
is, or is not, responsible for all the venereal ulcers met with in practice? 
and this is sufficiently implied in the question as originally worded. 
Gentlemen, I will not longer detain yon. I must apologize for f 3 
incompleteness and brevity of my remarks, necessitated, however, J 
the short time at our disposal. 
The conclusion which I have to offer you, is based, as I have ende* 
vored to show, f 
(1) Upon clinical experience, more especially in the confrontation 
persons affected with venereal sores. 
(2) Upon artificial inoculation. 0f 
(3) Upon the corroborative evidence presented by the symptom9 
the sores themselves. , Q 
For convenience of discussion I shall divide my conclusion into 
following propositions:— 
I. The virus of venereal sores is dual. . *c 
11. Some venereal sores are due to the inoculation of the syphih 
virus. UNITY OR DUALITY OF VENEREAL SORES. 
715 
of?’ 9ther venereal sores are due to the inoculation of the products 
supple inflammation. 
These two poisons may be inoculated simultaneously. 
Discussion on Dr. Bumstead’s Paper. 
saia .tei'rrt le reading of the preceding paper, Dr. R. W. Taylor, of New York, 
aj •~-'lhe Section is to he congratulated upon having presented to it such 
the p CeptionallT Perfect paper as that read by Dr. Bumstead ; it is certainly 
lano°eSt exPosition of the subject which I have ever listened to or read in any 
the&nL g6‘ And lam glad to be able to say that my experience coincides with 
betw erVations °f the distinguished writer. As bearing upon the distinction 
So e®u the virulence of the pns of a chancroid and that of an initial syphilitic 
°f b’/.W refer to a case observed by myself of a man who in the first year 
fl’om i llis fontracted gonorrhoea, and, having a long, tight prepuce, suffered 
for - .Potic vesicles, which assumed the character of chancroids ; buboes 
tlle »roins’ and the pus from these ran down the thighs’and pro- 
hot n which were healed with great difficulty. The man’s wife was 
ch 1 nor spe at the present time, syphilitic, but she too suffered from 
in vCroids. Another case was that of a newsboy whom I saw at a dispensary 
hay e'v York ; the boy was not in any degree syphilitic, and was believed to 
his ] been UP to that time virtuous, but was suffering from a bad sore upon 
ho M 5 the pus ran down and produced ulcers similar to chancroids; this 
by sexual intercourse subsequently contracted syphilis. 
r- E. L. Keyes, of New York, said:—Dr. Bumstead’s third proposition 
hsents the true question at issue. No doubt pus from simple inflammations 
Sn n pr°dnce ulcers upon persons in a condition to be easily impressed, but 
an ]1 cers are n°t identical with chancroids. Pus is, of course, irritating, 
U f different kinds of pus have different effects; but I do not think it proved 
simple pus applied to a healthy person will produce anything identical 
i 1 chancroid. The paper just read does not describe the ulcers said to have 
pl°duced by simple pus, and I do not think that it has been shown that 
pe/ Weie typical chancroids. Urethritis is quite common among married 
*°*s, and so are excoriations among persons with tight prepuces ; some 
Ye ?°Hs even cannot have sexual intercourse without producing herpetic 
sj 1 vesj but the resulting ulcers are not chancroidal. To say that ulcers from 
C{h e Pus are identical with chancroids, is going too far. If that were the 
Yj f.’ every one would be in imminent peril of becoming sooner or later a 
du 1111 k° this affection. In a majority of cases, the pus of acne will not pro- 
upon a healthy person an ulcer identical with chancroid, 
acl 1 . MSTEAD said:—The time allowed for the reading of my paper excluded 
of the sores mentioned in it; and I thought it sufficient to state 
aiUl had been unable to discover any difference between chancroids 
sores thus produced. I have said in the paper that the more healthy 
Person, the less liable will he be to the evolution of the sores. 
pea r* Keyes said:—l would ask Dr. Taylor when the chancroidal ulcers ap- 
jjed in the case which he has described? 
Taylor said:—I took very full notes of the case, but have them not 
te * Ule; I can say, however, that the herpetic vesicles appeared about the 
av_ 1 day after exposure, and that they assumed the chancroidal appearance 
ab£d the twelfth or thirteenth day. 
can/ Porter, of Kansas City, said:—l am a believer in dualism, but I 
cha ePevu that a chancroid can be produced from an inflammation not 
nor do I see how it is possible for herpetic vesicles to turn to 
that ulcers. I believe that chancroids are different from syphilis, and 
chancroids are always developed before the tenth day. 716 
BUMSTEAD, UNITY OR DUALITY OF VENEREAL SORES. 
Dr. Bumstead said:—Chancroids are always developed before the tent 
day, and the only way in which the development can be deferred is for n* 
virus to lie upon the surface some days without being taken into the tissues. 
Dr. Taylor said :—There was no possibility of that in the case which I 
mentioned, for the patient washed the penis in warm water frequently, and tn 
continual wiping of the gonorrhoeal discharge would have been sufficient 
remove the virus from the surface. , 
Dr. Keyes said:—lt is impossible for me to believe that a chancroid coni 
appear as late as eleven days after exposure. _ . 
Dr. L. D. Berkley, of New York, said:—l do not believe that the weigh 
of evidence sustains the proposition, and 1 believe that the chancroid has 11 
connection with syphilis. 
Dr. Charles Heitzmann, of New York, said :—There are some person 
very liable to pustules, and upon whom small lesions will produce then3' 
During many years that was my own condition. I have witnessed 
experiments in Vienna, but have seen no evidence of the analogy between t 
sore produced by simple pus and chancroid. 
On motion, the propositions appended to Dr. Bumstead’s paper were adopt 6 
as expressing*the opinion of the Section, with the exception of the third,1 
which, on motion of Dr. Bulkley, the following was substituted:—“Scie*1 
has demonstrated that suppurative inflammatory lesions, which resemble 
certain features what we know as chancroids, may be produced on vano 
parts of the body by inoculation with simple pus from various lesions.” 717 
LEPROSY as observed in the sandwich islands. 
BY 
FEAM H. ETOERS, M.D., 
[Communicated by the Secretary.] 
GOVERNMENT PHYSICIAN. 
Its lE| isto17 of leprosy as it exists on these Islands is yet very obscure, 
.advent; or origin cannot be traced with any degree of satisfaction! 
the present generation it is known as mai-pake (Chinese sick- 
Chi contending that the first case ever known here was in a 
The older class of natives formerly knew it under the name 
03^11683 °f chiefs), and describe the disease as it existed then, 
fore' as we ere at Present fllll6- Some of the older 
tati I^ners’ l)ave resided here for many years, and before the impor- 
bpn^11. fhe Chinese, recognize the present disease, or one closely resem- 
be t? lt,as having existed" here as far back as the year 1880. If this 
r.,.1ae5 it is certain not to have been brought here by the Chinese. 
Sy - 1(3 question of importance yet to be solved is, whether it is a disease 
to fel °r a form of syphilis peculiar to the climate and dependent, 
1 least some extent, upon the habits and diet of the people. 
r6as? 18 no easy matter to arrive at a positive conclusion, for there is 
j§i °nably strong evidence advanced for the support of both theories. 
casp'6 residence upon the Islands, I have examined over four hundred 
of ft le so-called leprosy, and lam as yet unable to determine which 
Btro e Wo positions is the more tenable, or which view rests upon the 
alrr/1'’01' eyidence. One great trouble or difficulty rests in the fact that 
Of evcry native either has, or has had, syphilis, acquired or inherited. 
c°linle. large number examined, I have found but two in whom there 
eXee ar7 doubt as to the pre-existence of syphilis, and in these two 
ip Pul°ns close relationship could be traced to persons having leprosy. 
tlw-v° forms or varieties of the disease are observed, viz.:—the anses- 
ruy Qp> flie tubercular. At the present writing, there is sitting in 
iiio- AlO6 a native woman about twenty years of age, married and hav- 
ing- W° cbddren, one six and the other three years old. She is of 
Picti}Urn height, weighs 146 pounds, and, to a casual observer, is a 
ish le °f health. Scrutinizing her more closely, we detect two brown- 
oi}]v l)ots5 one upon either cheek, which, to an experienced eye, tell 
Golq ,00 plainly the terrible fate that awaits her. Her left arm hangs 
yeai>aU(* ess at her side; this condition, she says, began about one 
sitICeaSo, with a numbness in her fingers, which lasted for a few weeks, 
elbowW] t^me I'! 161’6 has been an entire loss of sensation from the 
but a (i°Wnwards. In her case there is not only cutaneous anaesthesia, 
auq needle can be thrust through the skin, superficial fascia, sheath! 
auq 7Uscle itself, without giving rise to the least pain. The extensor 
exteucpXi°r n3Ußcles are relaxed, and can only be slightly contracted or 
laid n • ligamonts are very elastic, permitting the fingers to be 
fUlte back upon the dorsum of the hand. The skin of the affected 718 
ENDEHS, 
arm is dry, harsh, and flabby, all of the fatty matter has disappeared, a’1 
the muscles are also atrophied. There is slight anesthesia along tu 
course of the gastrocnemius muscle of the left leg. This patient hf 
had syphilis. There is no indication as yet of the existence of the dis' 
ease in her children. She disavows having been associated in any 
with a leper. , 
In the tubercular form of the disease, the earliest indications observ0 
of its approach are tubercles upon the base of the tongue, falling ofl 
the eyebrows, and a thick, corrugated state of the skin upon the forehea 
and cheeks. The ears become thickened, the helix being enlarged a’l 
the lobe at times as large as a hen’s egg. Ectropion is often found iiyth 
incipient stages. Frequently the existence of these early indication, 
after a few weeks or months is followed by ulceration. The fingers an 
toes drop off, this condition being accompanied by great distortion. 
some cases the bones of the fingers and toes become absorbed, exceP1 
small portions of the metacarpal and metatarsal bones, upon which t*l 
nails remain intact. There is more or less insensibility of the skin, 1 
not so marked as in the other form of the disease. When ulceration 0 
the nasal mucous membrane takes place, the sense of smell is lost, tn 
vomer is absorbed, and considerable deformity of the nose results. 
The present superintendent of the leper asylum, W. P. Ragsdale 
half white whose father was a Virginian, is a very sensible, educate 
man. He says that the first indication of leprosy apparent in his 
was an ulcer on the bottom of his foot which could not be healed. 
supposed this to be the result of syphilis, and so believed until the 
tion of the flexor muscles, and the thickening of the skin on his forehea 
and cheeks, occurred, when he recognized himself to be a leper. 
Another frequent accompaniment of this disease in its tubercular f°r 
is keloid tumor ; in fact, by some physicians this is considered as path eg 
nomonic of the disease. Cataract is often found in both forms of lepr°sß 
There can be little doubt that the two forms are varieties of one cofi1 
mon morbid condition. I have seen but two cases of elephantia5 
Arabum (Barbadoes leg), one in a native, the other from the island 
Tahiti. . ,e 
Leprosy does not appear to be more frequent in one sex than in 1 j 
other, but it is often, the case in women that as long as the menstrj)a 
function remains perfect, the disease seems to he kept in abeyance. 1 
least disturbance or irregularity of menstruation which occurs, causes* 
rapid progress in the disease. Conditions of society seem to have IB 
effect, the disease attacking high and low of native race. The d.isea 
is confined almost exclusively to the native population. I have obser' 
fifteen cases among Mongolians and four among Europeans, the hq 
being males of the lower order, living entirely with the natives, eatu o 
poi and salt fish, and sleeping in overcrowded filthy huts. Each ot tn 
white men presented undeniable evidence of the pre-existence of syp’*1 
The disease is not confined to any locality, or elevation, but wh 
prostitution is most rife, there the most cases will be found. I J36 1 ■ e 
the disease to be hereditary, and in illustration of this fact I will g1 
the following cases which are well substantiated : 
A native woman on this Island bore five children by a leprous 
the disease was developed in each of these children, between the ages of 
and twelve and they were taken to the Leper Asylum where they 
since died. The husband died from the same disease. The woman 
married a healthy man, and has now three children past the ages at whic i LEPROSY IN THE SANDWICH ISLANDS. 
719 
occurred in the other set. They are stout, healthy youngsters, with 
lndication of the disease in their systems, 
f weeks since the police brought to me a leprous woman, the mother of 
Wa.1 f°bbdren, the eldest eight years of age, the youngest two months. She 
of \ ar a(^vanced in the disease, her body covered with foul ulcers, w'ith loss 
lin» a^anges one baiKh corrugated skin, and ectropion, and she was suck- 
r S the infant, which, together with the two next older children, was appa- 
of«y bi good health. The eldest, a bo3r, bore evident signs of the existence 
an 16 c^seasei having tubercles upon his tongue, ectropion, a bronzed appear- 
P e.°f the skin, with slight thickening. As a rule, leprous women are sterile, 
lu this case we find the contrary, although she had had the disease, 
c°i'ding to her own statement, for thirteen years. 
arh strongly inclined to the belief that leprosy is not a disease sui 
but an offspring of syphilis, although from blew Brunswick, 
*nmda. Jamaica, Dominica, Guiana, Cape of Good Hope, and some 
as f3l' countries, come reports to the contrary. lam compelled to believe 
nf fd? until stronger evidence is offered by these writers for the support 
their theory. Dr. Stephenson, from Barbadoes, says:—l will not say 
olat syphilis can produce true leprosy, but it is more common in the 
spring of syphilitic parents. Dr. Hende, in his report from Mag- 
p in India, ascribes a portion of the cases to syphilis. Drs. Reed and 
lard, from Guiana, deny any connection between leprosy and syphilis, 
Dr> yan Plolsh, from the same place, says, “ I believe leprosy to 
of TT°nnecte(l with syphilis, yea, to be the offspring of it.” Dr Trousseau, 
Honolulu, says, “I believe that in syphilitic patients there is a pre- 
jiBPosition to leprosy.” Dr. Mcßobbin, a member of the Board of 
sv ln Honolulu, says, “I believe leprosy to be an offspring of 
y Philis.” The two last-mentioned gentlemen have had large experience' 
is disease, and so strong is their belief in its relationship to syphilis 
at they have stated that the eradication of syphilis from these Islands, 
°uhl eventually cause the disappearance of leprosy, or, according to* 
dift‘ number of cases of syphilis allowed to run its course, through its 
j terent stages, in such proportion will exist the number of cases of 
itP.ro?y- Here again, on account of the widespread existence of syphilis, 
if T to ascertain the extent of the contagiousness of leprosy, 
I be contagious. 
u the general acceptation of the word, by indirect contact, none of the- 
th . °al 111011 011 these Islands believe it to be so ; as to direct contact, 
b 01e.seems to be some doubt. The woman already referred to, who- 
o 10 five children by the leprous husband, still lives, and bears no signs 
th S{mPt°ms of the disease. The wife of the present superintendent of 
for ebers bas had three leprous husbands, and now lives, and has lived 
I)A.rilf'ny fears, at the asylum, and yet bears no evidence of the disease.. 
hk tp niiou, a Prussian priest, and a most excellent man, has devoted 
llej during the last few years, to the welfare of these people, living 
tVo farile secluded life, ministering to them in sickness and in health, 
pag1 Clng_ with and associating with them ; yet the blighting curse has; 
Sed him by, and left him as yet unscathed, 
ties eases might be noted to sustain the view of the non-contagious- 
-ofj. . fbe disease, yet I am strongly inclined to the belief that it is 
illQ conveyed by direct contact, through sexual intercourse or 
Isla11 111 °fber ways ; several instances have been known, on these- 
fhe 1S’ women who have married second and third husbands, after 
eath of the first from leprosy, their later husbands sharing the same 720 
ENDERS, 
fate as the first. Whole families, and those intimately connected or 
sociated with them, have thus become diseased. 
The natives seem to have no fear of the foul pestilence, and can oft®11 
be found huddled together, men, women, and children, sick and 
under the same covering; smoking the same pipe which comes poison® 
from the secretions of the leper’s mouth ; eating from the same calob&s ' 
when the hands and fingers are covered with ulcers. Dr. Manget, 'vrl 
ing from Guiana, says ; “ I have met with only two cases in which, nit 
minute inquiry, I believed the disease to have been communicated \ 
direct contact.” Dr. Regnaud, of the Island of Mauritius, says: 
have met with two instances in which the disease seemed to have be 
transmissible, in one instance from the husband to his wife, and in t 
other from a man to a child of his wife by a former husband.” 
Pollard and Yan Holsh, of Dutch Guiana, assert positively that d 
contagious. From Ceylon, Bombay, Madras, Bengal, Calcutta, Ma° 
pore, and Benares, comes the report that it is not contagious. , 
A few years since, when smallpox was epidemic upon these Islan ’ 
vaccination became promiscuous. Shortly afterwards, leprosy was larg® •> 
on the increase, and by many it was ascribed to this cause. The tn . 
Minister.of the Interior (a graduate of medicine, too), appointed lay)110 
to travel over the country and “ vaccinate everybody.” The subjects h’° 
whom the virus was taken were natives; it was transferred from j 
to arm ; and if leprosy is contagious, as this gentleman himself assert® 
in reports to the Legislature in 1872, the people of this country can,t° ‘ 
great extent, lay at his door the cause of the increase. In 1870, a G 
similar to the “social evil law,” in St. Louis, was enacted here by t . 
Legislature, and put in full force ; Dr. Mcßobbin, upon whom 
the duties of Medical Officer, with his usual zeal and earnestness, "r® Q 
to work and accomplished much good ; but this law was doomed to_ t 
same fate as that in St. Louis, and was repealed in 1872, the same i‘ 
of “licensing prostitution,” as it was termed, prevailing here as tn® 
That much good resulted, no one unbiassed by prejudice can fail to 13 
and had the law continued in full force to the present time, its en® 
would have been plainly visible, without the necessity for statist!®8 
tell-us of the good accomplished. Qf 
The Leper Segregation, or Asylum, is located upon the Island 
Molokai, where all lepers are confined. The asylum comprises ab0 
■eight square miles. It is a low plain surrounded on three sides by t 
ocean, which expends its mighty force upon this land, unbroken by 1 
or shallow water. It is with great difficulty that a landing can b® l 
■complished, and then only by the aid of experienced natives. Up°u 
remaining side rises the lofty pali or precipice of Kalanpapa, 2000 ® 
■high. In the side of this pali is cut a narrow path by which the as} 1 
proper is reached. It is a serious undertaking, to go down and re.tlmy 
as it must be done on foot, and a false step might land one more qul® 
at the bottom than would be agreeable. Having accomplished the 
scent in a quiet way, we find ourselves upon the flat or landing 
where there are a number of native huts, occupied by lepers ; e’ealld 
mount our horses and ride to the superintendent’s house, about 0116 
a half miles away. From this place we have a splendid view oi e 
ocean, the pali, and the asylum. It is a grandly beautiful sight; 
well worth the fatigue and dangers of the trip. The asylum )s p 
posed of 200 houses, in which live the lepers, alone, or with theiriaoop 
lies and friends. Directly in front of us is the hospital, built of LEPROSY IN THE SANDWICH ISLANDS. 
721 
ln a quadrangular form ; in this building are to be found the more 
vaueed cases of those not able to care for themselves ; nurses are fur- 
ii 8 V they are well cared and provided for. There are 696 inmates 
I)1 p • whole segregation ; their houses are clean and neatly kept ; food, 
jgoth in quantity and quality, all that they can wish. The establishment 
Well regulated and governed ; it is controlled by the Board of Health, 
■t| its present condition is greatly due to the energy and zeal of the 
le°ll‘ D. Wilder, President of the Board. The number of cases of 
Trosy IJOW a£ large upon the Island is very small, and the disease is 
j.j, lc\ently upon the decrease; and this decrease is, in my opinion, due to 
e improvement in the number of cases of syphilis, brought about by 
_le Government and Board of Health, which furnish all natives with 
edical attendance and medicines free of charge, and in this way induce 
p'em t° leave their old superstitious and harmful methods of treatment 
Plumas, or native doctors. Since 1866, no less than 1570 lepers 
UVe been received into the asylum, while 872 have died, leaving, at the 
present writing, 698 inmates. 
H an affection so grave, we can but feel how limited is our knowledge, 
‘ 11(| how far beyond the resources of our art is this blighting curse. 
we may be able to do something, not to relieve pain—for the suf- 
p lers usually pass through the several stages of the disease with but 
aft’ Pa^n suffering—but to stay the progress of the malady, and to 
‘ |:0,’d relief in intercurrent affections to which the debilitated condition 
the patients renders them peculiarly liable; as, for instance, pneumo- 
ub hepatitis, erysipelas phlegmonodes, conjunctivitis, etc. 
Ihe remedies which I have found most valuable in the incipient 
.tages of leprosy, are more particularly the protiodide of mercury, given 
a doses of one grain daily, with half a grain of opium, and pushed to 
,’ght ptyalisrn ; afterwards the liq'uor potassii arsenitis, twenty drops 
ai y, continued for some days, when, if circumstances are favorable, the 
mlegations of the skin disappear, the eyes assume a better color, and 
improvement in the general appearance of the patient is observed. 
.1 ® Improvement may continue for weeks or months, when suddenly, 
dhout any apparent cause except perhaps inclemency of weather, the 
lsease returns, and in all probability in an exaggerated form. In the 
•°re debilitated cases, the tinetura ferri chloridi is given with benefit. 
ds* -Donaldson and Boeck have found the internal use of mercury inju- 
’oiis in leprosy, but, given as before stated, I have found no evil results 
*less of the disease has attended this treatment in my hands, 
snl u an extenial remedy, I make use of the ointment of the iodide of 
g four, applied after washing thoroughly with warm water and carbolic 
g aP* In some cases, the itching of the entire surface of the body is very 
vere, so severe, indeed, that the sufferers will, in their agony, tear out 
Sees of flesh with their nails ; in this condition, I find the best applica- 
ntoll to be carbolic acid in the form of ointment, one part to four, which 
federally gives relief. 
Discussion on Dr. Enders’s Paper. 
Pin or.^le reading of the preceding paper, Dr. L. A. Duhrtng, of Philadel- 
rel a.’- •"—The paper is one of great interest, as it presents the question of a 
a lc>n between leprosy and syphilis, which has never yet been satisfactorily 
46 722 
ENDERS, LEPROSY IN THE SANDWICH ISLANDS. 
answered. My own opinion is that there is no relation between the two d's' 
eases. There is much division on the subject among those who reside 111 
countries where leprosy prevails. From the remarks in the paper, and ft'o!11 
my own observation, i would saj7 that syphilis exists to a large extent 111 
the Sandwich Islands, and that many cases there classed as leprosy are c°ul' 
plications of the two. 
The President, Dr. J. C. White, of Boston, said:—The facts presented in We 
paper are interesting, and many of them are novel to mo. I know that syp^1 
lis has for many years found a stronghold in the Sandwich Islands, and tl'a 
leprosy, recently introduced there, has spread most rapidly. The suggest'011 
of Dr. Enders concerning vaccination is valuable, as bearing upon the queS* 
tion of contagion in leprosy. 723 
ON THE TREATMENT OF SEBORRHCEA. 
BY 
C. HMTZMA2OT, M.D., 
OF NEW YORK CITY. 
Seborrhoea, in the definition of Hebra, “consists in a morbid secretion 
epidermis, which is impregnated with sebum, and either forms a greasy 
°ating or accumulates in scale-like masses upon a part of the skin which 
b jn other respects,.healthy.”1 This disease, so very common on the 
‘alp, where it bears the popular name of “ dandruff,” and on the face, 
specially on the nose, is, as dermatologists know, a very obstinate one’ 
ja difficult to cure. It is easy to remove the accumulated, fatty, epi- 
Ei'mic masses, by rich applications of fat, by repeated washing with 
Jater and soap, and by repeated shower-baths ; but a real and permanent 
Urp can rarely be obtained by these means, even in those cases which 
’>e di intimate connection with diseases of the womb, or with a general 
Rouble known as chlorosis, after the removal of such a primary or gene- 
a* disease. A short time after the treatment, the fatty scales return, 
sebaceous masses gather again on the scalp and on the nose, and the 
isease runs its course, leading, after many years’ standing, to atrophy of 
le sebaceous glands and the root-sheaths of the hairs, and at last to 
complete baldness. The latter result is very common with seborrhoea of 
j scalp, and was known to Hippocrates. Besides, the skin affected by 
ctjorrhoea is very liable to eczematous eruptions, especially when continu- 
ously scratched on account of an itching sensation commonly produced 
I an increased perspiration in summer time, or after excitement of the 
. rganism. If the disease be present on the face, repeated applications of 
1 dating agencies, especially of the alcoholic solution of green soap, as 
ec°inmended by some dermatologists, almost inevitably lead to a chronic 
Ermatitis with induration and stiffness of the skin, a condition which 
® ?es a singular aspect to persons who have suffered a long time from 
eborrhoea of the face. If the disease be established on the nose, the 
ionic inflammation very often leads to enlargement of the bloodvessels, 
I! , tho disease known as acne rosacea. Persons who have suffered in 
r I®lr youth from seborrhoea of this part, by and by acquire an enlarged, 
ec nose, and in my experience are very liable to deforming eruptions of 
‘ Cue rosacea, the more, of course, if alcoholic drinks be taken, even in 
quantities, 
ti 11 beginning of 1875,1 was accidentally led to the local applica- 
oo of a remedy, which, as far as I can say after a relatively short 
perience, is capable of removing the disease radically. This remedy is 
j. r* lo a case of chronic squamous eczema of the scalp, apparently the 
tj Bult seborrhoea, and complicated with a highly advanced baldness of 
part, I applied the tar tincture, and not only cured the eczema but 
* oduced a new growth of hair, leading to a complete restoration of the 
of T <^nl^’seases die Skin, by Ferd. Hebra, M.1).; Edition of the New Sydenham Society 
°ndon, vol. h, 1866, page 104. 3 724 
HEITZMANN, 
normal state. After a treatment of about two months’ duration, the 
patient was cured, and remains cured and full-haired up to the present 
time. 
The tar has been applied in seborrhoea of the scalp by Hebra, but only 
with the intention of removing the almost intolerable itching sensation 
... 0,1- 
by which the disease is sometimes accompanied. Furthermore, it has 
been applied in the form of tar ointment by Piffard, of New York, bufc 
only for a couple of weeks, alternately with different other remedies- 
Among the varieties of tar, I give the preference to the oleum rusci crll' 
dum, a product of dry distillation of the white birch. It is preferable to 
other kinds, as the oil of cade and the oleum fagi, on account of its rela- 
tively less offensive smell, this resembling the smell of Russia leather- 
Genuine oh rusci is very slightly soluble in fatty oil, but readily soluble 
in alcohol. In private practice it is almost impossible to apply a fatty 
oil, as, for instance, the linseed or almond oil, impregnated with 01. ruse1 
to the highest possible degree, because the smell of such a preparation i®, 
too strong, and to many persons intolerable. The-alcoholic solution ot 
01. rusci, the so-called tar tincture, again, is rejected by most of the 
patients, because it blackens the scalp and renders the patient incapable 
of transacting business with other persons. The form which I have 
chosen, after different experiments, is that of a pomatum, in which the 
smell of the oleum rusci is killed by 01. rosre, the only fragrant oil capa' 
ble of covering the smell of tar to a satisfactory degree. 
The formula which I have employed since March, 1875, is the folloW- 
ing;— 
ff. Olei rusci crudi, gss; 
Ung. aquas rosas, ; 
Olei rosae, gtt. x-xx.—M. 
The quantity of rose oil to be added depends somewhat on the wealth 
of the patient, as it is a very expensive substance. In summer time we 
may unite melted wax or paraffin with equal parts of cold cream, in ordol 
to make the pomatum more consistent. The greatest care should 00 
taken, on the part of the druggist, to mix the preparations namem 
exactly, and for a long time, inasmuch as the smell of tar is the _le 
noticeable, the more carefully the union has been effected by mechanic*1 
means. Every evening, before going to bed, the patient rubs into 
scalp, and not into his hair only, a quantity about the size of a sm a 
walnut; after that he has to cover his head with a tight, flannel nig Ip'' 
cap, in order to press the ointment somewhat into the skin, and to avo\ 
soiling the bed-linen. In summer time, as the wearing of a nightcap lS 
unpleasant, it may suffice to protect the pillow with a suitable cover- 
Next morning the remains of the pomatum have to be taken off with a 
dry linen cloth, and then the patient may apply some fragrant pomatunn 
Twice a week he should take a cold shower-bath of moderate force, an 
about two feet in height,and as often should simply wash the scalp wi 
water and Castile soap. Nothing further is necessary, and especially 1)0 
internal treatment whatever is required. 
The way in which the tar pomatum acts, is that after fourteen 
the falling off' of the hair is stopped; in fourteen days more the se0°of 
rhcea is gone ; and again, fourteen days later, a distinct new growth 
hair can be observed. After at least six weeks’ treatment, the disease 
in many instances cured. Slight relapses may occur, and are ream j 
dealt with by repeated applications of the tar pomatum of much shoi 0 SEBORRHCEA. 
725 
J former seborrhoea, and of several years’ standing, I succeeded in pro- 
bing a remarkable new growth of hair by the application of the above- 
J)araed pomatum for two or three months. In cases of seborrhoea of the 
ace> the continuous application of the tar pomatum, for six or eight 
eeks, will cure the disease and remove the stiffness of the skin. In 
Cases of seborrhoea of the nose, besides greasing with the pomatum, re- 
peated emptying of the enlarged sebaceous glands by mild squeezing 
the finger-nails is enough to cure the disease even in chlorotic 
SMs. As my experience embraces only twenty-eight cas'es of seborrhoea, 
bough all were treated successfully in the manner described, I do not 
Consider the value of the remedy as being thoroughly established. I 
Hog the method before the profession in order to enable every physi- 
ollll to try such a simple treatment, and shall be glad to learn the results 
°btained by others. 726 
THE TREATMENT OF SYPHILIS, 
WITH 
SPECIAL REFERENCE TO THE CONSTITUTIONAL REMEDIES APPRO- 
PRIATE Tp ITS VARIOUS STAGES, THE DURATION OF THEIR 
USE, AND THE QUESTION OF THEIR CONTINUOUS OR 
INTERMITTENT EMPLOYMENT. 
BY 
EDWARD L. KEYES, M.D., 
PROFESSOR OF DERMATOLOGY IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE, NEW YORK- 
I. Does a mild beginning in syphilis necessarily indicate that the 
malady will run a mild course, so that the duration of treat' 
ment may be regulated thereby ? 
11. Is the internal use of mercury debilitating? 
111. When is mercury useful in syphilis? Has it any control ove1 
the late symptoms ? 
IY. When is iodine useful in syphilis? Can it replace mercury 111 
any stage of the disease? ? 
V. Does iodine act by liberating mercury lying latent in the tissues ■ 
VI. Should treatment be continuous or interrupted ? 
VII. General outline of a course of internal treatment, 
yill. Conclusions, negative and positive. 
I. Does a mild beginning in syphilis necessarily indicate that the 
will run a mild course so that the duration of treatment may be regul^6 
thereby T—My subject restricts me to the constitutional remedies appl.0 
priate to the different stages of syphilis, and I shall keep as closely with1 
the prescribed limits as the nature of the question will allow. H,1 
necessary, however, to answer this first proposition before taking up th 
general consideration of constitutional treatment. _ ~ 
I need not cite authorities to prove that syphilis, commencing mil11 D 
is often looked upon as a trivial, self-limited disease. Such a belief Pl 
vails in the minds of many physicians to-day. It has received the sa,n 
tion of high authority. Diday,1 of Lyons, has taught it boldly for 
years, and Lancereaux in the main supports his views. Diday divu 
syphilitic patients into two classes. Of these, one class, embracing abp 
two-thirds of the whole number, says Diday,2 contains cases beginllll» 
mildly. The prognosis in these cases is declared to be good ; the pM 
are treated mainly by expectation ; and mercury is considered unne° • 
sary and even harmful. Oases commencing severely, the other c 
get mercury; but, so the teaching goes, they only get it as an evil 
bad than the severe syphilis which it is used to counteract, and 
obvious conclusion is that the remedy must be employed during 011 J 
1 Histoire naturelle de la Syphilis ; Paris, 1863. £es; 
2 Diday et Doyon, Th6rapeutique des Maladies v6n6riemies et des Maladies cu a 
Paris, 1876, p. 254. TREATMENT OF SYPHILIS. 
727 
time to overcome the symptoms, and must not be continued to 
injury of the patient. Lancereaux1 is particularly strong on this 
P°lnt, and I think that a similar conviction is widespread among the 
Profession in this country, the general notion being that mercury is bad, 
apd only to be used because syphilis is worse. And even if this were 
ll°t so, and if the profession should become a unit in regarding any given 
?ase of syphilis as liable to prove serious in the end, yet it would still be 
to subject all cases commencing lightly to prolonged treatment. 
. .he ordinary patient can neither convince himself, nor be convinced—after 
;lls first alarm is over, and his trivial early eruption past—that he is likely 
. suffer severely from his disease at some indefinite, future period, and 
1,1 the conviction that he will not so suffer, his physician is very apt to 
eUcourage him. 
It is certainly true that most cases of syphilis commencing mildly 
c°ntinue to preserve their mild type whether treated or not, and are not 
apt to lead to serious later troubles as where the earlier lesions are 
l?a(I, the chancre, perhaps, phagedenic, and the first eruption pustular. 
It is natural that this should be so. Phagedsena is a personal peculiarity, 
ai)d not a syphilitic symptom, and it is fair to assume that the quality 
°I constitution which allows phagedasna to occur in a given chancre, 
jvhl also cause the symptoms which follow it to be proportionally severe, 
ft is the same with a tendency to form pus on light provocation, either 
111 the elimination of an internal poison, or from external cause; this 
Pyogenic tendency is a personal matter and by no means a symptom of 
Syphilis, and where it shows itself in the early outbreaks of the disease 
by a pustular or even by a vesicular eruption, it is only natural that the 
course of the future symptoms should prove severe. 
I 1 hat these qualities of phagedsena, pustulation, etc., are personal, and 
P°f due to the acquisition of any especially bad type of disease, I think 
18 easily demonstrable. I have seen more than once two patients whose 
Syphilis had been derived from the same source, run a widely different 
course in their symptoms. The fact seems to me to be that an individual 
shows himself up physically when he is prostrated by the first onset of 
syphilis. A light beginning in the disease seems to indicate that the 
Patient has power to rally and make a good fight. The physician, there- 
°.res lulls himself into a belief that the patient can manage his disease 
Without much aid from medicine, and, as the remedy, mercury, is regarded 
as an evil, he concludes that the patient is best oft with as little of it as 
possible. 
. This reasoning would be unimpeachable were the premises accurate, 
at they are not so. First, mercury is not an evil. It is not debilitating, 
Jat tonic, in health as well as in disease, when continuously used in 
JTlnate doses. This I think can be proved, and, if so, it becomes obvious 
iat even if only a small percentage of the mild cases of syphilis become 
Bevere after a lapse of years, it is justifiable to submit all cases to such a 
c°iitiiiuolls treatment as, itself tonic and beneficial to the patient, shall 
Pjove capable of keeping down symptoms during its use and for a con- 
querable period afterward. Second, no one can tell how many cases 
c°ißmencing mildly may become severe in the end. That very many do 
' Traits de la Syphilis; Paris, 1874, p. 548. “Un certain nombre de spScialistes, etc. . 
p ’ se credent obliges d’administrer le mercure pendant plusieurs mois, quelquefois meme 
ji aeilt des annSes; . . . . loin de s’opposer it la marche ultSrieure de la maladie, 
h conduisent le malade il I’anSmie on a I’obSsitS.” 728 
KEYES, 
change in type is certain. The journals abound in such cases, and the 
experience of those who are accustomed to deal with the disease i® 
always rich in incidents bearing on this point. I need not go beyond 
my own note-book to illustrate this. 
Case I.I—A gentleman had chancre and a faint eruption for which he took 
mercury in considerable doses during a few months. After ten years o* 
health, he had syphilitic iritis, and a gummy destructive ulcer on the penis 
which resisted eight weeks of energetic treatment (caustics, etc.) at the hands 
of a surgeon, and cicatrized in three weeks under steadily increasing doses ol 
the iodide of potassium. 
Case ll.®—A medical student had chancre and indurated inguinal glands 
which were unmistakably syphilitic. He underwent treatment by small doses 
of mercury at my hands. His type of disease was so mild that he had no 
eruption whatever, nor any sign or symptom of disease except one indolent, 
indurated, post-cervical ganglion. Therefore he concluded that I was in error, 
and stopped his treatment entirely after a few months. In eighteen months 
I treated him for syphilitic hemiplegia. He had had no symptom meanwhile- 
Case lII—A physician got an insignificant sore, followed by a slight papll' 
lar rash. He took no mercury, but was treated by cathartics. The rash went 
away, and he remained perfectly well for nine years. Then a lump appeared 
upon the top of his head, and remained stationary during eleven years. Hud 
now the patient had a fever, and, on getting up from it, the node spread, 
softened, and swept away an enormous piece of his skullcap. The wound 
healed kindly under the use of iodide of potassium. 
Case 1Y.S—A gentleman had urethral chancre. No eruption followed that he 
could remember. He certainly took no mercury, and remained well forttwee 
years, when he broke out with syphilitic ecthyma which disappeared after the 
use of arsenic for a time. Then his brain gave out, and was declared to be 
softening by one of the most noted experts in nervous disease in Europe* 
Finally this got better spontaneously, and a rapidly advancing, gummy, destruc- 
tive ulceration invaded his soft palate. This got well immediately, with gi’ea 
improvement in his other symptoms, under the use of iodide of potassium alone* 
Case Y.—A physician got chancre. A few mucous patches in the mouth 
followed, but, he stated, no eruption whatever. He took mercury for a yeai- 
Not a symptom appeared for thirty years. Then he died during a sharp 
attack of intelligential and convulsive troubles which he would not treat,110_ 
believing them to be syphilitic. The autopsy revealed a large gummy tuino1 
in his brain. . 
Case YI.—A gentleman got chancre followed by a light eruption. This 
was treated homoeopathically and disappeared. Sixteen years afterwards he 
applied for treatment, being almost covered with nodes. He had ulcers in hi® 
throat and syphilitic lung disease. Steady improvement attended the mixeC 
treatment. 
Case VII.—A gentleman got chancre and fell into the hands of an anti' 
mercurialist who dosed him freely and continuously for a year with iodide 
potassium and sarsaparilla. His earlier symptoms were not severe. In oll.e 
year ulcers appeared on both legs. The dose of the iodide was increase1 - 
The ulcers progressed in depth and area, three on the right leg measuring 
over one inch in diameter each. He now changed his physician. His 
adviser discontinued the iodide of potassium and ordered protiodide of 
cury. Improvement began at once. In two weeks the ulcers were cicatrize 
He now ceased treatment, but, after two years, a gummy ulcer destroyed 
portion of the septum of the nose ; for this he consulted me. 
1 Van Buren and Keyes, Genito-Urinary Diseases, etc.; New York, 1874, p. 537. 
2 Ibid., p. 650. . _ 
3 Van Buren and Keyes, Clinical Contribution, etc., Archives of Dermatology, vo'- h 
108. Cases 111. IY. V. and VI. were seen by me in connection with Dr. Van Buren. TREATMENT OF SYPHILIS. 
729 
These cases are not very exceptional. The list could be largely in- 
creased, but I restrict myself to these few cases because they sustain the 
Point at issue from almost every side, and because some of them bear 
also upon other facts which will be used in subsequent portions of this 
Paper. It will be seen that all these cases had a very light syphilitic 
attack in the beginning, and that they were all managed differently. 
Case I. had a light eruption, and took mercury in considerable doses for 
a few months. Case 11. had no early eruption, and took a very little 
mercury for a very short time. Case 111. took no mercury, but was 
treated by cathartics. Case IV. took no mercury, but was treated by 
balsams, because bis chancre was urethral, and his malady mistaken for 
gonorrhoea. Case V. took mercury for one year, and remained well for 
thirty. Case VI. was treated homoeopathically. Case VII. was treated 
tor one year with iodide of potasiura. I have had no patient who had 
been syphilized, but the seven cases cover nearly all the other methods 
°t treatment: that by expectation; by cathartics; by diuretics (balsam, 
etc.); by mercury for a short time in large doses, for a short time in small 
doses, for a year in fair doses ; by homoeopathy ; by iodide of potassium 
from the first—and all of these, starting mildly, turned out to be severe 
°ases of syphilis. 
It is indeed notorious how many bad cases of disease there are in which 
there has been very little early eruptive trouble, and in which the pre- 
vious history of the patient shows treatment only during a tew months. 
This treatment for a few months seems to be what nearly all cases get, 
aad although very many of them, be they light or severe at first, escape 
SeHous subsequent trouble, yet there is no guarantee in the prevailing 
modes of treatment that they will so escape, nor can a light beginning be 
c°unted upon to signify a type of disease necessarily mild. 
I have not thought it necessary to search among the array of corrobo- 
mtive cases which modern journals afford tor material to further substan- 
tiate this point, preferring to adhere to personal cases, for the history of 
'vhich I can vouch. I cannot, however, retrain from alluding to a recent 
article by Fournier,1 a record of forty-seven cases ot cerebral syphilis, 
aud itself a strong argument against the too readily accepted maxim 
that mild syphilis needs but little treatment. Ot the torty-seven cases 
oldy two were severe from the first, one was rather bad, thirty were 
ordinary cases, and fourteen “ actually benign,” One of these latter was 
tbe case of a medical student who got what is termed “ un chancre de 
rien” (a mere trifle of a chancre), had a little papular rash and sore throat 
°nly, and took mercury for a few months. Alter seventeen years of calm, 
there came an explosion of syphilitic epilepsy, hemiplegia, hebetude, 
dementia, and death in spite of all the skill and care ot Fournier and 
Iticord. My conclusions to this introductory section therefore are: (1) 
that all syphilis is severe and treacherous, and that further efforts are 
Justifiable in attempting to perfect its treatment; and (l) that seemingly 
’ght cases need as thorough a course of medication as those cases which 
are apparently more severe. 
11. Js the internal use of mercury necessarily debilitating?■ Time would 
fad me should I attempt to go into this question exhaustively, yet upon 
ms solution hangs the strongest possible argument for or against a con- 
T Syphilis est elle plus commune dans certaines formes de la diathese, etc.r 
Ucole de Med., Aug. 30, 1875. KEYES, 
tinuous use of mercury. If mercury is an evil, if its influence is debih' 
fating, then its use would only be justified by its ability to overcome 
some greater evil, some more debilitating agent; and it should be dis- 
pensed with in every case as quickly as possible. This indeed is the 
accepted view of the mercurial question in syphilis. I think, however? 
that it may be shown: (1) That mercury in minute doses is a tonic, and, 
(2) That mercury in minute doses has been in use in the profession as a 
tonic, in non-syphilitic cases, for very many years, and sanctioned by the 
highest authority. 
(1) That mercury in minute doses increases the number of the red blood 
cells both in syphilitic and in healthy individuals, I think I have demon- 
strated with the hematimetre, publishing my results in the January 
(1876) number of the American Journal of the Medical Sciences. rJ-° 
that paper I must refer for details. Space will not allow me to reproduce 
the evidence here. I have, however, corroborated the conclusions therein 
reached by repeated, new experiments, during the present year, and tho9o 
conclusions I beg leave to adduce in evidence now. They are based upop 
the counting of red blood-corpuscles in over one hundred different speci- 
mens of blood, which number has been greatly added to since the publi- 
cation of the paper without occasioning any modification in the resuh9 
at first arrived at. These conclusions are: (a) That 5,000,000 red cor- 
puscles in the cubic millimetre of blood is a full, high average for tbe 
adult, healthy male, etc. (in New York); (6) That mercury decreases the 
number of the red cells when given in excess, especially in hospital 
(this was also conclusively proved by Wilbouchewitch1); (c) That syphib9 
diminishes the number of red corpuscles below the healthy standard;_ vy 
That mercury in small doses, continued for a short or for a long perioo’ 
in syphilis, alone or with the iodide of potassium, increases the numb01 
of red corpuscles in the blood, and maintains a high standard of tb0 
same; (c) That mercury in small doses acts as a tonic upon health/ 
animals, increasing their weight. (Liegeois and Bennett cited.) 
larger doses it is debilitating or fatal; (/) That mercury in small d°9o.s 
is a tonic2 to individuals in fair health, not syphilitic. In such inol' 
viduals it increases the number of the red blood-corpuscles. 
I must again express regret that I cannot bring out the evidence hol6’ 
which led directly up to these conclusions in such a way that I can 906 
no possible escape from them, and, referring those interested to the oG- 
ginal paper, I again ask to incorporate these conclusions as a part of 01 
present argument. This proof of the tonic action of minute doses 0 
mercury is scientific, but the demonstration from the clinical side is 11 
less positive. 
(2) We are all familiar with the well-known tonic consisting °* j 
minute dose of corrosive sublimate in compound tincture of bark*, 
first learned it from the late Valentine Mott, who was loud in its prao/ 
as an “ alterative” in the cases of strumous children. I cannot tracer 
authorship of this compound. It is very favorably mentioned as havi 
“been long recommended both for scrofulous taint and the more deda10 
forms of tuberculosis,” in Copland’s Dictionary of Practical Medi 
1858 ;3 and I find it spoken of as a preparation in common use, *u 
1 De I’influence des Preparations mercurielles sur la Richesse du Sang en Globules ro 8 
•et en Globules blancs. Archives de Physiologic, 4et 5, 1876, p. 508. 
2 During as long a period as the experiments were kept up. Keyes, loc. cit. 
3 A"ol. iii. p. 760. TREATMENT OF SYPHILIS. 
731 
lecture by Sir Astley Cooper, which appeared in the Lancet in 1823.1 
praises it as an alterative “for the removal of chronic diseases in 
phildren.” Modern ideas of “ alterative action” are not very clear, and 
ln connection with this mixture I never understood how mercury 
could be beneficial, until the truth flashed upon me, while counting 
olood corpuscles with the hematimetre, that mercury in minute doses 
was tonic in all cases in which it could be digested. I think that this 
l°hic action of mercury in small doses must have had much to do with 
establishing the professional confidence in former days in so-called alte- 
rative2 medication. 
This conviction of the value of minute doses of mercury as an “ alte- 
rative” [i. e., tonic), not in syphilis but in all chronic disease, I find to be 
JJost deeply rooted in the minds of the older members of our profession 
throughout the country. I have received many letters, from far and 
Cear, from representative men, stating that they had inherited the faith 
tl'om their preceptors, and had been for years in the habit of using 
fthnute doses of mercury, long-continued, as an alterative in chronic 
debilitating disease; that they had used it empirically, but with good 
I have received similar answers from all the older men whom I 
have questioned. What can be stronger evidence than this that mercury 
111 minute doses is tonic, increasing the vitality of the individual; and 
Xvhen to this is added the scientific proof, by actual counting, that mer- 
cury increases the number of the red blood-corpuscles, the chain of evi- 
dence seems complete. It may be well here to mention a remedy on 
many of the profession in New York were accustomed to rely some 
T®ars ago with confidence for the cure (or certainly the relief) of Bright’s 
disease. It was two grains of corrosive sublimate in an ounce of tincture 
the sesquichloride of iron. The dose was ten drops (not minims), con- 
taining about one-fiftieth of a grain of bichloride ot mercury, a very fair 
tonic dose ; and that improvement attended its use in many cases, is un- 
questionable. Finally may be cited the popular sanction of minute 
d°ses of mercury as a tonic which is found in the history ot Swaira’s 
Panacea,3 a nostrum at one time in very general use. This remedy cou- 
nted of a minute quantity of corrosive sublimate in compound syrup ot 
Sarsaparilla. Swaim is believed to have gotten the idea from an old 
°°k, his first business having been that of a book binder. 
idle then all the evidence goes to show that minute doses of mercury 
ai'e tonic, out of syphilis as well as in it, the proof is equally strong that 
Uiercury in large doses is debilitating, if at all continued, whether in 
syphilis or out of it. This is proved by history, by clinical experience, 
aild by actual blood counting with the hematim&tre, as has been shown 
dy Wilbouchewitch and by myself, in the articles already referred to. 
‘ yol. i. p. 111. 
U. Kent Spender, of London, refers to the action of corrosive sublimate (Journal of Cuta- 
s °us Medicine, No. 15, 1870, p. 187), saying that it indirectly promotes the nutrition of 
1 )eral tissue elements, and speaks of Dr. Billing’s mention ot its action as tonic. In a 
n iff nie> Dr. Spender says tha.t Billing (First Principles of Medicine, sth ed. 1849, 
‘ 09) states that the “ tonic” action of mercury illustrates the rationale ot the operation 
paically called “ alterative.” He does not enlarge or explain further. 
Ve ‘ D- Squibb, of Brooklyn, informs me that this nostrum, appearing about the 
ai! |®23, was extensively advertised, and enjoyed unbounded popularity, bringing great 
mpth to.its inventor. In 1828, Prof. Hare, of the University of Pennsylvania, discovered 
v ,rcury in the mixture. He published the fact in the Amer. Journ. of Med. Sciences,, 
fa ‘ lv-> 1829, p. 530, whereupon Swaim denied that the “ Panacea” contained mercury. In 
Sn .mercury does not now seem to be one of the ingredients. Mr. Neergaerd analyzed a 
pecunen 0f Panacea for me, but failed to find any mercury. 732 
KEYES, 
111. When is mercury useful in syphilis? Has it any control over the 
late symptoms f—lf it be once admitted that mercury is useful during any 
stage of syphilis, the proof that it is a tonic theoretically establishes its 
value during all stages of the disease; for the on the one 
hand, and clinical observation on the other, prove conclusively that 
syphilis is essentially a debilitating malady, and that it lessens the 
number of the red blood-cells. Yet mercury is not alone tonic, it is anti- 
dotal to syphilis; not only generally to syphilitic symptoms, but specifi- 
cally when locally applied, as Koebner1 has shown, particularly for con- 
dylomata, referring also to Ch. Hunter and Hebra ; and as Monti2 haS 
demonstrated by causing the local disappearance of patches of eruption 
by injecting the bichloride subcutaneously into them, while other patches 
at a distance remained comparatively unaltered. In a general syphilid 
eruption, the advantage of combining local with general means is strik' 
ingly shown by the much more prompt disappearance of lesions which 
have been subjected to the local use of mercury, than of the same lesion8 
elsewhere seated and not locally treated. This I have repeatedly noticed* 
Every one admits the power of mercury in postponing and modifyirln 
the earlier symptoms of syphilis, and of shortening their course wheo 
they do appear. Even the anti-mercurialists allow this, their claim 
being either that mercury prolongs the attack on the whole by p° 
poning the symptoms, since the disease must run its course—or that 
suppresses the virus and causes the appearance of tertiary lesions by 
debilitating the constitution, or in some other way. Ho statistical °l 
other evidence with which I am familiar has ever established either 0 
these assumptions,3 while the almost universal advocacy of mercury 111 
syphilis, in one form or another, by a majority of the best minds in th® 
profession in all countries, goes far to show that this is the only hones 
remedy for syphilis with which the profession is familiar. As for the tw° 
points of the anti-mercurialists—that mercury used early only postpone® 
the symptoms, prolonging the total duration of the disease, and tba 
tertiary symptoms are due to mercury—if time allowed, any number 0 
cases might be cited in opposition to this view; such as Cases 111. an( 
IV. of this paper, in which, no mercury having been used, the disease 
was in full force after twenty-one and fifteen years respectively, in fb 
most advanced tertiary type; or Case VII., in which mercury cure 
1 Archiv f. Derm. u. Syph., B. 1., S. 628; quoted from Jahresber. d. schles. Gesellsch- 
vaterland. Cultur. . . 
2 Jahrbuch. f. Kiuderheilknnde, 1869, S. 381. Beobacbtung Über die Behandlung ( 
Syphilis congenita et acquisita mittelst subcutaner sublimatinjectionen. y. 
3 Undoubtedly statistics exist on both sides of the question, but they fail to prove a 
thing positive. Quite recently Jullien (Gaz. Hebd., Sept. 18 and Oct. 2, 1874), in a 
tistical paper attempting to establish the propoi’tion of cases of tertiary disease occurl^.[lo 
in those who had taken mercury for their earlier symptoms, as compared with those 
had been otherwise treated, found in 218 cases of tertiary disease that 59, more than 
quarter, had not taken mercury, while all the rest had taken it. The number of caseiielv 
nervous syphilis he noted to be much greater proportionally in those who had taken i 
cury. All this, however, proves nothing except that syphilis naturally runs on to ter 
symptoms when untreated. Statistics cleverly handled are capable of proving alnios 
thing in relation to syphilis, because the disease itself is so capricious. In this oa?® iv, 
statistics were made up from letters received from physicians in France, England, and 
and undoubtedly in these countries three-quarters of the well known physicians give .ry 
cury early in syphilis, and it would be but fair that three-quarters of the cases of rff|ien 
syphilis found should turn out to have taken this remedy. This is especially probable jfle 
the statistics are compiled by one who is no lover of the drug, and his figures lose all ,tjary 
when it is remembered that there is no record of the cases which did not become tu 
under the mercurial and anti-mercurial courses. TREATMENT OF SYPHILIS. 
tertiary ulcers, which failed to improve under fair doses of iodide of 
Potassium, in a patient who had been treated by the latter remedy 
alone for a year after his chancre appeared. 
That mercury retains its value late in syphilis is amply illustrated by 
he well-recognized power of the mercurial, general fumigation, in many 
a,dvaneed forms of syphilitic ulceration, late in the disease ; by the great 
Vateeof what is known as the mixed treatment, especially in controlling 
Peculiarly chronic and grave symptoms of late syphilis; and by the 
hUrnerous cases of nervous syphilis found in the journals of the day, in 
the turn in the symptoms is noted as the point at which the gums 
touched. Occasionally a case is found in which the customary 
°l’uis of iodine cannot be borne late in syphilis, or in which they do not 
seern to meet the requirements ot the disease. Under these circurn- 
stauces an appeal to mercury alone will often yield a victory over symp- 
-ollls until then rebellious. Case YU* of this paper is in point, rner- 
CUI7 having succeeded where iodine had failed. While then it seems 
I]°t doubtful that mercury retains its power in every stage of syphilis, 
it is no less true that it cannot be relied upon in emergencies in cer- 
ate, especially the gummy, forms of tertiary disease. Here the differ- 
ed preparations of iodine take the lead. 
As a final illustration of the power ot mercury over tertiary lesions 
teay be cited its undoubted value in inherited syphilis. Here the lesions 
ai’e grouped in a disorderly manner—tertiary, perhaps gummatous, dis- 
ease of the bones, lungs, kidney, thymus gland and liver, often accom- 
panyiug secondary symptoms on the skin and mucous membranes—yet in 
these cases mercury is generally relied upon, and often proves capable 
a °ue of routing the enemy. I conclude, therefore, that mercury is of 
v&lue during the whole treatment of syphilis, in minute doses through- 
°jte, for its tonic and anti-syphilitic action ; in larger doses, as the occa- 
-551011 arises, to suppress outcropping symptoms, the action here being 
Purely anti-syphilitic, and not tonic. 
IY. When is iodine useful in syphilis ? Gan it replace mercury in any stage 
ffhe disease?—ln studying this point, I have again had recourse to the 
euiatim&tre to watch the effect upon the red blood-corpuscles of the in- 
,ernal administration of the preparations of iodine. My conclusion, 
clSed upon a considerable number of blood-counts made by myself, and 
teapy by my friend Dr. L. A. Stimson, is that iodide of potassium is a 
?llte, and increases the number of the red blood-cells. It does this in 
f ,steges of syphilis. I have not yet tried its effect upon the healthy 
Uclividual, but notably in some experiments by Dr. Stimson this point 
arjQe out, that while iodide of potassium, given immediately after the 
Ppearance of a chancre, increased the red blood-cells with proportion- 
,l ih greater rapidity than did mercury given under similar conditions 
°r the effect of mercury during the first depression preceding the out- 
r°p of the earliest eruption is often very slight), yet, in spite of this 
sweater increase in the number of the red blood-cells, the administration 
lQdide of potassium did not retard the appearance of the secondary 
■fuiptonis to the same extent as did the use of mercury. This fact cor- 
esponds to the well-known results of the experiments of Grass!, who 
6 ermined that iodide of potassium increased, while mercury decreased, 
e proportion of the red blood-cells to the whole mass of blood when 
Sed in syphilis. In Grassi’s day, mercury, when used at all, was 734 
KEYES, 
always given in excess, and his conclusions, although-obtained by chemi- 
cal methods mainly, are undoubtedly accurate. 
These statements of Grass! have been made use of to construct a rido 
of practice; namely, to give iodides and tonics early in syp>hilis, avoid- 
ing the supposed depressing influence of mercury. But when it appears 
that the iodides do not seriously interfere with the outcrop of the early 
eruptions, while mercury certainly does; and when it turns out that 
mercury in small doses (but large enough to greatly modify the disease) 
is tonic, the rule of practice founded on Grassi’s experiments fails to 
find any scientific support, and must fall to the ground. Case VII. 
this paper illustrates this point. This patient was dosed with iodide ot 
potassium for a year, but his early eruptions appeared none the less, 
although they were undoubtedly mild, and his tertiary symptoms came 
on in due time, perhaps as early as the}7 would have come had no treat- 
ment been used. lodine doubtless has some modifying influence over 
syphilis during its whole course, but not enough to make it wise to sub- 
stitute this drug for its more powerful rival early in the disease. 
I see no reason to believe that iodine has any eliminative power in 
syphilis, and I have failed to discover any evidence to show that it tends 
to prevent relapse. That it holds a place, however, in the treatment ot 
syphilis, is undoubted ; and a very high place it is. When tissue-inm' 
trations take place; when the lesion approaches the gummatous typ®’ 
when there is considerable connective-tissue proliferation, especially B 
takes place rapidly, whether the affection is of an external or of an i°' 
ternal organ; when nodes form upon the bones; when the cartilageS 
begin to soften; when ulceration is spreading rapidly, then the prepaid' 
tions of iodine used unsparingly for the symptom are the right hand ° 
treatment. Here nothing can replace iodine. To its benign influence, 
when well assimilated and rapidly pushed, the most formidable lesm1)s 
yield a quick response. 
In certain of the chronic lesions occurring late in syphilis, the 
of mercury is greatly enhanced by combining some preparation of iodu1 
with it; but where the lesion is a gumma, mercury may be dispense 
with at once, and entirely, and iodine pushed with a lavish hand nnt1 
the symptom yields. Mercury, however, must be resumed to seal tn 
cure and prevent relapse, and it must be given with long patience 
scrupulous care that it is thoroughly assimilated. In syphilis, thereto1’0, 
when the lesion is gummatous, no matter where it is situated, iodf110 
may replace mercury with profit to the patient; but under no other cU' 
cumstances can it take the place of this drug, although it may often 0 
advantageously combined with it. lodine is indeed what many hav 0 
considered mercury to be, a remedy not at all curative of syphilis, bll, 
causing the disappearance of certain of its symptoms, A curative age" . 
it is not, because it has little if any power of shortening the duration 
the disease, of keeping off or modifying many of its symptoms, or ot PlO 
venting relapse. 
V. Does iodine act by liberating mercury lying latent in the tissues A"" 
think that this question may be briefly disposed of in the negate * 
That iodine taken at the same time renders a given quantity of mercuG, 
more active, is probable, this being perhaps the secret of the success 
the mixed treatment for chronic obstinate lesions, not gummatous. & 
whatever power as an anti-syphilitic remedy iodine possesses, it proba V 
exercises by its merit as a tonic, increasing the number of red cells 1 TREATMENT OF SYPHILIS. 
735 
Ie blood ; for this it does even early in the disease, in spite of the de- 
pressing influence of the virus. 
'V hen a patient has been carrying a certain amount of mercury with- 
-ollt showing it in the mouth, the sudden administration of iodide of 
Potassium may call forth symptoms of salivation. Indeed, iodides given 
a|one, in some exceptional cases, have produced quite marked symptoms 
°1 mild salivation. But a little positive evidence outweighs any amount 
. negative testimony, and whatever power iodine may have in render- 
*ng mercury active, still, in its own sphere, in controlling gummy exu- 
in any of its forms, iodine does not yield a hair’s breadth to any 
or demand the least assistance from mercury. An excellent 
bearing on this point was printed editorially in the Gazette des 
“pbpUaux for January 28, 1860.1 Cases 111. and IV. of this paper are 
directly in point, iodine alone having cured patients who had never 
.ben mercury. Case VII. might be referred to as evidence on the other 
®lde; but, as I have already stated, some forms of tertiary disease, nota- 
ry some of the ulcers, seem to demand mercury for their treatment, and 
J’ield to it much more promptly than to iodine. In this case, also, I could 
ll°t ascertain to what extent the iodide had been pushed, and at best the 
Evidence is negative, while the other is positive. 
The late Prof. Boeck, of Christiania, informed me, while in this coun- 
-5 that, when tertiary symptoms occurred in his patients who had been 
Seated solely by syphilizatiou, he was in the habit of using iodide of 
Potassium with good effect, combined with a continuance ot syphiliza- 
tjon. In these cases surely there was no antecedent mercury, the libera- 
tion of which could do the work. And finally, in proof that the iodine 
Possesses the power, it is only necessary to recall that, in those frightful 
oases of devastating disease which we sometimes meet with, and which 
to the iodides, the dose must not be restricted, but pushed with 
Rapidity up to the point of tolerance, the amount of the dose assimilated 
being in direct relation to the rapidity ot cure. 
TI. Should treatment he continuous or interrupted ?—The answer to this 
floestion has already been brought out in what has been written. Ihe 
ooiitinuous use of iodine need hardly be considered, tor I feel unable to 
delude this drug among the curative agents ot syphilis. It has enor- 
mous power in overcoming certain symptoms, but as these symptoms are 
the use of iodine should also be interrupted. While the 
lasts, and for a certain time afterwards, iodine is called tor; 
pt as it does not prevent relapse, or shorten the whole course of the 
I§ease, there is no occasion for its prolonged use. Mercury, on the 
°ther hand, has received the palm as the anti-syphilitic, at least the 
®yniptomatic, anti-syphilitic, remedy, par excellence, from a majority of 
be best medical scholars and authorities up to the present time. It is 
nntidote to the poison, whatever the nature ot poison may be. 
think that the results of blood-counting by the hematimetre, used 
uP°n the blood of syphilitic patients who had taken small doses ot rner- 
CUry continuously for long periods (over years),2 proves that mer- 
is not debilitating, but, indeed, a tonic, when used in minute 
v Although the writer states that he thinks iodine often does not act well unless mercury 
'?fen previously used. 
Aeyes, loc. cit. 736 
KEYES, 
Clinical experience also has convinced me of the value of the continued 
treatment. I have employed it in all cases, light or severe, in which I 
could control the patient, since the early spring of 1869. Generally *- 
have not commenced treatment until the post-cervical and epitrochlear, 
glandular engorgement, and an eruption, have come to confirm the diag- 
nosis. My observation has included nearly all the cases of my partner, 
Professor Yan Buren, and I have to thank him for his kindly sugges- 
tions which have led to many of the steps in this investigation, au 
investigation which has convinced ns both more than ever of the value 
of the uninterrupted use of mercury in small doses in the treatment of 
syphilis. It has become a rule with us, to which we find but few excep- 
tions, that patients, after acquiring syphilis, remain in as good and often 
in better health while under treatment than previously. Severe cases 
are the rarest of exceptions, and tertiary symptoms (in those treated 
from the start) nearly unknown. Slight localized lesions, such as & 
scaly spot on the palm, a cluster of a few papules here or there, appear- 
ing from time to time, are, customarily, all that mark a continuance of 
the disease, except the lesions of the throat and mouth. Slight ulcer3 
about the throat, mucous and scaly patches in the mouth and on the 
tongue, are apt to persist and recur at intervals, for long periods. These 
are the main, very often the only, symptoms requiring attention after 
the first eruption has passed, and they respond to local measures, or to & 
slight increase in the strength of the general treatment. 
Usually the continuous treatment is kept up for from two and a half 
to three and a half years, or even longer, and in all cases, if possible, 
until six months, and sometimes a year or more, after the appearance of 
the last syphilitic symptom. Many of the patients so treated are 
married and raising healthy families—themselves to all appearance3 
perfectly well. 
Of course it is impossible to state how many of these patients are ab- 
solutely exempt from any further relapse. Seven years and a half are not 
sufficient to pass final judgment on any method, but against other method3 
may be urged; (1) That the numerous bad cases constantly met with 
have all been treated by them ; (2) That salivation is certainly harmful? 
(3) That mercury, not pushed to salivation, but used in large doses, ha3 
been proved to be debilitating by the h6matimbtre (Wilbouchewitch, 
Keyes), by clinical experience, and by experiments upon animals (Ue' 
geois, Bennett, Wilbouchewitch, and others); (4) That the intermitting 
treatment is simply symptomatic, and virtually makes one confess tba 
he has no remedy for the disease, but can only moderate the symptom3 
until such time as they may see fit to cease to reappear. 
For the continued treatment with minute doses of mercury it may o 
urged,on the other hand: (1) That it has given good results thus far (seven 
and a half years); (2) That it is scientifically and theoretically correct 
use continuously for a given evil an antidote which can itself be prove 
to be beneficial to the individual, be he sick or well; (3) That it seem 
proper to use an antidote continuously against a poison which is contmm 
ous, although having long periods of latency. For the poison must 
continuous and still present in the tertiary stage, although it has tn 
lost much of its virulence and power of transmissibility. How else c* 
we account for the undoubted fact that parents with tertiary disease m j 
produce children with inherited syphilis (I have notes of such cashe>h 
and inherited syphilis is well known to be capable of transmitting 1 & 
in full force to the nurse and other healthy persons by contact, f TREATMENT OF SYPHILIS. 
Lhat this continued treatment is only a modification of the “coup sur 
c°up” plan, so widely practised, for the quantity of mercury is aug- 
mented upon any outcrop of symptoms, the minute, continuous dose 
being maintained in the intervals. It is, indeed, not very widely dif- 
ferent from the common, symptomatic, interrupted treatment, yet I can- 
but believe that it is a great improvement upon both of the ordinary 
Plans. 
VII. General outline of a course of treatment in a typical case.—When 
the first eruption appears, or sooner if by confrontation or other sure 
the existence of syphilis is placed beyond any possible doubt, my 
habit has been to put the patient upon a mercurial, and to increase the 
h°se, slowly if there is time, more rapidly if the eruption is pressing, 
Paying all possible attention to hygiene, food, surroundings, care of teeth, 
until slight diarrhoea with colicky pain is complained of, or until 
the gums just begin to be touched. The amount required to produce 
this effect is now known to be the patient’s dose, beyond which he can- 
hut safely go without aid fr.om opiates, or changing the form of admin- 
istering the drug, and at which, if it is maintained, the effect on the 
Suueral health will be injurious. Having found this dose, it may be 
Maintained, if the eruption demands it, by giving opium, bismuth, rice, 
milk, etc., until the symptom yields ; then it should be reduced to one 
half, or a little below this point (this dose will prove tonic to the patient), 
and there maintained day after day, continuously, year in and year out, 
Waiting for other symptoms. 
Should such symptoms occur, for there may be none except mucous 
Patches, which local means will relieve, I think it is well to give the 
patient mercurial baths,1 when practicable, two or three times a week or 
ufteuer if they do not prove depressing, maintaining the same internal 
m gradually added to the tonic dose, or inunction may be practised, until 
he symptoms are subdued, when the tonic dose is to be again resumed; 
and unremittingly continued. 
•Later in the disease, should any of those symptoms supervene which 
are known to be favorably influenced by iodine, the iodide of potassium 
?!' ®°dium may be combined with the mercurial (preferably with the 
Miodide of mercury), and the two continued (mixed treatment). 
.Should cerebral symptoms come on; or bones, or nerves, or muscles, or 
Hseera, or any of the tissues become involved in any ot the forms ot 
gauirnatous growth (this, however, I have not yet seen in any casewvhere 
16 directions have been strictly followed from the first); then the iodides- 
aie to be used unsparingly for the symptom, it being ot little importance 
hether the mild mercurial is continued for the time being or not. 
. Many deviations from this simple course may be necessitated by vary- 
ing eases, especially when the continuous treatment is only commenced 
ate m the disease. I think that a case treated from the first symptom 
IQuld receive mercury continuously, in small doses, for a period not less 
an two and a half years, or, in any event, until at least six months 
ave passed after the entire disappearance of the last clearly syphilitic 
■s' aiptorns. It is hardly necessary to add that all treatment may be sus- 
to 1 \Wo drachms of black oxide after a few minutes of steam (not hot air), the whole bath 
ast not over twenty minutes, is a fair average. 
47 738 
KEYES, 
pended without ultimate disadvantage should any acute disease acci- 
dentally occur within the limits of this time. 
My time has expired, and it would be hopeless for me to attempt to 
take up a consideration of exceptional cases, either of patients such a 9 
those who cannot take mercury or iodine, or of peculiar forms of disease, 
or surrounding circumstances, where these remedies seem powerless, and 
wffiere an appeal to change of air, or to derivation by the bowels (Zitt- 
man’s decoction), or derivation by the skin (syphilization or tartarization), 
seems to effect more than can be done by following the rules established 
by success in the majority of cases. 
I cannot consider the value of mercury locally, as a means of treatment 
of the lesions, or of other local remedies ; nor the relative value of iodin6 
used as the tincture (internally), or as the iodide of potassium, of sodium, 
of ammonium, of calcium, or of amylum, or as metallic iodine with 
albumen, or as iodoform ; nor of the varied use of these agents by the 
stomach or rectum. My remarks have been general, and intended to 
apply to the typical case, and I have endeavored to group them so as to 
lead up to the following negative and positive conclusions, which I noW 
beg respectfully to lay before you, and on which I ask the expression ot 
your opinion. 
Negative Conclusions.—Views for which there would seem to be 
positive foundation in fact;— 
I. Syphilis commencing mildly needs but little treatment, and does 
not require mercury. 
11. Mercury given internally is necessarily debilitating. 
111. Mercury is only useful in secondary syphilis. 
IV. lodide of potassium is of considerable value in secondary syphilis. 
V. lodide of potassium is of no value unless preceded by the use ot 
mercury. 
VI. lodide of potassium acts by liberating mercury which has been 
lying latent. 
Positive Conclusions.—Propositions which, in the present state of 0111 
.knowledge, may be affirmed ; 
I. Mercury is an antidote to the syphilitic poison, and of service 111 
controlling all its symptoms in all (even the latest) stages ot t*’e 
disease, its power over gummata being least marked, and not 0 
be relied upon. 
TI. Mercury in minute closes is a tonic. . 
111. lodine cures certain symptoms of syphilis, but does not preveu 
relapse. 
IV. The use of mercury, long-continued, uninterruptedly as far as Pult^ 
ticable, in small doses, from the time of the earliest eruption, cot 
stitutes the best treatment of syphilis. 
Discussion on Dr. Keyes’s Paper. 
After the reading of the preceding paper, Dr. L. D. Bulkley, of New Y° ’ 
•said ;—Dr. Keyes’s first positive proposition requires qualification, for 01. 
is very injurious in gummatous cases. An exception should also be V , 
■certain rare cases. 1 had a patient who had intercourse on the fourth oi ’ 
a chancre appeared in due course of time, and the man came to me lot TREATMENT OF SYPHILIS. 
739 
ttient in the following September. I observed this case constantly for a year 
a half, and it developed all the symptoms possible during that period. 
■*-&t that man could not from the first take mercury without positive injury. 
Dr. Keyes said:—l myself know of a worse case, in which the patient lost 
loth eyes from the disease, but could not take mercury in an}' form. The 
Proposition, however, does not profess to cover every idiosyncrasy. 
Dr. R. W. Taylor, of New York, said:—The paper gives distinctly and 
clearly what many books leave in doubt, namely, the time of beginning mer- 
curial treatment. I think that there are many good reasons for using mercury 
before the secondary lesions begin; in cases in which the induration of the 
chancre is marked, it will melt away under the influence of mercury, I have, 
however, seen cases in late stages in which too much reliance had been placed 
upon mercury. For the late lesions of the skin, the iodide of potassium will 
he found very useful. 
Dr. Keyes said;—l recall two cases in which the chancre appeared upon 
the lip • in these, having no doubt that the chancres were syphilitic, I gave 
Uiercury at once and with good effect. 
Dr. Bulkley said:—lf the diagnosis is made at first, there is no reason 
wh.V mercury should not be at once administered. If I had the slightest sus- 
picion that a sore was syphilitic, I should feel it my duty to give it immediately. 
, Dr. Taylor said :—ln any case of doubt, however, the future of the patient 
18 Rot imperilled by waiting for the further development of the disease. lam 
fully convinced of the tonic qualities of mercury, and have known it to be used 
better effect than iron or quinia in cases in which the latter are the com- 
mon remedies. Pains at night, which refused to yield to morphia, I have known 
f° be allayed by an eighth of a grain of mercury daily ; mercury is also very 
efficient in controlling syphilitic fever. 
Dr, WiLLiAM Oldright, of Toronto, said:—l would ask Dr. Keyes to specify 
particular symptoms for which he would give iodide of potassium, and to 
SaJ whether iodide of potassium is better than other forms of iodine? 
Dr. Keyes said :—ln lesions of the joints, nerves and viscera, tubercular 
affections, etc., it is well to give the iodide. Its action is so ready and 
®o plain when given in large doses in such cases, that in a week oi ten days 
physician can tell whether he is upon the right track, and, it he finds that 
he is not, can fall back upon mercury. Other iodides may be used, but I give 
hhe preference to the iodide of potassium because it is the most easily assimi- 
lated. 
. Dr, Bulkley said;—Mauriac has presented a series of cases of bone lesions 
111 Which the iodide failed and mercury had to be resumed; 1 myself, too, have 
Seeu such a case. 
Dr. Keyes said;—l have not seen many cases of bone lesion early in the 
disease, but in those which I have seen I have not interrupted the mercurial 
course, though 1 have given the iodide in connection with it. I know that there 
?re some tertiary lesions which do not yield to the iodide, but the rule is that 
is of benefit to them. 
Dr. Taylor said :—Where troubles of the fibrous tissues and bone lesions 
c°me on earty, I have always used the iodide; they will not yield as well to 
Mercury alone as to it and the iodide combined. 
Dr. Charles Heitzmann, of New York, said:—l would ask Dr. Keyes 
having said that the iodide of potassium will not prevent a relapse, 
le means to assert that mercury will prevent a relapse in syphilis? 
Dr. Keyes said:—l would not make such an assertion absolutely. lean 
°'% speak from my own experience, and I am well satisfied with the course 
? »iy patients under the mercurial treatment. Mercury has caused them to 
iave better health than they enjoyed before they contracted syphilis. I can- 
llot say that they will not have other symptoms, but I am convinced that the 
Continuous treatment with mercury is the most scientific, the most philosophi- 
the most harmonious, and in fact the best. 740 
KEYES, TREATMENT OF SYPHILIS. 
Dr. Heitzmann said :—I have employed Dr. Kejms’s method of treatment, 
and have found it unable to prevent a relapse. 
Dr. Taylor said :—Generally, after two or three years of mercurial treat- 
ment, the patient is practically cured as a syphilitic, and it seems to me useless 
to debate about the unimportant disorders that may subsequently occm7. 
Dr. Heitzmann said:—l have seen, in Vienna, cases of mild beginning, 
which have got well, without any decided treatment, and others that have re* 
quired the most careful management. I believe that syphilis can be cured, 
but whether the cure should be attributed to the skill of the physician or to 
other causes, no one can say. 
Dr, Berkley said ;—lnstead of giving mercury every da}7 of every month, 
while the treatment lasts, I generally keep my patients under constant treat- 
ment for from three to six months, then let them drop one week a month, for 
three months, then two weeks a month, and sometimes let them alone for a 
month at a time; thus they do not take so much mercury,but keep the system 
always under its influence. 
Dr. Taylor said :—I would ask Dr. Keyes whether, after uninterrupted 
treatment for two years and a half, he has not found a decrease of blood-cor- 
puscles, and been forced to cease treatment, and after a while resume with in- 
creased doses ? 
Dr. Keyes said:—The reverse of this is the result of experiments. One- 
twelfth or one-eighth of a grain of the bichloride, three times a day, is a large 
dose; one-thirty-fifth to one-fiftieth of a grain is a tonic dose. Wilbouche- 
witch gai7e large doses, and kept his patients housed in close hospitals, and of 
course the number of their red corpuscles decreased. I had a patient who 
after continuous treatment for two and a half or three }7ears had six millions 
of red corpuscles to the cubic millimetre, the best blood-count I have ever 
known. This patient has never had any trouble since, and has become the 
father of a perfectly healthy child. 
Dr. Taylor said:—By constantly taking mercury, the patient becomes 
tolerant of it, and therefore, as Fournier has said, the treatment should be 
stopped for a time in order to allow the system to recover and become more 
susceptible to its action when again administered. Moreover, as syphilis does 
not show itself by long and continuous evolutions, it is consistent to treat it 
intermittingly; both before and since reading Fournier’s paper, I have used 
the intermittent treatment with excellent results. 
Dr. Keyes said :—Tolerance is not established when mercury is given in 
tonic doses. The intermittent treatment is nothing more than symptomatic 
treatment, leaving the patient in the intervals to take care of himself; my plan 
is to keep the patient in good condition by giving him the tonic dose until the 
symptoms appear, and then to give him the anti-syphilitic dose. 
Dr. L. A. Duhring, of Philadelphia, said :—The only way of arriving at a 
satisfactory conclusion as to the best manner of administering the drug, is by 
observing series of cases treated by both methods. In my practice I use both 
methods, making ray selection with reference to the patient himself and the 
peculiar circumstances of his case. I see advantages in both methods. I think 
that the plan suggested by Dr. Taylor is practically the best, and that that 
suggested by Dr. Keyes is often impracticable. 
On motion, the propositions appended to Dr. Keyes’s paper were adopted as 
expressing the opinion of the Section. 741 
THE TREATMENT OF SYPHILIS. 
BY 
CHARLES R. HRYSDALE, M.D., 
SENIOR PHYSICIAN TO THE METROPOLITAN FREE HOSPITAL, PHYSICIAN TO THE 
BOLSOVER STREET LOCK HOSPITAL, LONDON. 
[Communicated by the Secretary.] 
It is, in ray opinion, a most fortunate circumstance that the members 
1 the International Medical Congress at Philadelphia have determined 
*? discuss the treatment of Syphilis, because it cannot be said that any 
e|ear body of doctrine has as yet been laid down as to how this should 
e carried out, whilst there never has been at any time in the history of 
so good an opportunity for coming to a correct conclusion on 
Clje matter. 
Syphilis is now well known to have been quite a new disease in Europe, 
s°uiewhere about the end of the fifteenth century. As to whether it had 
existed formerly in America and Japan, it seems to me that our historical 
do not enable us to come to any clear conclusion. At its first 
°|Ubreak, syphilis was so perfectly an unknown disease that the regular 
Physicians confessed that they did not know how it should be treated* and 
t Was handed over to a host of illiterate persons who, as usual, treated 
le disease so badly that at the end of the fifteenth century it was, it 
Bcems, a terrible and revolting spectacle. 
Mercury was employed, probably in the form of inunction, in the 
leatment of syphilis, as early as 1497; but Paracelsus was the first to 
ccommend its administration internally, about the year 1570. At first, 
lereurial inunction was confined by physicians of repute to cases of true 
®Aphilis, before the confusion-period when gonorrhoea and soft sores were 
hut down as belonging to syphilitic inflammation ; but, gradually, this 
ethod of cure was applied also in cases where no true syphilis was 
fuesent; and, as salivation was caused, much misery and disease were 
ucasioned by the use of the drug. It was chiefly from this reason that 
,]e period of the Peninsular War was such an important one in the 
ls.t°ry of the treatment of the disease. In 1812, whilst that war was 
fOll,1? on, Lh'- William Fergusson wrote a letter on the treatment of 
}philis, which was read at a meeting of the Royal Medical and Chirur- 
of‘ ®ocietA °I London. In this letter, he showed that the natives 
kpain, although entirely untreated by mercury, generally made good 
from their venereal ulcers, whilst the British troops had their 
ies in very many instances terribly aggravated by the careless use 
1 inunction. This letter of Dr. William Fergusson was fol- 
Wed by a number of important experiments made by Rose, Guthrie 
P>enilen, John Thompson, of Edinburgh (the teacher of James Syrae)* 
P es.ruelles, and especially Fricke, of Hamburg, all of these observers 
aving treated both soft and hard sores without mercury. On the whole, 
great was the advantage which accrued in their experience from the 
suse of salivation in gonorrhoea and soft sore, that most of these 742 
BUYSDALE, 
authors were strong anti-mercurialists, for a long period of their prac- 
tice, at least. 
About the year 1838, M. Ricord entered on his office as chef cle clinif16 
of the Hopital du Midi, of Paris; and from that time we may date most 
of the accurate ideas we possess about venereal diseases. He made it 
abundantly clear that gonorrhoea was not a syphilitic symptom, and? 
hence, it was no longer treated with mercury. He next withdrew sott 
sores from mercurial treatment, and thus confined his attention to the 
mercurial treatment of true syphilis. For many years, M. Elcord treated 
the hard sore and its sequelae by a six months’ course of iodide of mer- 
cury, in small doses; of late he has prolonged the time of treatment to 
about a year. The great surgeon of Edinburgh, Mr. James Syme, and 
his distinguished pupil, Professor Hughes Bennett, most vigorously pro- 
tested against the long mercurial courses advised by Ricord and his fol- 
lowers, and the Edinburgh School has of late years been, on this account, 
on the whole, anti-mercurialist in its tendencies. 
The author of this essay, in a pamphlet published in 1863, adopted 
anti-mercurialistic views, and treated from 1860 to 1870, his syphilitic 
patients entirely without mercury, whether for the hard sore, or for 
secondary or tertiary lesions. The result of this treatment went to show 
that many cases of true syphilis were very mild indeed, the whole dis- 
ease consisting in such cases in a few discrete eruptions, with occasion- 
ally slight alopecia, and sore-throat, coming after indurated sore with 
enlarged and indurated inguinal glands. Tertiary symptoms, however, 
pretty frequently supervened after non-mercurial treatment of the early 
symptoms of the disease, in the form of gummy tumor of the testicle, 
sloughing sore-throat, or ozaena, with destruction of the small bones of 
the nose. Hence, the lesson taught by abandoning mercury for a time 
was that syphilis was not unfrequently a mild disease; but that it also 
was not uncommonly a grave affair. 
At the present juncture, it would seem to me, from the evidence given 
in 1867 by the members of the Societe de Chirurgie, of Paris—Biday, 
Yemeni!, Lefort, etc.—as well as by that most learned of all writers on 
syphilis, M. Alfred Fournier, of Paris, taken in conjunction with the 
evidence of Henry Lee, Hutchinson, Be M£ric, and Berkeley7 Hill, m 
London, that mercury, when administered very carefully, and in small 
enough doses, so as never to excite salivation in the slightest degree, and 
for a sufficient length of time, has (what has been styled perhaps rathe1’ 
sanguinely) some antidotal power in extinguishing the virus of syphih8* 
Mr. Hutchinson, who is fond of hypothesis in this matter, speaks ot 
mercury destroying the germs of syphilis, and affirms that if mercury be 
given in the period of the initial lesion, it will often nip the disease s° 
completely in the bud that not a trace of secondary syphilis may appeal- 
Hutchinson gives very small doses of mercury and chalk, not more, as -L 
understand him, than half a grain, twice daily; but he has never clearly 
indicated for how long a time he keeps up this treatment in the primary 
and secondary periods of the disease. M. Alfred Fournier is the m°y 
strenuous of all modern defenders of mercury in the treatment of syphdl9- 
In his lectures, delivered at the Lourcine Hospital, of Paris, he boldly 
alleges that, without doubt, of all causes for the appearance of tertiary 
lesions, not one is so potent as the negative one—omission of mercuria 
courses from the early treatment of this disease. He is very caret1 
not to advise short courses of mercury, or to lay down hesitating rule" 
as to the length of time it should be given. He is no believer in t 1 TREATMENT OF SYPHILIS. 
743 
Possibility of diagnosing mild from severe syphilis, as Diday thought 
Jl6 could do. All hard sores and secondary eruptions are, accordingly, 
treated by Fournier for the first two years of the existence of syphilis 
oy means of interrupted courses of the iodide of mercury, so as to ad- 
minister that medicine for some ten months in the course of the two 
years. His dose is from five to ten centigrammes of the green iodide of 
mercury daily, L e., from about three-quarters of a grain to a grain and 
a half of the iodide in the twenty-four hours. 
Although I am not entirely persuaded of the complete truth either of 
Hutchinson’s germ-theory and the antidotal powers of mercury, or of 
Alfred Fournier’s theory of prophylaxis against tertiary symptoms, I 
have been so far influenced by the views of these able syphilographers, 
Hat I have, of late years, given rather lengthened courses of the green 
mdide of mercury, or of mercury and chalk, to all my syphilitic patients 
1,1 the early periods of their disease. Commencing with two-thirds of 
a grain in twenty-four hours, accompanied by two grains of extract of 
jiyoscyaraus, in the form of a pill, I found myself constrained to lessen 
He dose to one-third of a grain of the green iodide, as a usual formula. 
Fven with this small dose, salivation not unfrequently occurs if the 
patient be not carefully watched. This result of this treatment has not 
hitherto been in any way discouraging. Ho accident of gravity has ever 
°ccurred with these doses, and the patients seem to pass through the 
Hseolar and eruptive period (as well as through the iritis, which occa- 
sionally ensues even in the midst of a mercurial course), in a very favor- 
able manner. I cannot, as yet, pronounce distinctly whether these pro- 
nged courses have warded off tertiary symptoms, but trust that, bv 
this apparently innocuous treatment, I may have in some cases prevented 
He appearance of that dreaded stage of the disease. 
It must not be supposed that Fournier has carried all his Parisian 
Medical brethren with him when he proposes this long-continued mer- 
curial treatment of syphilis. I found, indeed, M. Lancereaux, in a 
conversation which I had with him in the month of May last, 1876, 
opposed to Fournier’s idea that long mercurial courses were 
capable of preventing the occurrence of tertiaries. It will he remembered, 
oy those who are familiar with the literature of syphilis, that Diday, in 
his work on the “ Natural History of Syphilis,” published in Paris in 1863, 
of opinion that no particular cause for the appearance of tertiaries 
had been shown to exist. M. Lancereaux shares, it seems, this conviction 
™hh Dolbeau and Perrin, as declared in their speeches at the Societe de 
Phirurgie in 1867, and is of opinion that no mercury need be given either 
Hr the hard sore or the secondary rash, because these may disappear of 
Hernselves. He would reserve mercurial treatment for the tertiary period 
°f the disease. M. Despres never administers mercury at any period of 
syphilis, but trusts to iodide of potassium as a remedy for tertiary syrnp- 
Hnis. M. Hardy, in common with other physicians, gives mercury con- 
joined with iodide of potassium in the tertiary period ; and the school 
°I Aix-la-Chapelle, in Prussia, seems to prescribe the inunction cure in 
all periods of the disease. 
Before leaving the question of the treatment of the early periods ot 
syphilis, I cannot refrain from saying one word as to the confusion 
"'vhich has recently been occasioned by the writings of the late Dr. Mor- 
gan, of Dublin, and of Mr. Jonathan Hutchinson, as to the nature of the 
s°lt sore, and the tendency of these doctrines to cause a revival of the 
Heat men t of that lesion by mercury. I beg to protest with all my 744 
DRYSDALE, TREATMENT OF SYPHILIS. 
powers against any but local treatment of soft chancre. It is no more 
requisite to administer mercury in that disease, in order to ward oil 
syphilis, than it is to give it in gonorrhoea. Mr. Hutchinson asserts 
that mixed sores are very common, and seems to hint that it might often 
be safer to administer the antidote to syphilis, on the chance that the 
soft sore might be followed by the hard one; but such practice is, in 
my opinion, a step backwards to the doctrines which were dominant 
when Ricord and Bassereau made their great discoveries. 
Supposing that we have been unable to prevent our patients from 
arriving at the tertiary stage, or that they have come to ns already 
affected with some gummy deposit, whether in the skin, the mucous 
membranes of the throat, or the viscera, what should then be our treat- 
ment? For my part I have no difficulty in saying that the great remedy 
for the gummy period of syphilis is the iodide of potassium; and that 
it is often most dangerous to delay in administering this drug. Mercury 
is often, I am persuaded, entirely useless in the case of tertiary sore- 
throat, sarcocele, tertiary epilepsy, or specific lung disease; whereas 
large doses of the drug so marvellously brought into use by Wallace, of 
Dublin, in 1834, will often effect a rapid and surprising cure. 
The rule in practice ought to be that sloughing sore-throat, or ozmna, 
ought at once to be treated by ten-grain doses of iodide of potassium, 
administered three or four times daily. So, too, with ulcers of the lower 
extremity and the face, and with phthisis syphilitica. 
It seems to me, then, that the indications for mercury in the period 
of gummy products are few ; and that it should only be used when the 
iodide of potassium has been tried and found wanting. Above all, I think 
we should never give mercury alone in the tertiary period, as seems 
to be the fashion at Aix-la-Chapelle. By administering mercury with- 
out iodide of potassium, in the tertiary period, we run the risk of seriously 
compromising the health of the patient, for, whilst inert mercurial treat- 
ment is being pursued, the soft or hard palate may be perforated or de- 
stroyed. If, then, the practitioner be inclined to give merciuy in the 
period of gummy products, he should at all events combine it with the 
iodide of potassium. It must be borne in mind that iodide of potassium 
occasionally, though very rarely, may produce symptoms of acute poison- 
ing. I have sometimes seen eruptions of a formidable nature, vesicles 
filled with sero-sanguinolent fluid, caused by small doses of that great 
remedy for syphilis; and once saw a case which apparently proved fatal. 
In such cases, the disease may be mistaken for syphilis, and more iodide 
of potassium administered. 
Summing up the views contained in the previous pages, I would say at 
this moment that;— 
I. Mereuiy, in very small doses, should be given in prolonged courses 
during the first eighteen months of syphilis, leaving oft’ occasionally, 
and most carefully watching the patient’s teeth, etc. This should be 
done with the view of preventing the occurrence of the tertiary period. 
Mercury should be given in the period of the hard sore, with the hope 
of arresting the progress of the disease towards the eruptive stage. 
11. When tertiary symptoms appear, they should at once be treated 
by large doses of the iodide of potassium, combined, in very rare cases, 
with small doses of the bichloride of mercury. In general, the iodide ot 
potassium is all that is needed to cure tertiary lesions, at any rate tempo- 
rarily. 745 
Measures adopted in Denmark to prevent the 
SPREAD OF VENEREAL DISEASE. 
BY 
S. EFGELSTED, M.D., 
BIW existed in early times, in Denmark, a sort of control with re- 
tf oct loose women, but it seems to have been with a view of rendering 
them wore easily distinguishable from other women, partly by ordering 
tho1!1 t0 wear a certain dress, partly by assigning for them the places 
jk y Were permitted to live in. Thus, for instance, in the year 1496, 
nHans published over all the kingdom, edicts, ordering that com! 
half ,Women and harlots should wear, as head-dress, a cap, half red and 
Wl * no stuff better than “ Deventyrsk,” and no better linen than 
might be had at eighteen Skilling an ell.1 
n a law given by Christian the Second,2 we find among other things:— 
Uv^-G t*lat common loose women living in towns shall not be permitted to 
Ul Street-S an(l Goes with other good and honest people, but there shall be 
an( to them particular quarters of the towns which they are to inhabit; 
affo will that they must and shall wear good clothes, etc., such as they can 
th> f and procure ; they shall not, however, be permitted to wear mantuas, 
a'hl we-^T maJ *'e distinguished from other, modest women and honest people ; 
clop e Wlll that they shall not be molested by blows and wounds. Whoever 
8 such a thing shall have his neck forfeited. If anybody should lose his 
tyomS laH not be judged by any court. But by this is not understood such 
ea ms are on terms only with one fellow. They may live in places conve- 
PUi! r them, such as the}' please to choose in the town, not, however, in 
ees where there is most and greatest commercial business, 
mi 
eXi tGSe provisions indicate that, in those times, a sort of control 
]ar]S ed with respect to public women, and are besides a proof (particu- 
\ He latter of them) of a high degree of humanity in promising these 
r en protection against violence and molestation, 
of I)r°cess of time, another way was chosen, and, influenced by the fear 
diseases, an attempt was made to counteract the propagation 
maJ? Sarae by persecuting women suffering from those diseases. This 
the 16 Seen’ f°r instance, from a writ issued by Christian the Third in 
dog/ eai‘1546, from Aarhus, to all superintendents of the whole king- 
-01 Hen mark,3 in the following terms:— 
dit-e^.rove to all. May it be known to all that We have learned from the 
°ftep 0liS He comra°n hospitals of the kingdom, that in these hospitals are 
Emitted women who formerly, when young and healthy, have lived in 
PHYSICIAN-IN-CHIEF TO THE COPENHAGEN HOSPITAL. 
1 j „ 
1820. ' endt, History of the Beginning and Progress of Venereal Disease in Denmark 
2 L 
3 Jans£ven by Christian 11., published by Resenius, 
• VVendt, op. cit. 7-16 
ENGELSTEJL), 
notorious profligacy, and led an indecent life, and have thereby been spoil®0 
by pocks, French disease, and other complaints. We therefore beg and l'e' 
quest that you instruct and give orders to all parish priests, in the towns 
well as in the country, throughout the whole diocese, that they ever and agal'1’ 
from the pulpit, do proclaim to the common and lower classes of the peopl®’ 
that it has been resolved, that wherever there may be found such loose all 
spoiled women who, in consequence of their wicked and lewd life, have bee*1 
spoiled by pocks and French disease, or other such foul and leprous disease, tbe) 
shall not, after this day, be admitted to or received at any hospital, there 
be supported and nourished, so that everybody may know this, and avoid 
abstain from such bad and loose life. 
Since that time, several legal provisions and edicts have been published’ 
by which the propagation of venereal diseases has been partly prevented’ 
as far as could be done, by attempts to restrict profligacy. Thus:—• 
• is 
Any male who is found to come to a whore-house to commit fornicatiolb 
to be punished; the first time with imprisonment during a week, the sec°d 
time double the length of time. Females being in such houses, in order 
give themselves up to lechery, are to be whipped at the whipping-post, or °Oll 
fined in a house of correction. (Danish Law, 6-13-20.) 
Pimps and bawds seducing an}' man’s wife or daughter to live in profligaCy 
and lead a wicked life, are to be whipped at the whipping-post, and driven °u 
of the town by the hangman. (Danish Law, 6-22-1.) 
They who keep whore-houses are to be punished by being whipped at t 
whipping-post, and exiled from the province where they have been living? 0 
confined in the house of correction. (Danish Law, 6-22-5.) 
The police-master shall diligently investigate that nothing is publicly d° 
against modesty and decency, and particularly that no whore-houses are kep ’ 
and shall do his best that those who keep them, as well as those who freqlie| 
them, may be seized and summoned before the police court; and that t 
brothel-keeper, as well as those who have been found in such houses in ore 
to give themselves up to lewdness, may, after being convicted, be sentence, 
and punished according to law. (Police Regulations, October 22, P7OL *0& 
11., Chapter 3, § 1.) 
They who keep public houses in Copenhagen are forbidden to keep in 
female servants than are really wanted, or to permit loose women to lodge 
their houses, if they will not be sentenced and punished for pimping. (T°w 
hall placard, July 28, 1828.) 
If females are found to stay in houses of bad repute, to stroll about 1 
streets by night, or to have subsisted by idleness, without being able to a°coU 
for their having a substance sufficient to permit them to live in idleness with0 
hurting anybody; or if such persons, though they have been hale and hca* . ’ 
have not for a year had any regular service, then they ought to be, the n 
time, summoned before the police office, there to receive a warning, not 01 g 
to keep away from such ill-famed houses, but even to take regular serv? J 
lawful labour, or have a legal profession ; and if, after this, they continue t 
former life and conduct, he (the police-master) shall sentence and punish the 1 
after the laws, as vagrant persons of no use, but rather hurtful to the pu 
and send them to work in the house of correction. (Instructions f°x 
Police-master of Copenhagen, March 24, 1741, § 9.) 
Besides this, the edict of November 27, 1775, contains several sr® 
provisions to prevent lewdness from being practised by women kept 
inn-keepers and others for that purpose, and also many directions 
regard to the behavior to be observed by such persons with respec 
their female servants, and also for the behavior of women out of w 
with regard to the lower dancing houses, all to the same purpose, 
finally, § 9 contains the following:— VENEREAL DISEASE IN DENMARK. 
747 
-Loose and idle women who have their lodgings in separate apartments and 
o°nis, ought, at the request of the police-master, to account for their manner 
living; and they are to he punished if complaints are brought forth with 
esPect to the seducing young men, or the like. As to women who trespass 
j*Sajnst this, the police-master ought, according to circumstances and the pecu- 
JifU’ity of the case, and without appeal, to sentence them to pay a fine from 
to ten Rbd., or to be punished by detainment, with bread and water, and 
?xP°sure at the pillory, or to be punished by imprisonment in the rasping- 
°Use or “Bornehus,” or other house of correction, from one to three months. 
. Towards the end of the last century a most important provision was 
lssued for preventing the propagation of venereal disease, viz.:— 
J Royal Rescript of March 14, 1188, to the Civil Governor and Bishop of 
>e Diocese of Aarhus, of the following contents:— 
It has been reported to the King that the venereal disease has for a number 
?. years been prevailing in the diocese, and that the chief cause of its con- 
Oiuing is supposed to be that the infected, partly from shame and partly in 
1(ler to avoid the costs of the cure, conceal the complaint, or apply to quacks, 
1,1 til they suffer most severely from the disease, and spread the contagion. In 
0l(ler to remedy this, it is decreed by these presents that all belonging to the 
°wei- c|asses infected with venereal disease, whether wealthy or poor, shall be 
devoured with completely free cure, and have the attendance of the surgeon of 
he district to which they belong; and the surgeon shall have for his pains, 
lofti each such patient, a payment of two Rdl.; and all sick persons who, 
to trustworthy information to be relied upon, are not rich enough 
° Pay for their being attended while sick, must be treated gratis; and all the 
of medicine, the doctor’s fee and his conveyance, and the support of 
e poor, are to be paid proportionally after the standard of the land-tax ; and 
j King also wills that the patients from different parishes shall, if possible, 
assembled in one town, in order to be cured in the most convenient and 
*°rtest wa}’; and that persons of the lower classes, who do not in due time 
to be cured, shall, after having been cured, be punished with imprison- 
Gnt with bread and water, or other arbitrary punishment dictated by the 
‘ Ref magistrate according to circumstances. In the mean time the bishops 
ould duly admonish the clergymen to tell the names of the sick or suspected 
are known or may become known to them. 
iKy royal rescript of July 2, 1790, the above rescript was extended to 
.® a rule for the whole kingdom of Denmark. By letter from the minis- 
.*y ot home affairs of December 21,1863, these rescripts have been 
hterpreted in the most liberal manner possible. This letter was issued 
I 1 consequence of an inquiry from the Direction of the Infirmary at 
„ a>'hus, whether they were obliged to receive venereal patients arriving 
*orh other districts, and whether the city of Aarhus was obliged to pay 
i e eosts of their stay at the hospital, or whether the costs should be paid 
the district where those persons had their home. The jurisdiction of 
e district admitted that the hospital was in duty bound to receive any 
Iphilitic patient who should ask for admittance, but was of opinion that 
Je costs in such cases, where the persons concerned had their homes in 
ter districts, and had only come or been sent to Aarhus to be received 
an hospital to be treated for and cured of syphilis, should be paid by the 
'Jtricts or towns where the persons in question had their homesteads; 
i ereas the costs ought to be paid by the city of Aarhus, if the patient 
resided there even for a short time. The ministry agreed with what 
116 district had said, but decided that the costs for cure and support at 
le hospital should be paid by the district or town where the patient had 748 
EXGELSTED, 
his homestead, only when the patient had come to Aarhus inconsequence 
of a summons of the competent authority, in order to be cured there? 
but not if it were in consequence of his own resolution, or the summons 
of private people, in which case the general rule was to be applied, that 
the patient’s homestead must pay the cure. 
Although prostitution has been acknowledged as a matter of fact, 
has not been thought proper, as it has been termed, to legalize it by 
legal provisions; but it has been tolerated. This tolerance has been 
looked upon as legal authority in consequence of the oI 
March 9, 1809, according to which, women belonging to the jurisdiction 
of Copenhagen were summoned, if suffering from venereal disease, \° 
apply to the police within a fortnight. Persons conforming to this 
summons were promised free cure and support, and their names kepl' 
secret with regard to persons not concerned, and they were free from 
being accused and punished, even if their conduct had been such that? 
conformably to the police regulations, they might have been accused oi 
lewdness and idleness; whereas they who did not apply were threaten®0 
to be acted against with the whole severity of law. It was in order 
avoid, as much as possible, everything that might give to prostitution a 
stamp of legality, that no formal concessions were given either to publi® 
women or to their keepers, and that neither of the parties was to pay 
the tolerance shown. The position of public women was not regulate0 
by laws and regulations, but they were under the discretionary authority 
of the police. 
As early as the commencement of this century, visitation of pubh 
women was introduced at Copenhagen. Between the years 1800 an 
1807, the police-master Haagen engaged a physician in order to insp®c 
the prisoners, and to examine public women. By royal rescript 0 
June 6, 1815, which formerly could not be published, the control 111 
Copenhagen was very much improved. This rescript runs as follows 
To the Police-Director of Copenhagen: We have received a memorial m 
■which has been most humbly proposed to ns such means as might be employ61 
against the spreading of syphilitic contagion in our royal residence of Cop 6 
hagen, and after having duly considered the matter, we by these presen 
notify you that, concerning tins, we most graciously have established the 1° 
lowing stipulations:— . 
(1) You are authorized to enjoin all who may be looked upon as belongin» 
to the class of trading people, going under the general name of inn-keep6l 
under pain of punishment according to the law of November 27, 1775, to gl' 
up to you their names in full, and the houses they are living in, and when th .) 
are about removing, and then at the same time what and how many fenJa 
servants or lodging females they have at their houses, when and whence y1 j 
have come, and when they leave their service, and where they are then gOll 
all this for the purpose of procuring for the police an exact knowledge whet > 
any such inn-keeper, under cover of the trade for which he has a license, 
intend keeping a whore-house. . 
(2) You are likewise authorized to demand from loose and idle women £ 
according to the placard quoted, § 9, ought to account for their mod® 
living, to let you know their lodgings, and any change of the same, on palU 
the above punishment. _ 
(3) You must strictly take care that no women, against decency, 
allure males by indecent gestures or words, in doors or windows, or m 
street; and you must sentence women who thus trangress, to punishm 
according to the placard of November 27, 1775. . # 
(4) To women suspected by the police, and living alone, and to girls bvl ° VENEREAL DISEASE IN DENMARK. 
749 
public houses that have attracted the suspicion of the police as favoring 
*ewc| 1[ pe 
you are to have distributed instructions how to know the venereal 
. lsease, which have been printed by the care of our Chancery, and you must 
Ill(luce them to have always these instructions in their houses. 
(5) You must order all women named under the foregoing (4) to have 
yeuiselves visited at their own houses by their own physicians (which phy- 
SlClans ought to be named to you and acknowledged to be skilful), or by the 
P°bce physician, in places which you must choose; you also must charge them 
0 Procure a report from the physician, and this report ought to be delivered 
the police office the same day that it has been procured. 
, (6) You must superintend that the reports of the physicians are punctually 
olive red, and after that must have them arranged in such tabular form 
hat they may be easily inspected in order to discover immediately if anybody 
as neglected to have herself visited, or to deliver her physician’s report. 
(*0 You must give such directions that every one neglecting to deliver such 
ePort, shall immediately be visited by the police-physician. 
18) Besides this visitation, which is to take place every month, you must, 
hfter deliberation with the town-physician, and at not fixed terms, have such 
olnen visited by the police-physician, for the purpose of having a continual 
c°ntrol that can be relied on. 
, (9) As by rescript of this da}r to the direction of the poor-house of Copen- 
lagen5 the same has been charged to have women who are found to be infected, 
aken to an hospital to be cured, and also to grant to those who ask for it free 
and support there, you are not permitted to allow any woman who is 
.?Und to be infected, to have herself cured at her house, unless you be assured 
this may be done without exposing the public to any danger. 
C 10) Whenever a woman who is living alone or in a suspected public house, 
an(l who, after having received from you the above-mentioned instruction how 
0 know the venereal disease, is by investigation of the police found to be in- 
lected to such a degree that she cannot excuse herself by pretending ignorance 
? the existence of that disease, and has not then applied to be cured, and has 
the mean time neglected the visitation ordered by law, she shall not be 
a lowed free cure and support as otherwise given to such patients, but she her- 
fell? if she is living alone, or otherwise the inn-keeper at whose house she has 
6en living, shall be ordered to pay the costs of her cure, and in want of pay- 
ent the costs are to be worked off by public labor. 
(H) If any woman or man has been found to have infected a person of the 
P. lei* sex, and the person thus accused is convicted of having known her or 
irnself to be suffering from the disease, and to have nevertheless ventured on 
factions intercourse with the other sex, the same is to be punished by the 
Police, with fines or corporal punishment according to circumstances. 
a writ from the Government-office of August 20, 1822, there is 
epoated what the police-physician has formerly been charged with, and 
tnong other things the visitation of public women; but at the com- 
Oficement °f 1841, there had not yet been introduced any definite 
lode of visitation. When the same was to take place, about once a 
follth (formerly, most likely, four times a year), the public women were 
tbhbioned,at their lodgings, by the police-officers. In March, 1841, vish 
a ton was ordered to take place twice a month ; in June, 1844, it was 
Provided to take place once a week ; at length, in July, 1858, twice a week 
each woman. This is now maintained, and the women are no longer 
Abnoned at their lodgings to each visitation, but, on a card given to 
ach of them, since 1852, the days are indicated on which they are to 
PPfar in order to be examined. Each woman is separately examined 
tlv Je sPeculaßi, and besides the inspection of the exterior genitals and 
skin of the thighs and belly, the anus and the cavity of the mouth 750 
EjStgelsted, 
are also examined. At every opportunity endeavors are made to detect 
the persons with whom the women infected with venereal disease ha^0 
been in contact. Such persons are then, through the police, invited to 
have themselves visited and duly treated. 
With respect to the men of the army and the navy, there are particular 
provisions with regard to venereal disease. The staff-physician of the 
navy is, according to instruction of July 10, 1789, § 11, to take care thab 
among the persons levied for the navy, nobody is suffering from itch’ 
syphilitic exanthemata, ulcers on the legs, ruptures, etc. Whenever a 
vessel is to put to sea, a visitation is ordered to take place. ~ 
With respect to the army, a writ from the ministry of war (College ° 
General Commissariat) dated May 5, 1804, orders that the men shallJ30 
visited before they are sent home, in order to prevent their bringi°c> 
venereal disease to their respective communities. If they are found b? 
be suffering from such disease, they are detained in their garrison unP 
the competent chief-physician can give them a certificate of health, d- 
circular of August 5, 1805, from the same board, provides that, at tde 
beginning of their time of service, an instruction shall be given to the 
soldiers respecting the symptoms of the disease, that they may know tllo 
dangers connected with their concealing or neglecting the same. 
sergeants, musicians, and soldiers are visited when beginning their tin-10 
of service, when being dismissed, and as a rule regularly twice a month- 
in order to prevent, as far as possible, the propagation of syphilis in tn 
cities, military persons suffering from that disease are required to indicA0 
the probable source of their disease, so that the police may know it, allC 
prevent such woman from further propagating the disease. 
The measures taken to prevent the propagation of venereal contag 
have been, as may be seen from the preceding notices, arbitrary, nu 
consequently not sufficiently to be relied on. This has been remedied nj 
the following;— 
Law of April 10, 1814, respecting Measures to prevent the Propagation °- 
Venereal Disease (approved by the Parliament and by the King): 
§ 1. Persons suffering from venereal disease, whether able or not to 
their cure, are entitled to claim medical attendance at public expense, and 1 
the mean time they are bound to submit to such cure if they cannot prove the 
having private medical attendance; if the circumstances of the persons affgC 
are such that the contagion from them to other persons can be satisfactq1 J 
prevented only by their removal, or if they do not observe the instructing 
given in order to prevent contagion, they must be taken to an hospital to 
cured. Respective questions are, if necessary, to be decided by the baihn <. 
Copenhagen by the director of police) under recourse to the minister of justw | 
and the observance of the obligation can be enforced by coercive fines, dicta 
by the authorities. Persons who receive support through regular public a j 
and are found to be suffering from venereal disease, must be taken to an hospl ‘ 
to be cured. If, after the disease being cured, there is a particular reason 
fear relapse of the same in a contagious form, the physician who has atten 
the patient may give her the injunction to appear before him at a fixed tu• ’ 
or to produce a certificate from an authorized physician that no such re/ eS 
has taken place. This injunction may also be enforced by coercive 
dictated by the above-mentioned authorities. .\i\ed 
§ 2. A child suffering from venereal disease must not be given to be sUCgUp- 
by any other woman than its own mother, nor is any nurse knowing of 0f 
posing herself to be suffering from the disease, permitted to take the c 11 
any other mother to suckle it. Respective transgressions incur the pel VENEREAL DISEASE IN DENMARK. 
751 
e'itioned for the crime in question, in § 181 of the General Civil Penal Law, 
be] Ul demean time the transgressor, if the disease has been propagated, shall 
bound not only to indemnify the infected persons for the expenses connected 
b their cure, but also to give indemnity for the sufferings and losses occa- 
ned by the disease. The same duty of indemnification is incumbent on any 
i.ls°n who places a child at nurse, knowing that it is suffering from venereal 
***, ov suspecting it to be so, or who gives a child, suspected of the disease, 
~3e suckled, without previously informing the foster-parents or the nurse 
at the child is suffering or suspected. These legal provisions are also ap- 
*able to public authorities who place children to be fostered or suckled. A 
is to be looked upon as suspected of suffering from the above-mentioned 
’svase, even if no symptoms of it have been observed, if the mother is suffering 
1 “as formerly suffered from the disease in any of its constitutional forms, and 
lree months have not elapsed since the birth. 
“3. If a woman, not belonging to those who, by regulations or rules, are 
bemitted to the inspection of the police as belonging to prostitution's defini- 
..Ve'y suspected of subsisting by prostitution, she is to receive warnings from 
*e police, and to be informed of the consequences connected with the neglect 
I the warnings. In the mean time, if she consents to it, or admits herself to 
)e fading a licentious life, she is to be examined by a physician, and, if she is 
bund to suffer from venereal disease, to be submitted to cure according to § 1. 
w°man duly taught and authorized can also be trusted with this examination, 
an(t in that case the consent alluded to will not be necessary. 
§ 4. § igo of the Penal Law has been changed in such a manner that the 
l eHalty of imprisonment mentioned in the same may, where no compulsory 
x'°i‘khouses exist as appointed bylaw for expiating punishment for vagrancies, 
e changed to compulsory work for a period not exceeding ninety days. If a 
is accused so as to be punished according to § 180 of the Penal Law, 
S is to be examined by a physician, and, if she is found to be suffering from 
Ve’iereal disease, is to be submitted to cure according to §l. After having 
the punishment, she is again to be warned according to § 3, and may 
be submitted to the inspection of the police, conformably to the rules 
§iten in the following paragraphs. 
§ 5. If a woman, in consequence of the preceding paragraph, is submitted to 
ie inspection of the police, or voluntarily submits to it, she is to be ordered 
- the police to submit to medical examination at fixed periods, and to give 
b°tice of every change of lodgings. If, when examined by a physician, she is 
°Und to be suffering from venereal disease, she is to be submitted to cure 
fording to § I. 
6. Transgressions of the injunctions given in consequence of the preceding 
Paragraph, are punished by imprisonment with bread and water for a period 
\°t exceeding four days, imprisonment with the usual prison-fare not exceeding 
ixteen or compulsory labor not exceeding twenty-four days (compare § 4.) 
sUeh woman does not present herself to be examined, and has no admissible 
,eas°n for her absence, and is afterwards found to be suffering from venereal 
she may, if residing at Copenhagen, or any other place having, in con- 
of the law of February 4, 187 C§ 2, Libra C., legal provisions for the 
llspection of licentious women, by the decision of the respective police masters, 
..e submitted to the rules and regulations of that place respecting the inspec- 
-10,1 °f licentious women. But she cannot be ordered to live in public houses 
lrdess her conduct after that time necessitates such measures, 
p v L A woman who has already been sentenced according to § 180 of the 
eilal Law (compare §4 of this law), and who is again found to have been 
of subsisting by prostitution, is, besides being punished in consequence 
the said rules, with the restriction mentioned in the preceding § 6, to be sub- 
i to the regulations or rules for the inspection of licentious women, as 
ollg as, after having suffered the punishment, she continues to sojourn at 752 
ENGELSTED, 
Copenhagen, or any other place for which, in consequence of the law of Feb1® 
ary 4, 18'Jl, § 2, Libra C., such rules are given. 
§ 8. The inspection mentioned in § 5 ceases, as far as the woman in quest!®® 
has not already formerly, in consequence of §§ 6 and 7, been submitted to, 0 
has herself submitted to, the inspection which according to regulations and ride 
is instituted in certain places for licentious women, at all events at the expllJ| 
tion of six months. If, with respect to a woman’s situation or conduct, s®c 
change has taken place as may be considered sufficient security with resp®c 
to her future conduct, the police master ought to exempt her from inspect!®11 
before the expiration of the period mentioned. 
§ 9. The medical examinations mentioned in this law are, if at the place 111 
question no local police-physician has been appointed, to be executed byt®_ 
public physician of the place, and in the locality designated by the police. 
this the physician receives an annual remuneration, fixed by the 
and approved by the minister of justice, or, if such remuneration has not bee® 
fixed and approved, a payment, for each examination, of 4 Kroner (2 Bd.) t°* 
the first person examined at the same time and at the same place, and 1 Krou® 
(48 Skilling) for each following person. The remuneration is paid from 111 
town fund, in the country from the fund of repartition of the district, and 
Bornholm from the united fund of town and district. The physician is 110 
separately paid for a certificate stating whether the person examined has bee® 
found or not found to be suffering from the disease. The medical examinati®0 
mentioned in §§ 3 and 5 may also, with the permission of the police-masteP 
and on condition that the particular regulations given are observed, be execute1- 
by an authorized physician approved by the police, with whom the woman 111 
question must then herself settle the matter. 
§ 10. They who at public expense are taken to an hospital to be treated 1® 
venereal disease, are not permitted to leave the hospital before they have bee® 
dismissed by the physician of the hospital. Transgressions of this rule ®ie 
punished by imprisonment with bread and water not exceeding five days, 01 
simple imprisonment not exceeding one month. , 
§ 11. Lawsuits in consequence of §§ 4, 6, and 10 of this law are prosec id® 
in the same manner as public cases, but at Copenhagen with closed doors. 11 
police is authorized to forbid persons, keeping public houses, to lodge worn®® 
who have received warnings according to § 3 of this law, and also to for®1 
them to employ such women for the entertainment of their guests, or as servants* 
If women submitted to the inspection of the police or subsisting by proSt * 
tution, or persons assisting and lodging them, are guilty of transgressions ®l 
neglect of the above prohibition with respect to regulations or rules which,J® 
consequence of law of February 11, 1863, §B, or law of February 4, IS1)? 
§ 2, C., are given for the inspection of licentious women, the police-master1 
authorized to sentence such persons to a fine not exceeding 100 Kroner (®u 
rix-dollars), imprisonment with bread and water not exceeding four days, ® 
imprisonment with the usual prison-fare not exceeding sixteen days, or co®1 
pulsory labor not exceeding twenty-four days. 
Full effect was afterwards secured to this law by the police, through ® 
practical provision. It being well known that a great number of tb 
women who, in the capital, were comprehended in the above law ca®lC 
from other jurisdictions, and that, on the other hand, women who in tb 
capital had received warnings according to § 180 of the Penal Law, 0 
who bad been entered in the registers of public women, left the capll® 
and went to the provinces in order to continue a licentious life there, 1 
was attempted to bring about a control based on a regular co-opera tie 
between the police of Copenhagen and that of the rest of the kingd 
with respect to such women during their removal to different part® 
the country. It was stipulated by the police of Copenhagen that, when VENEREAL DISEASE IN DENMARK. 
753 
®Ver a woman under inspection as mentioned in §s,or at length entered 
in the registers for public women, gave notice that she would leave the 
owig or wag pnown by the police to go to another part of the kingdom, 
le respective police authorities should be informed of it; from such 
Authorities the police of Copenhagen then requested similar communica- 
nts, and to be informed of every sentence passed against any woman 
,?r transgressions after having received warnings according to § 180 of 
ae Penal Law. In an appendix to the Police-Intelligence, published 
cll the first and fifteenth of every month, and sent to all the police 
Authorities, informations are given 'partly with regard to Copenhagen, 
respecting all women under inspection, or having left inspection, or 
Altered in the registers for public women and again crossed out, partly 
tvuh regard to the whole kingdom, respecting women who have been 
for transgressions after warnings according to § 180 of the 
ei*al Law. 
. The warning mentioned in the law is by the police of Copenhagen 
pen to the respective women by means of a printed blank, as fol- 
Transcript from the Registers of Warnings, kept by the Police of Copenhagen, for 
licentious women. 
Case No. . . • 
t, Year 18 . .the . . . has been given to 
i e following warning: 
rt? at years old, and now lodging at 
aving admitted herself to have incurred positive suspicion ot subsisting by prostitution, 
arnlng is given to her according to $ 3 of law of April 10, 1874, and she has been given 
an ?g^erstaud that a transgression of the warning, according to § 180 of the Penal Law, 
Jw « 4 of the law above mentioned, will entail upon her punishment of imprisonment or 
CO®Pulsory labor. 
0r the correctness of the transcript: 
Police Inspector. 
omen who, according to law, are submitted to the inspection of the 
fi°hee, receive a printed blank of the following contents:— 
TV an script from the Registers of Warnings, kept by the Police of Copenhagen, for 
licentious women. 
, Year 18 . . the , who, according to sentence passed 
JT® criminal and police court, division for public police cases, has suffered punish- 
°f • . . . . for transgression against $ 180 of the Penal Law, appeared, 
and refPve(l renewed warning conformably to the warning given to her the • _ 
ent was read to her, and she was given to understand that a transgression would 
A upon her punishment of imprisonment or compulsory labor. 
187 a the same time declared to her that, according to $ 4 of the law of April 10, 
Lin ’ S^e Was submitted to the inspection of the police, and she was, therefore, given the 
, Action to appear, for the purpose of medical examination, in that division every 
and +" • ’ day, between . . . and . . • o’clock in the afternoon, 
a give notice of any change of lodgings within twenty-four hours, under penalty ot 
thig1'51.meut according to the said paragraph, if she should in any way transgress against 
■p 
0r the correctness of the transcript; 
, Police Inspector. 
11 this transcript are also printed the contents of the penal law, and 
th ex^ract Lorn the law of April 10, 1874. Public women entered in 
tii? re§isters according to the law of April 10,1874, have been, since that 
trje’ according to §8 of the law of February 11, 1863, subjected to 
u,:rnent according to the following regulations:— 754 
ENGELS TED, 
Regulations for the Inspection of the Police respecting public women in 
Copenhagen. 
By whom the inspection is to be made.—§ 1. The inspection incumbent on the 
police with respect to public women, is to be made conformably to § 31 0 
police instructions of June 7, 1869, by the third police inspector, and uncle1 
the superintendence of the police director. The increase of medical assistance 
required in consequence of the execution of the sanitary measures connect*?* 
with the said inspection, and also the distribution of the medical functions,lS? 
according to § 7 of the law concerning the re-arrangement of the police 0 
Copenhagen, to be regulated by supplements to the police regulations 0 
June 12 of last year [1873], and to the police instructions of June 7, 1869. 
Public Women.— §2, Every woman registered as a public woman is subjected 
to these regulations, and to the right of punishing which the police director 
has been given by the law respecting the mode of treatment of public pobce 
eases, of February 11, 1863, § 3. (Compare law of April 10, 1874, § 12.) 
§ 3. No woman can, at her own request, be registered among public women 
before she has completed her eighteenth year. Exceptions, however, may n® 
made with regard to women who are well known to have already become ad- 
dicted to a licentious life, and when all endeavors to reform them have prove* 
fruitless, and if they have, at the same time, completed their sixteenth yeab 
and are of sufficient bodily development. 
§ 4. No married woman can, at her own request, be registered as a pubhc 
woman, unless she has been abandoned by her husband ; and the latter, if IIS 
declaration in this respect is to be had, refuses to renew cohabitation. 
§ 5. With regard to every woman, registered as a public woman, exact in- 
formation must be produced of her name in full, place of birth, age, homestead 
and last place of residence, her own personal situation and preceding life, to' 
gether with her motives for this step. It is therefore the duty of the pobce 
inspector, whenever a woman requests to be registered as a public woman? 
and especially if she has not already been submitted to the inspection men- 
tioned in §§ 3-7 of the law for measures to prevent the propagation of venerea 
diseases, to satisfy himself that such woman fully knows the import and cons6' 
quences of her intention, and by admonitions, by the assistance of her relation9? 
and by other means at his disposal, to try to induce her to better purposes? 
and, if possible, facilitate her return to decent life. , 
§ 6. If, after the above injunctions having been observed, it is found tlm 
her request ought to be granted, she is to be submitted to medical examina 
tion, in order to ascertain whether her bodily constitution should in any ]va' 
prevent her from being registered, and whether she is at the time free lr°ul 
venereal contagion. She is afterwards, by the police inspector, and before tu 
protocol, to be acquainted with all the contents of these regulations, the nee 
ful of which is to be entered in the registers, and after this read to her, in t 
presence of valid witnesses, and agreed upon and signed by her. She is th 
registered in the list of public women which is to be kept in schematical fonn? 
containing, for each woman, an extract of notices concerning her person. 
§ 7. When inscribed, such a woman receives, against a certain payment, 
control-book containing the paragraphs of the present regulations Avith regnl 
to her position as a public woman, as well as other rules that are to be 0 
served by her, together with rubrics for medical visitations during a wim 
year. On the title-page is written her name in full, and the day \vhen inscribe ? 
on the next page the days on which she is to present herself for medical exa 
nation together with subsequent changes in that respect, and on the last 
of the book her lodgings, and, if she is living in a public house, also the nn 
her of her room, together with later changes in this respect. j 
§ 8. Public women, with the exceptions afterwards mentioned in §§ 15 al^o 
49, ought always to be in the possession of their books of control, in °rclel , 
be able to produce them whenever so requested by the police. It is strong VENEREAL DISEASE IN DENMARK. 
755 
lost, 'l^0u pawn Liem, or I'o loocl them to others. If a public woman has 
of j* lei Joob of control, she ought, immediately, to inform the third inspector 
o ’ wben a new copy, marked “ renewed,” is to be given to her. 
livin' !rhe Pnblic women are divided in two classes: (1) Women who are 
belo hy themselves; (2) women living in public houses. To the first class 
fO WV those inscribed in consequence of §§ 6 and 7of the law of April 
taL i ’aS l0"g aS their collduct does not necessitate their being ordered to 
b' lodgmgs in a public house ; (b) those who have special permission to live 
cuernselves. Such permission can be given by the police inspector, but, as 
onh’.y to those women whose conduct has always been unexceptionable, and 
feeing the consent of the landlord of the house. This permission may be 
guih C at any time, and this ought to be done with such women as are often 
12 a?f trunsgressions of these present regulations, particularly of §§ 11 and 
• All other women must live in public houses. 
Uhl J?' Every public womalb whether living in a public house or by herself, 
if j bave the permission of the police inspector to change her lodgings, and 
twL 6 18 herself the cause of her removing, she is only permitted °to remove 
”-e a month. 
f0 §J |’ Public woman is permitted to have her child at her house after its 
ttfitt n 8ar’ and l)y no means the children of other people. She is not per- 
v- .ed to have her sweetheart at her house. She is not permitted to receive 
s>ts from males wdio are not yet adult. She is not allowed to receive any 
Vn from males visiting her. She is not allowed to lodge other women. 
le Police has free access to inspect her rooms by day and night, 
s 12. Public women must carefully abstain from any disorder and from 
*ndecent behavior in streets and public places, and must strictly observe 
(I? nbes given them by the police in that respect; especially are they forbidden : 
1 I appear in any indecent or sensational dress; (2) to show any indecent 
o haviorj (3) to flock, to follow anybody, to accost or call anybody by words 
b Slgns ; (4) to place themselves at their windows, or to be standing in the 
°tise-door, in the street, or on the foot-pavement before their houses; (5) to go 
hi yI>.mPany with several others, or to marshal up, or walk up and down streets, 
.bc places, and walks; (6) to have other places in the theatres or public 
aces of amusement than those permitted by the police; and (7) to be sitting 
hmStS co^ee bouses, restaurants, and similar places of entertainment. Dur- 
tiot tbe lumps are lit, the regulations given under (4) need 
bet, observed bJ public women living in the following streets : Holmensgade 
Tee.n Lille Kongensgade and Vingaardstrsede, Brondstroderne, and Diderik 
an ] ''3ol’sgang. Public women are never allowed to go through Amaliegaderne 
pri Plads, nor, after particular orders from the police, in the 
bo11Clpjd streets of the city later than noon. Public women living in public 
lan!868 are ncd Pei>mitted to appear in the street from the time when the street- 
to F,S are btj until they have been put out; the police-director is authorized 
a *ow exceptions from this injunction. 
vj . Lb Public women are strongly forbidden to apply to males who have 
or f beni? or to the relations of the same, in order to ask money from them, 
ejc 01 other reasons. But they may request, and according to circumstances 
‘ Poet, the intervention of the police. 
f{o L To public woman is permitted to go beyond the limits of the jurisdic- 
jmaVf f*le noi’thern and southern parts of the district of Copenhagen and the 
hoi S< lcL°u of the island of Amager, nor to be absent more than twenty-four 
a plFy',- F*e*ore heing permitted to undertake a journey, she is to be visited by 
disg soon us any public woman thinks herself infected with venereal 
presase’ sbe ought to apply immediately to the examining physician, or to 
bei. ent berself at the hospital kept for that disease, and there she must deliver 
Info COnL'°Lbook, that it may be sent to the police-inspector together with 
Nation respecting her being admitted at the hospital. Every public 756 
ENGELSTED, 
woman admitted at an hospital for any other complaint than venereal disease, 
must also deliver her control-book at the hospital. 
§ 16. Whenever a public woman is by illness prevented from coming 4° 
the medical inspection, she must every day of the usual examination send to 
the police-inspector an attestation from the physician attending her, concern* 
ing the nature of her illness, and that there is no symptom of venereal disease, 
or else apply for the inspector’s permission to be examined at her home. 
§ 17. Whenever a public woman, certificate of marriage, has proved that 
she has been legally married, she is to be immediately obliterated from tli® 
registers of inscription. 
§ 18. A public woman otherwise wishing to be obliterated from the registers 
of inscription, ought to apply to the police-inspector, whom she is to make 
fully acquainted with her future profession, occupation, and lodging, and who 
is then to inform the police-director of the case, and he is then to decide 
whether her request can be complied with ; she must, however, if she does not 
adopt a solid position of life, or may by other means come to a situation off6l' 
ing sufficient security as to her future conduct, continue to be under the inspec- 
tion of the police, and be subjected to the right of punishing with which,the 
police-director is invested according to § 12 of the law of April 10, 1874, until, 
after having shown an unexceptionable conduct during three months, she ma> 
be definitively obliterated. 
§ 19. Every woman obliterated from the registers of inscription, ought to 
receive a warning conformably to § 180 of the Penal Law, and it ought to be 
said to her that, if she again tries to subsist by prostitution, she will be prose- 
cuted and punished, and submitted to the measures ordered by §§ 4-7 of the 
law of April 10, 1874, and, among other things, be immediately entered in the 
registers as a public woman if she has formerly been punished for licentious 
life. „ 
§ 20. Public Houses.—The police is authorized to allow the existence ot 
houses to afford lodgings for public women, under the inspection and responsi- 
bility of a hostess living in the house. Such concession may exceptionally be 
given to male persons, who are then subjected to the same regulations given, 
in the following sections, for the hostess. 
§ 21. Concession to keep a public house is given by the police-director. 
is always granted for an undetermined period, and preferably to old pubbc 
women whose conduct has been without grievances. When such concession i® 
sought for, the house must be exactly described, and it must be proved tha4 
the house-owner’s consent has been given, 
§ 22. Such public houses can, without theconsent of the magistracy, only be 
permitted in the following streets : Lille Brondstrode, Diderik Badskjorsgaug, 
Dybensgade, Faruergade, Gaasegade, Helsingorsgade, Holmensgade (between 
Lille Kongensgade and Vingaardsstrode), Hummergade, Knabrostrode, M&B' 
strode, St. Gertrudstode, Tornebuskegade, and Yogumagergade. A street 
once having become free from such public houses, new ones cannot be estab- 
lished there without the consent of the magistracy. 
§ 28. Every hostess keeping a public house, shall be submitted to the Pre' 
sent regulations, and the right of punishing given to the police-director by 
§ 3of the law of February 11, 1863. She must also conform to the injunction® 
which the police may find it necessary to give her. 
§ 24. No married woman, dependent on her husband, can be permitted 4° 
establish a public house, without the written consent of her husband. 
§ 25. In a public house no other inmates are pexunitted, without the pel' 
mission of the police-director, but only the hostess, her husband, and children 
under the age of 7 years, the public women, and the necessary female servants* 
All rooms for public women ought to have consecutive numbers on the on ' 
side and the inside of the door, written in plain figures. 
§ 26. They who keep public houses are bound to observe the greatest p°s' 
sible cleanliness, and to procure all such things as the police-director, nftel VENEREAL DISEASE IN' DENMARK. 
757 
raving discussed the matter with the examining physician, may prescribe with 
espect to health. The windows facing the streets must always have Venetian 
mds that are locked up. 
§ 27. The hostesses of public houses must be accountable for the lodging 
Qinen’s coming to medical examination at the fixed hours, and in clean and 
decent dress. 
0J 28- They who keep public houses cannot by any means refuse to the police 
nicers to inspect the house, by day or by night. 
§.29. They are not permitted to give lodgings to any public woman, without 
etuying it to the police. The police-inspector must fix the number of public 
olßen allowed to each house. 
§ 30. The hostesses of public houses are bound to inform the police-inspector 
the name, age, and native place of each of their servants, and the latter can 
nny be engaged witli the consent of the police-inspector. Hostesses who are 
»married, or separated or divorced from their husbands, can be submitted to 
e<>ical examination as ordered by §§ 40-49 and 52-54. 
j §3l. The police is authorized to fix the payment which the woman living 
-11 Public houses must pay both for room and fare in the house, and the hostess 
S conform to this injunction. 
. § 32. The hostess is answerable for the observance of the injunctions given 
jll § 11, and she also can be rendered answerable that public women living at 
tjer bouse observe the injunctions of § 12, as far as, according to the nature of 
le same, she is able to have any influence in that respect. 
§ 33. When a public woman has been given notice from her hostess to 
.eßiove, both of them must, at the same time, appear before the third police- 
nspector, in order to have the necessary remarks added to the registers of 
Ascription, and in the woman’s book. Removal may be notified from both 
ldes, with only twenty-four hours’ notice. 
, § 34. The hostesses are subject to punishment if women are found in their 
burses who have not their books of control, and have not given notice that 
leV have been lost, or who have not been duly announced to the police con- 
°l‘,nably to § 29. 
§ 35. The hostesses of public houses must always have in their possession 
extract from these present regulations, containing all injunctions with 
egard to them ;it must be bound like a book, and must bear the name of the 
and the street number of the house, and state the number of public 
o|tten permitted to live there, 
j. § 36. Any dissension taking place between the hostess and the public women 
I*'_l! 1& at her house, concerning their situation in that quality, is to be decided 
y the third police-inspector, and may only by his permission, or that of the 
0 ice-director, be brought before a tribunal. 
§ 31. All sorts of games with the guests are forbidden in the public houses. 
§ 08. Objects having been forgotten in such houses ought to be delivered to 
® P°lice within twenty-four hours, 
* le h°stesses are not permitted to leave the town for more than one 
Sanitary measures.—§ 40. Every public woman ought to be, as a rule, sub- 
ted to ordinary medical examination twice a week. 
§ Extraordinary medical examinations are to take place as often as the 
fj° >ce-oflocer thinks it necessary, and they do not exempt the public women 
°„rn ordinary medical examinations, 
jjg The ordinary medical examinations are made in the public localities 
for that purpose; and there must be at least two such rooms in conve- 
-oParts of the town, besides the rooms for examinations at the police 
Ce‘ Medical examinations may also be allowed to take place at home, 
popre localities are fit for such use. This permission is granted by the 
iee'director with respect to public houses, but may be given by the police- 
sector to women that have private lodgings. The police-inspector is also 758 
ENGELSTED, 
authorized to permit a woman who has private lodgings, to have her own 
physician, approved by him, whose certificate that she is not suffering from 
any venereal disease then replaces the medical examination. Such permission 3 
may be recalled at any time. 
§43. Public women who do not appear to be medically examined, or who 
are not at home in their houses at the time fixed for their examination, are to 
be arrested and taken to the police office to be examined, and are also subject 
to punishment. 
§ 44. If any public woman tries to prevent the examination from being made 
as exactly as the physician thinks necessary, she is looked upon as having not 
appeared; and, according to-circumstances, can also be taken to an hospital 
for observation. 
§ 45. Whenever an ordinary or extraordinary examination has taken place, 
the physician is to inscribe in the control-books of the public women, and in 
registers kept for that purpose, the day when the medical examination took 
place, the state of health of the woman, the nature of the complaints observed, 
and other remarks he thinks useful. All these remarks ought to be made by 
the examining physician in person. 
§ 46. Every public woman who by ordinary or extraordinary examination 13 
found to be suffering from venereal disease, is to be taken immediately to an 
hospital, and have along with her a certificate declaring the nature of the coin- 
plaint and where it is. Persons who show dubious symptoms of this disease 
are likewise taken to an hospital until it has been decided whether they ai’e 
infected or not. In consequence thereof, women who are living alone, and ai’e 
permitted to be examined at home, must appear at the hospital if they have 
not been found to be sound; and the hostesses of public houses who ai'e 
allowed to have the examinations made in their houses, are co-responsible that 
persons living in their houses, and who at the medical examination are found 
to be infected or are suspected of being so, are immediately sent to the hospital- 
§ 47. Every conveyance of loose women between the police office and the 
hospitals must be by carriage, and, as far as possible, at the cost of the respec' 
tive women. 
§ 48. Any public woman who, after having been declared to be suffering froin 
venereal disease, removes from her lodgings, is immediately to be apprehended 
and carried to the hospital, and, after being cured, is to be punished. Likewise 
every public woman who is found to be suffering from the said disease without 
having declared it, will be punished if, according to the declaration of the 
physician, it must be supposed that, in consequence of the nature of the disease, 
she cannot possibly have been ignorant of it. Every public woman who 13 
conscious of, or supposes herself to be afflicted with, venereal disease, and ha 3 
nevertheless sexual intercourse, will be prosecuted and punished according t0 
§ 181 of the Penal Law. 
§ 49. Whilst public women are at the hospital, their control-books aie 
deposited at the police office, and are only returned to them when they have 
been dismissed from the hospital after having been cured. They are als°i 
during the rest of their stay at the hospital, subjected to the injunctions of_the 
police with respect to their conduct, and submitted to the right of punishing* 
§ 50. Public women are bound to observe strictly the sanitary rules given 
to them by the examining physicians, or the police-inspector, or tire physician3 
of the respective hospitals. 
§ 51. The examining physicians are not permitted to treat public women, 
their hostesses, or the servants of the hostesses, for venereal disease or any 
other illness, nor to receive any fee from them or from others on their accouu • 
Payment for medical examinations, etc. § 52. Extraordinary medic® 
examinations shall not be paid for. Likewise the ordinary medical examin® 
tion, in at least one of the public localities for examination, is to be mac 
gratis. For other ordinary examinations, when executed in the public room 
for examination, must be paid 25 Ore, or 50 Ore for each separate examination VENEREAL DISEASE IN DENMARK. 
759 
j'-fter the time when they ought to have taken place ; and, when executed at 
°ttie, 1 Krone if the examination is executed in a public house, and 1 Kr. 50 
I>e when in private lodgings. 
§ 53. The fee for examinations at home, as well as for examinations to 
e paid for in public rooms for examinations, is to be paid in advance for a 
°rtnight to the third police-inspector, and, as to examinations in public 
'°uses, paid by the respective hostesses or hosts, or else by the respective 
'v°rnen. The hostess or the woman is given a mark for each examination paid 
,0r i*l advance, when the examination takes place, given to the physician and 
him to be delivered to the police-inspector. 
§ 54. Every public woman who has not paid in advance, and, according to 
le above rules, in due time, is in consequence thereof bound to appear at the 
J!ext medical examination (§7) in the rooms for examinations gratis, and at the 
lUie fixed for such examinations. 
§ 55. The control-books for the public women, as well as the books, etc., 
'v'dch, according to these regulations, must be found in public houses, are 
urrdshed by the police, but are paid for by the respective women or hostesses 
Wlt|i a price like that which the police has paid for them. 
fivers provisions.—§ 56. Public women subjected to these regulations who, 
Yh°ut the precincts of the town, are guilty of transgressions against the 
0 ligations under which they are, according to these regulations or in conse- 
quence of the same, are to be punished as if the transgressions had taken place 
Ruthin the precincts of the town. 
§ 57. The police-director is, by § 12 of the law of April 10, 1874, authorized 
0 dictate punishment by fines not exceeding 100 Kr., imprisonment with 
11 ead and water not exceeding four days, and imprisonment with the usual 
jjl is on-fare not exceeding sixteen days, or compulsory labor in the institution 
tor compulsory labor at Copenhagen, to public women, hostesses (and hosts) 
have a concession to keep public houses, and to the servants whom the 
Police-inspector has permitted the hostesses or public women to have. 
§ 58. All expenses occasioned by the inspection of public women are to be 
Paid by the municipal fund which receives the payment fixed by §52 for rnedi- 
examinations. 
Similar regulations may, according to § 2, 0., of the law of February 
>lB7l, be made for country towns. 
y o positive results of the law of April 10, 1874, can, of course, yet be 
Pointed out with respect to the diminution ot the venereal diseases ; but 
®heh effects can be stated as will give an idea of the results that may be 
lioped for. 
rp.-^0 greater number of public women has been registered than formerly. 
le respective yearly numbers were 
1872 289 
1873 294 
1874 353 
1875 345 
llt before that time the numbers were as large; thus in 
1862 354 
1863 352 
1864 304 
a,ld tor the rest it has been between 200 and 300. i>ut tlm number of: 
under control, by being submitted to medical inspection without 
Jeing registered as public women, has risen to a very high degree. The 
1111 ruber of women suspected of a licentious life, and who have produced 
attestations from private physicians, are 760 
ENGELSTED, VENEREAL DISEASE IN DENMARK 
1872 
. . 337 
1873 . 
. 567 
1874 
. 1027 
1875 
. 1340 
These numbers show that, since 1874, control has been effected with & 
very great number of the sort of women who are the most dangerou8 
with respect to the propagation of venereal contagion.1 The great im- 
portance of this control may be seen from the following table, in which 
the first columns refer to the women under inspection, and the others to 
women not under frequent inspection, but occasionally apprehended an(l 
examined by the police. 
Result of examinations of women 
under inspection. 
Result of examinations of women 
not under inspection. 
Number of 
examinations. 
Number found 
diseased. 
Number of 
examinations. 
Number found 
diseased. 
Years. 
27674 
PER CENT. 
780 or 2.8 
602 
PER CENT. 
173 or 28.7 
I860 
27825 
772 “ 2.7 
551 
167 “ 30.3 
1861 
81229 
935 “ 2.9 
653 
192 “ 24.4 
1862 
30483 
1056 “ 3.4 
651 
216 “ 33.1 
1863 
32020 
1046 “ 3.2 
642 
169 “ 26.3 
1864 
29106 
1050 “ 3.4 
476 
122 “ 25.6 
1865 
27863 
990 “ 3.6 
642 
152 “ 23.6 
1866 
23538 
686 “ 2.9 
888 
171 “ 19.2 
1867 
22622 
814 “ 3.6 
722 
230 “ 31.8 
1868 
23407 
800 “ 3.7 
806 
261 “ 32.2 
1869 
25740 
879 “ 3.4 
602 
181 “ 30.0 
1870 
25748 
679 “ 2.6 
655 
182 “ 27.7 
1871 
26145 
823 “ 3.1 
637 
253 “ 39.7 
1872 
25547 
751 “ 2.9 
786 
229 “ 29.1 
1873 
26783 
885 “ 3.8 
953 
300 “ 32.5 
1874 
29165 
907 “ 3.1 
670 
178 “ 22.2 
1875 
1 Among special affections I will only mention mucous which have been fou| 
nine times as often in women not under control as in those registered and regularly i°- 
spected. SECTION ON OBSTETRICS 
PRESIDENT OF THE SECTION. 
EGBERT BARNES, M.D., 
OF LONDON. 
ALEXANDER R. SIMPSON, M.D., WILLIAM H. BYFORD, M.D., 
vice-presidents. 
OF EDINBURGH. 0F CHICAGO. 
SECRETARY. 
WILLIAM GOODELL, M.D., 
OF PHILADELPHIA. 
On taking the chair, Dr. Barnes said: 
I do not know how I can express my thanks for the veiy unexpected honor 
being called upon to preside over this Section—one of the most important 
with this Congress. In England we recognize the value of this 
anch of study, but thore is no country that can claim supcrioiity over Ame- 
ka in the development of the science of Obstetrics. A our wi itei sai e acknowl- 
edged as authorities, and, as you are in the lead, it is incumbent upon you to 
cnltivate and improve your discoveries. It is incumbent upon us all to culti- 
pte the practice of obstetrics, for it lies at the very root of the human iace. 
I have been asked why I did not attend a congress in St. Petersburg, which 
111 ay be called a great medical centre. I preferred to come heie, and jet it 
®eerns singular to leave the centre and come to what we might call the on sic e. 
k is no slight task to spend three weeks of one’s holiday on the stormy ocean, 
Hit our assembly to-day is an event—it might he called an epoch in tie is- 
7ry of Medicine. I cannot sufficiently express ray sense of the honor con- 
ned upon me. I hope to hear some interesting discussions upon the topics 
A°Ught before us, and have no doubt that I shall go hack to ray home wiser 
ian when I came. 762 
THE CAUSES AND TREATMENT OF NON-PUERPERAL 
HEMORRHAGES OF THE WOMB. 
PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN IN THE CHICAGO MEDICAL COLLEGE. 
WILLIAM H. BYFORD, M.D., 
The short time at my disposal makes it impossible for me to give any* 
thing more than a brief outline of the etiology and therapeutics ot 
uterine hemorrhage, and I shall, therefore, confine myself to a succinct 
expression of the views which may be fairly sustained by our present 
knowledge of the subject. 
Without stopping to discuss at length the meaning of the terms ap' 
plied to uterine hemorrhages, I may say that I shall use the words 
“ uterine.hemorrhage” and “ metrorrhagia” in the same sense, and shah 
apply them to such losses of blood as occur between the menstrual 
periods, or in unusual amounts at the time of the periods themselves* 
An excessive, or too long-continued, flow of blood at a menstrual period 
is practically neither more nor less than metrorrhagia, originating in like 
causes, and amenable to the same treatment. 
Causes of Metrorrhagia. 
Non-puerperal hemorrhage is properly regarded as a symptom, and the 
consideration of its causes brings to our attention a great variety of 100p1 
and general pathological conditions. Exceptional cases of metrorrhag 
sometimes result from direct violence to the uterus, or from sudden apcl 
severe shocks to the system, which apparently act upon the uterus hi 
common with other organs, and cause it to bleed because of its inherent 
tendency to do so. The pathological causes which induce uterine hemor- 
rhage do not always—perhaps do not generally—act singly, but two 01 
more of them are found associated in most cases, some being essential’ 
and others merely auxiliary. The uterus, by virtue of the condition® 
upon which menstruation depends, is naturally a hemorrhagic organ ? 
and it is in consequence of its anatomical and physiological peculiaritm® 
that the ordinary and frequently acting causes of uterine hernorrhag6 
are rendered so potent and effective. 
The more obvious phenomena of menstruation are doubtless the resin 
of a definite reflex nervous influence exerted by the ovaries upon tne 
uterus. Although this influence is more distinctly manifested in tfe 
great hypersemia which precedes the occurrence of the catamenial dis- 
charge, and the changes in the utricular glands and mucous merabraji® 
of the womb, yet it is unquestionably constant in its action and paralk 
in this respect to that which presides over the motions of the heart, fbe 
arteries, and the alimentary canal. Generated in the nervous apparatus 
of the ovaries, and contemporaneous with the changes called ovulatm11 
in those organs, this influence is probably conveyed by afferent nerves ( 
the genito-spinal centre (the existence of which was first established by NON-PUERPERAL HEMORRHAGES OF THE WOMB. 
763 
Hulge,of Greifswalde1), or to some other reflecting ganglion, whence it is 
Se,lt back to the uterus, giving rise to a wonderful series of tissue-changes 
hiring the month. Some of these changes have been lucidly described 
Dr, John Williams, in the Obstetrical Journal of Great Britain and 
island, and by our own talented young countryman, T)r. Engelman, in 
Gs recent essay upon the subject, published in the American Journal of 
Y'istetrics. These changes are aptly termed by Aveling, nidation and 
cle,ddation. 
few days before the menstrual flow makes its appearance, the whole 
jderus, and especially its mucous membrane, becomes greatly hyper- 
Jopbied and very vascular; when the discharge begins, the membrane 
18 invaded by fatty degeneration. This process is so rapid that, in four 
°r five days, the entire mucous membrane disappears, leaving the mus- 
cnfiir structure of the inside of the uterus exposed, while some remnants 
0 the utricular glands are left, and found entangled among the denuded 
fibres. As soon as fhe monthly flow ceases, a reproduction of the mem- 
JriHie is commenced, and it continues to grow until at the end of twenty- 
eJght days its menstrual maturity is attained. Accompanying these 
changes in the cavity of the uterus are others equally remarkable, affect- 
lng all the other tissues of the organ. The bloodvessels become enlarged, 
aiM circulate an increased amount of blood ; the fibrous tissue is devel- 
°ped beyond its inter-menstrual condition ; while hypersesthesia indicates 
extraordinary nervous endowment. In fact a true hypertrophy of the 
fitcrus occurs. During the discharge, the process of involution reduces 
tlle organ to its smallest dimensions, and the hemorrhage ceases. The 
Cuhnination of this hypertrophy in the discharge of blood from the 
fiferus is doubtless not merely an accompaniment, but a consequence of 
fio breach of capillaries in the mucous membrane. Ihese of course are 
fifiysiological phenomena, but I desire to invite attention to the fact that 
. strongly resemble pathological conditions, and would be so considered 
any other organ in the human economy. Moreover the dividing line 
A Ween health and disease in uterine hemorrhage is as difficult to trace 
as that between sanity and lunacy. 
If is not difficult to understand that an exaggeration of the hypersemia, 
01 unusually rapid disintegration of the uterine mucous mernbiane, 
fi°ulcl cause more than a normal amount of flow; nor that a want of 
Accordance in time might be followed by the same result. most 
crises of uterine hemorrhage are traceable to conditions which distuib 
equilibrium of these phenomena. The causes which thus act are 
Va,'ied and numerous. 
Morbid nervous influences which increase the discharge of blood from 
. e uterus, sometimes emanate from the nervous centres, and hence may 
6 properly termed centric ; much more frequently, however, they are 
through the nervous centres from other and sometimes distant 
and these last are entitled to the denomination of reflex or eccentric 
influences. . l , 
Mental and emotional excitement emanating directly from the brain, 
apd cerebral and spinal excitement originating in inflammation or func- 
-1(?ual exhaustion of the brain or spinal cord, are examples of centric 
e tological influences. Many years ago I witnessed the ravages of an 
a bober das Centrum genito-spinales des N. sympatheticus, "Virchows Archiv f. Path, 
und Klin. Med., Band XV., S. 115-126, and Chicago Journal of Nervous and Mental 
leases. 764 
BYFORD, 
epidemic of cerebro-spinal inflammation, in which uterine hemorrhage 
was of almost universal occurrence among those adult females who fed 
under its influence. 
Morbid reflex nervous influences afford a more numerous class of causes. 
First among them, both in frequency and importance, are those arising 
from abnormal conditions of the ovaries, such as congestion, inflammation, 
displacement, and erotic excitement. Next to the influence of these 
bodies is that exerted by the mammary glands. Menstruation is generally 
more profuse when it occurs during lactation. The effect of mammary 
irritation in causing congestion of the uterus, and thus promoting hemor- 
rhage from it, is well illustrated by the familiar fact that sinapisms or 
blisters applied to the breasts will often cause metrorrhagia. Vesical 
irritation or inflammation, which gives rise to tenesmus; rectal irritation? 
as from the presence of hemorrhoids, or ascarides ; and dysenteric inflam- 
mation, through the reflex influence which they exert upon the uterus, 
are generally recognized causes of uterine hemorrhage. Among othe- 
reflex causes may be mentioned certain forms of indigestion, hepatic 
congestion and inflammation, and some of the disturbances of the small 
intestines, as may also strong impressions upon the cutaneous surface, as 
from cold, or from the long-continued application of heat in warm 
climates and seasons. 
All of these last-mentioned causes I think act through the reflet 
system of spinal nerves, and perhaps also through the agency of the 
sympathetic ganglia which perform a reflex function between the viscera- 
The morbid effects of the various reflex nervous impressions are rendered 
more effective and intense by the presence of such uterine diseases as 
predispose to hemorrhage by increasing the vascularity of the uterus. 
Many pathological conditions which conduce to the production of uterine 
hemorrhage, independently of direct nervous influence, act by increasing 
the hypersernia of the uterus. When the mucous membrane is granulated, 
or is the seat of inflammation, of flbrous polypus, or of malignant fungus, 
the circulation of the uterus is increased, and harmony in the process oi 
nidation disturbed ; and these conditions will be accompanied by an 
unusual and long-continued flow of blood. Subinvolution, congestion 
and inflammation, hyperplasia, tuberculosis,cancerous and fibrous deposits 
in the muscular structure, and chronic and acute endometritis, in addition 
to preventing the normal deciduous changes in the mucous membrane 
the uterus, maintain a permanent hypereemia, and thus render the womb 
prone to large losses at each return of the menstrual period. We have 
in fact abundant reasons for assuming that chronic hypersemia, no matter 
how produced, will, by virtue of the malnutrition connected with ik 
prevent menstrual changes from being effected in an orderly manner, arm 
thus render the raucous membrane more frail in organization, and con- 
sequently incapable of resisting the force of vascular pressure to which 
it is periodically subjected. 
Besides the causes of uterine hypersemia last alluded to, and existing 
within the tissues of the womb, there are many other outside pathologic- 
conditions acting in a different way. Some of these cause venous hyppr' 
semia by mechanical retardation of the circulation, while others give ns® 
to both arterial and venous hypersemia by nutritional attraction, aim 
others again cause arterial hypersemia alone, by forcing unusual amounts 
of blood into the organ. Among the most frequent and important causes 
of venous retardation are displacements and flexions of the uterus—-pro' 
cidentia, retroversion and retroflexion—the former by stretching the hon-puerperal hemorrhages of the womb. 
765 
tbe“S rendering their course more tortuous, the latter by twisting 
and r • thuf lessening their calibre; exudations into the cellular tissue 
of , i *itoneal pouch, from cellulitis and local peritonitis, and effusions 
Pre_ '°°( ln the cul-de-sac of Douglas, in retro-uterine hematocele, by 
and 7ug Upon the veins’ Prevent a free return of blood from the uterus, 
liter- IUS CaUSe venous hyperasmia. Retardation of movement in the 
une veins may also be caused by obstruction to the venous circulation 
asen. rGmote fr°m the womb, as the pressure of a tumor upon the 
dish? -g VGna CaVa’ by a loaded condition of the large intestines, by 
of ki!01? or enlargement of the liver, by obstruction to the free passage 
uiooci through the heart from valvular disease, and even by certain 
pulmonary affections. a 
ma f }he of causes giving rise t0 both arterial and venovs hypersemia, 
the Rk mentloned bbrous, fibrocystic, polypoid and fungous growths of 
to lbrous structure of the uterus. These all increase the flow of blood 
i and through the vessels of the uterus, both arteries and veins are 
In !?ased 111 capacity, and to these changes is added general hypertrophy. 
o,r tbese cases, the hypersemia of all the tissues is sometimes enormously 
eat, and the losses of blood are proportionally large and dangerous* the 
cniorrhage, unlike that from venous obstruction, is not checked by the 
aiptying of the vessels, but continues until the arterial and cardiac vis- 
' 9o is weakened by approaching syncope, 
p Causes producing arterial hypersemia alone, are hypertrophy of the 
Cart, general plethora, febrile excitement, and violent exercise. The 
enne hypersemia in these cases is caused by unusual arterial and cardiac 
P essure alone. When not attended by local pathological conditions, the 
CRiorrhage in these cases is not apt to be serious, 
y ther not uncommon causes of hemorrhage from the womb are various 
\he<XSe.s °f blood. Among these may be mentioned scurvy, leucocy- 
chlorosis, albuminuria and syphilis. It is not likely that the 
OCe the composition of the blood is the sole causative influence 
p*erating in the above-named conditions. In scurvy, for instance, we 
iiow that the solid tissues—whether as a primary condition or as an 
r) °t the blood-changes—are diseased, the capillaries more fragile than 
gUrai, and consequently less capable of resisting the cardiac impulse, 
th evideuce that the vicious condition of both blood and solid tissues is 
ad 1 CfUBe uterine hemorrhage in scurvy, the well-known fact may be 
.ed that bleeding is very easily provoked in other mucous membranes. 
ls the more likely to take place from the mucous membrane of the 
or yUIS’ because °f the great normal fluctuations in the circulation of that 
c„gan’ aPd aDo because the vitiated state of the blood would naturally 
e Se. disturbance in other conditions attendant upon menstruation, 
lia • la% the decidual changes. It will be seen therefore that the pecu- 
ot7lfy in the operation of this variety of cause, is not due to the presence 
or f° or general hyperseraia from retardation of the venous circulation, 
bio I?rn arterial and cardiac pressure, but is due to the tendency'- of the 
ipe°d to escape through the walls of the vessels, and to the inability of 
the Capillary tubes to resist the circulatory force ordinarily applied to 
tfip 8 an°ther cause of hemorrhage from the womb, must be mentioned 
bad law of the human system to continue a long-established 
’ a^ter the original cause is removed. This is probaSly the only 
obs0aal explanation of those rare uterine losses which are sometimes 
Served in pregnancy, and in cases where both ovaries have been re- 766 
BYFORD, 
moved. The habit of bleeding continues after the ovarian, reflex, nervous 
influence has been withdrawn from the uterus. 
Still another rare, yet very dangerous, cause of uterine hemorrhage, Is 
that known to surgeons as the hemorrhagic diathesis. The writer has seen 
one case in which he believes that the bleeding was clearly attributable 
to this mysterious condition, and which proved fatal. It was that of a 
young girl who died with her second menstrual flow. 
The wide range of causative conditions found connected with uterine 
hemorrhage is but an inverse exhibition of the sympathetic relations of 
the uterus. When diseased, it exercises an almost universal pathological 
influence upon other organs, and as a consequence it is susceptible of being 
impressed to the same degree by certain morbid conditions of all import- 
ant viscera. In this assembly of intelligent practitioners it will not be 
regarded as making an undue claim to say, that the practice of gynaeco- 
logy requires a more thorough theoretical and practical familiarity with 
the details of all the branches of medicine than any other of the so-called 
specialties. We are not prepared to treat the most common of female 
diseases without being able to scan with scientific scrutiny every organ 
and function of the body. Nor until we can compete successfully with 
the general practitioner, the surgeon, the alienist, and the neurologist, m 
the therapeutic processes of their respective departments, may we hope 
to exercise in the highest sense the office of the gynaecologist. These 
remarks apply with force to the comprehension of the causes and treat- 
ment of hemorrhages of the unirapregnated and non-puerperal uterus. 
Treatment of Metrorrhagia. 
I find it quite impossible to satisfy myself as to the best order in which 
to bring forward the various measures proposed for treating uterine 
hemorrhage. Those which have for their object the removal of the caus- 
ing conditions, properly fall under the head of curative means; while those 
which we employ to stop the bleeding temporarily, until the remedies 
of the first order have accomplished their purpose, seem as naturally f° 
belong to the category of palliative measures. We find in each of these 
divisions, however, remedies which act in both ways, and the palliative 
means are often radical and energetic. Notwithstanding the many 
obvious deficiencies in this arrangement, it seems to me to be the best 
that I can adopt. 
Palliative Treatment.—Before entering into a detailed description of the 
more essential, remedial methods of curing the various forms of hemor- 
rhage, it will be profitable to consider some of the important, minor 
measures which are applicable in almost all instances. As the great 
majority of hemorrhages occur at the menstrual periods, we often have 
opportunities of adopting measures in anticipation of them. These 
measures are sometimes calculated to entirely prevent an exaggerated 
flow, and at others to very much modify it; and in all to greatly promote 
the action of more direct remedies. The patient should abstain from an 
causes of local or general, vascular or nervous excitement. Among these 
causes are mental and bodily fatigue, emotional excitement arising from 
certain social relations, sensational books, and the contemplation of erotm 
objects. The patient should also abstain from stimulating drinks and 
highly seasoned food; her clothing should be loose and cool, so that no HON-PUERPERAL HEMORRHAGES OF THE WOMB. 
767 
Pai’t of the body may be constricted, and the genital organs should not 
>e too warmly covered. Her bowels ought to be kept regular, or rather 
i'ee. The secretions from the skin, liver, and kidneys should be main- 
ained as nearly as possible in a normal condition, and tonics, such as 
jG'senic, strychnia, and quinia, with digestible, nourishing and unstimu- 
ating diet, should be given in quantities sufficient to keep the health up 
the normal standard. Other things which will contribute very 
Neatly to good results, are plenty of pure air, night and day, and 
Moderate, muscular exercise. Many other general directions will sug- 
gest themselves, which I cannot stop now to mention. 
Mrhen the time for the paroxysm has arrived, and the hemorrhage has 
commenced, isolation, quietude, and recumbency are very important pre- 
cautions to be enjoined. Position indeed may be made to do much 
S°od of itself. If the hemorrhage is not severe, mere recumbency will 
y6 sufficient; but if it is protracted, the hips should be elevated,and sorne- 
lfues it will be beneficial to raise them so high as to cause the blood to 
p’uvitate to the fundus uteri, and to fill the whole genital canal before 
any of it passes out. To a considerable extent this may be made to act 
fs a tampon. The position chosen to effect this object may be on the 
Jaek, or upon the knees and chest. If the latter position can be com- 
manded, it is much the best, as the reversal of gravitation is more com- 
Idete. Cold and acid drinks, cold applications to the hypogastric and 
Saci’al regions, hips and vulva, and in the vagina, are also among the 
lemedies applicable to almost all cases. 
Many practitioners value astringents, administered internally, in 
uterine hemorrhage, but I have found so little benefit from them when 
sj?t given with opium or belladonna, that I seldom resort to them. 
.here there is much pain in the pelvis, and a dry state of the skin, 
ffiuum and ipecacuanha are often very servicable. Lobelia, gelsemiura, 
aconite, and veratrum viride, may also be mentioned as very 
le<fuently applicable where there is vascular and nervous excitement. 
, Perhaps the medicine most generally applicable in paroxysms of uterine 
emorrhage, is ergot. In all cases of local arterial hyperasmia, as in 
tumors, hyperinvolution, etc., we may expect good from its employment. 
at it will generally fail to be useful when the uterine hyperasmia is 
as in retroversion, pelvic infarction from periuterine effusion, 
abdominal tumors, etc. It will not act efficiently in cases of carcinoma- 
,°Us deposit, granulations of the mucous membrane, or tuberculous 
of the fibrous texture of the uterus. 
In the more dangerous instances of hemorrhage, these pal- 
lative measures are not sufficient. In some, the amount of loss is so 
and occurs so suddenly, as to threaten the life of the patient. Or, 
life is not in danger, the discharge may be sufficient to lead to other 
Ver.y serious, remote consequences. These emergencies are to be met by 
Stlch means as will promptly arrest the flow, and keep it in check until 
°m’ative processes can be instituted. Fortunately this may be done with 
leat certainty by mechanical and chemical appliances generally at our 
The genital canal, practically closed at its upper extremity, 
aim conveniently open at its lower termination, admits of being impacted 
0 an impermeable degree, and allows of topical applications to its whole 
fMent. In using either form of these topical measures, the effort should 
e made to apply the remedy as near to the bleeding point as possible. 
hen practicable, we may secure the best effects by employing the 
and chemical means conjointly. The mechanical means em- 768 
BYFOED, 
brace the different forms of the tampon. Plugging arrests the hemor- 
rhage by forcibly opposing the evacuation of the blood, and by thus 
imprisoning it in the smallest cavity. The blood so confined, coagu- 
lates, and fills the space between the tampon and the bleeding sur- 
face with a fibrinous clot which also closes the mouths of the vessels- 
When plugging is skilfully performed, the relief is temporarily perfect, 
and gives us valuable time for other treatment, or allows the cyclical 
period to pass, when the hypersemia subsides. The chemical means con- 
sist in the use of powerful haemostatics. By their chemical action upon 
the solid constituents of the blood, they produce a much firmer coagulum 
than results from mere stasis, and, if applied to the ruptured vessels, seal 
them up with coagulated plastic material, while if further away the 
coagulum forms a chemical tampon which opposes the flow toward the 
vulva. Used with the mechanical tampon they may be made to fill the 
interstices of the material of which it is formed, and thus solidify the 
whole mass. 
In the greater number of dangerous cases of the kind of uterine hem- 
orrhage treated of in this paper, the mouth of the womb is sufficiently 
patent to permit the introduction of the plugging material saturated 
with a haemostatic preparation into the cavity of the uterus. Dr. Sims s 
method of preparing the material and performing the operation of plug' 
ging the womb is admirable in its simplicity and efficiency. The sub- 
stance used is the finest article of cotton-wool, saturated with a liquid 
composed of one part of the strong solution of the subsulphate of iron 
and two of water. After the cotton has been perfectly saturated, it is 
deprived of the major part of its fluid by pressure, and is then allowed 
to dry until ready for use. The application is made by wrapping a sufli; 
cient quantity of the dried iron-cotton around a long, small piece of 
whalebone, and introducing it into the cavity of the uterus, when the 
cotton is detached and left there. If the hemorrhage is comparatively 
moderate, one of these pieces may be sufficient; if severe, it will be 
necessary to stuff the uterine cavity full. This can be best accomplished 
by having the patient placed on her side, and the uterus exposed by 
Sims’s speculum. To facilitate the removal of this ferruginous tam- 
pon, the suggestion of Dr. J. D. Chadwick, of Boston, is, I think, a 
valuable one, viz., to wrap strong thread loosely around the cotton as 
surrounds the whalebone. I prefer this method of using the haemostatic 
to its injection, because the shock from the application is much less. 
If the mouth and cervical cavity of the womb are not sufficiently 
open to permit of the introduction of this haemostatic preparation, w® 
may plug the cervix with prepared sponge. The first sponge should be 
pushed through the cervix into the cavity, and up to the fundus uteri, 
so that when it expands its upper end may possibly reach and press upon 
the bleeding point. If large enough, the cervical cavity will be com- 
pletely filled and the bleeding effectually checked. The sponge should 
be carbolized, and well secured, before it is introduced, by passing n 
strong piece of twine through it, from one end to the other. Neither 
the cotton nor sponge should be allowed to remain longer than twenty- 
four hours, and half of that time is usually long enough. After removal, 
the vagina may be cleansed, and the application repeated if necessary- 
I have sometimes been obliged to renew the sponge tampon several times 
in the same case, though this is not usually required. 
If these means are not at hand, or if the case is not sufficiently urge in 
to require plugging of the uterus, we may resort to the vaginal tampon- NON-PUERPERAL HEMORRHAGES OF THE WOMB. 
769 
ihis may be made of cotton, of which pieces as large as pullets’ eggs may 
used, rolled somewhat solidly, and each secured with thread and 
uhricated with oil or lard. A sufficient number to perfectly till the 
v.agina should be prepared. The patient should be placed on her left 
Slde, with the limbs flexed, and the upper one thrown forward over the 
uther. The operator, standing at the back of the patient, inserts into 
he vagina two fingers of the left hand, with which he draws the peri- 
neum well backward. This will open the canal so that the clots may be 
Easily removed with the Angers, when, with the right hand, the cotton 
h'ay be placed with great facility in the vagina. At Arst several on the 
and around it, and then the whole vagina may be packed solidly under 
he eye of the operator. If Sims’s speculum be at hand, it should be 
hsed instead of the two Angers to hold back the perineum. Or we may 
Vai7 this according to the process described by Dr. Thomas, in the Ame- 
r'can Journal of the Medical Sciences tor July, 1876, page 147. After 
dating the vagina, “pieces °f c°tton, soaked in water, pressed and flat- 
eued out by the Angers, each about the size of a very small biscuit, are 
Passed into the vaginal cul-de-sac by means of forceps till this is Ailed. 
Aden other pieces are packed flrmly around the cervix until only the os 
ls.visible—a smaller pad is then pressed Armly against or introduced 
wThin the cervical canal, and the whole vagina is then tilled to its lowest 
p°rtion.” An ordinary surgeon’s roller answers admirably for a plug, 
may be introduced by Arst inserting one end, and then passing it up 
short folds until enough has been placed in the vaginal cavity to All 
Up compactly. In most cases where we desire to leave the patient, the 
affipon should be retained by a compress and “T” bandage. 
, W hen we have reason to anticipate a sudden occurrence of severe 
lemorrhage in our absence, we may instruct the patient or nurse how to 
Plake and" apply a very safe vaginal plug. A sponge, large enough to 
* the vagina closely, may be prepared by wetting it in a strong solution 
0 alum, or in a weak solution of subsulphate of iron, passing a piece ot 
? tong twine or tape through the centre, and then wrapping it with tape 
uu elongated shape to its smallest dimensions. It may then be laid 
s'de to dry. When the necessity for its use arises the tape is removed, 
aud the sponge thus compressed may be passed without any resistance 
into the vagina. It is soon expanded by the blood, and the 
~a&hial cavity thoroughly Ailed. A few of these sponges prepared ready 
.?r instant use will enable the patient to prevent any material loss until 
J6 Practitioner arrives. The plug may be removed by the tape or twine 
. euever desired. The plug may be allowed to remain from eighteen to 
pVeuty-four hours, when it should be withdrawn, and, the vagina having 
een thoroughly cleansed with carbolized water, replaced if necessary. 
. Curative Treatment.—The central nervous disorders which cause ute- 
i *1® hemorrhage will, when recognized, require the treatment set forth 
the various works upon these subjects. I need not, therefore, dwell here 
tar 1 management of the spinal and cerebral inflammations and irri- 
] lons, nor upon the numerous forms of emotional excitement which 
flad to metrorrhagia. The treatment of the reflex, morbid, nervous in- 
aences, belongs more particularly to gynaecology, and will call for all 
e ingenuity and varied knowledge taught in that branch ot practical 
e Mine. The ovarian derangements, being the more obvious and com- 
.Mn of these, may be noticed first. Our means for replacing and retain- 
§ln position displaced ovaries are very meagre. The patient must be 
49 770 
BYFORD, 
coniinetl to the horizontal position, with the pelvis elevated as much 
practicable. The knee-chest position is the best, and may often be manl' 
tained for a considerable part of the twenty-four hours. Generally the 
displacement is accompanied by congestion or inflammation of the ovary? 
which increases its size and weight. When this is the case, the treatment, 
in addition to position and quietude, recommended during the inter- 
menstrual period, will consist in the use of counter-irritants, hip-baths? 
hot water vaginal injections, and alteratives, administered internally? °.r 
applied externally in the form of ointments, or per vaginam as suppose 
tories, injections, etc. Among the alteratives, the muriate of ammonia 
will be found very valuable. When there is much debility, the bichlo- 
ride of mercury, dissolved in the compound tincture of cinchona, 10 
among the very best. lodine, iodide of potassium, and iodide of iroll 
should also be named as efficient alteratives in these conditions of the 
ovaries. One derivative measure which I desire to mention as especially 
beneficial in these cases is dry cupping over the sacrum, often repeated- 
To be effectual the cups should be large,and allowed to remain fora long 
time, say an hour or more. When there is much pain in the ovaria11 
regions, suppositories of the extract of belladonna and ergot, once or twice 
daily, will not only relieve the pain, but will do much towards allayill-? 
the inflammation. 
When hemorrhage occurs in a nursing woman, if it is of sufficient; 
gravity, the child should be weaned. At the time of the paroxysm,d 
the breasts are tumid and tender, cold may be applied to them to relieve 
both the uterine hemorrhage and the mammary congestion. These pa' 
tients require invigorating measures in connection with the local treat' 
merit of the breasts. 
The vesical or rectal tenesmus which gives rise to hemorrhage mllS 
be treated by the remedies found necessary after investigating the can9®' 
So, also, with diseases of the stomach, bowels, and liver, as well as with 
the effect of cold or of long-continued heat. 
Subinvolution and chronic congestion of the whole uterus require t° 
be treated very much alike, by the application of such remedies as com 
dense the uterine tissues—ergot, belladonna, quinia, electricity, cold in- 
jections, compresses and sitz-baths. When there is no tenderness, ergo 
will be found a very efficient remedy, if administered for a sufficient 
length of time—several months for instance. If there is considerabl6 
tenderness and pain, belladonna and quinia will be best adapted to the 
case. Ergot in some instances induces sensitiveness and heat in the pelvi° 
organs, and then it should be used very cautiously. This effect of ergo 
is especially noticeable when there is chronic local peritonitis or cellulitlS' 
If there is a high degree of sensitiveness, a mercurial alterative may veO 
properly be given in connection with the belladonna and quinia, and/1 
good form for administering it is the bichloride of mercury dissolved lIJ 
the compound tincture of cinchona; or we may use mercurial inuncti/0’ 
or mercury in suppositories. I have not been able to do much good d 
these cases with iodine in any form. If given with iron, as the iedlo 
of iron, it has occasionally a good tonic and alterative influence. The® 
conditions of the uterus are very obstinate, and require a continu0 
treatment, oftentimes for many months. +-c 
The treatment of endo-metritis is too well described by system^1 
writers on gyncecology to require more than a very brief notice. _ 
consists mainly in a persevering continuance of stimulating applicatio1 
to the diseased raucous membrane. I do not like the term caustic, 1° HOH-PUERPERAL hemorrhages of the womb. 
771 
tl G? tThe strongest remedies used for this purpose are applied so sparingly 
Jat their effects are little more than strongly stimulative. In the light 
°ur present knowledge of the processes of menstruation, these remedies, 
■nested by Dr. Atthill, should be resorted to immediately after the 
onthly flow has ceased. By common consent of the profession, in this 
untry, the treatment of granulations of the uterine mucous membrane 
l]sists in scraping them off, and the teaching of Sims and others has 
ac e the process sufficiently familiar not to require description here, 
(though not curative, the same treatment may be mentioned as most 
1 ncacmus in arresting the hemorrhages resulting from cancerous granu- 
ll°ns. In a discussion of Dr. Hanks’s recent paper, Dr. Peaslee gives 
j e Vei'J judicious advice not to cut into the sound tissue in the process. 
] cases of malignant fungus, we may often arrest the tendency to hemor- 
im injecting alcohol, by means of a hypodermic syringe, deeply 
ro the substance of the part. This process frequently repeated some- 
mes retards the growth very materially. The tincture of the chloride 
rjr°n, similarly used, will often have the same effect. 
. various conditions which give rise to retardation of the venous 
lrculation, require to be treated according to the improved methods 
’cw so well understood by the profession. The displacements of the 
crus which are arranged among these conditions, must be corrected by 
]e various ingenious appliances designed for this purpose. And this 
?ay be done during the time of the preternatural flow with the expecta- 
loa of moderating it at once. 
, -Lff. T. D. Pitch, of Chicago, has recently proven this last assertion in 
le management of a case occurring in a patient who had just passed the 
The uterus was retroverted, and all the means resorted to 
not even moderate the metrorrhagia until the organ was elevated 
,ric‘ retained in position by'an appropriate pessary, when in a short time 
16 bleeding ceased. After the subsidence of the flow, the patient re- 
-ovedved the instrument, on account of some slight inconvenience which it 
sjave her, but the flooding began again in a very few hours, and contin- 
-oed> notwithstanding repeated efforts to arrest it, until the pessary was 
lce more introduced, when the hemorrhage again subsided, and has 
ct returned. The patient was still wearing the pessary when I heard 
her case. 
j, subject of the treatment, and especially the surgical treatment, of 
Or 4°rS t^ae uterus which cause arterial hypersemia and uterine hem- 
fr 1 iage, ig too extensive to be entered into in this paper ; and I refrain 
P°m considering it the more willingly because it will no doubt be ex- 
haustively and.ably discussed by Dr." W. L. Atlee in the paper which he 
to read before the Section. I cannot, however, forego the duty of 
some suggestions as to the method of treating these growths 
internal remedies. 
°f ex^rerae danger from hemorrhage, connected with fibrous tumors 
aCr he uterus, is not so often encountered since the profession has become 
tli with the great influence exerted upon certain conditions of 
Bev lln^rnPregnated uterus by ergot. It is now understood that fully 
n-j per cent, of hemorrhagic cases of fibrous tumour of the ute- 
cef 111 rendered free from danger, as far as the hemorrhage is con- 
perllet ’by an intelligent and persevering use of ergot, and that in twenty 
the Cent"’ le tumors may be removed. In using ergot, in these cases, 
tak In°de administering it cannot be uniform. Some patients cannot 
e ]t in any sufficient doses to answer the purpose; some cannot take 772 
BYFORD, 
it in the form of fluid extract, or wine, but can take the solid extract W 
the form of pills; others can take it in any form. When the stomach 
will not tolerate the ergot, it may be given hypodermically, or per rec- 
tum in suppositories, and I believe that it can be made to act efficiently 
when given in any of these wTays. 
Whatever method or form we may adopt in the administration 
ergot, we should give it in sufficient quantities to produce a sensible 
effect by causing contractions and pain, and there is no better rule to 
guide us, as far as I can judge, than to give it in increasing doses unto 
that result follows. Twenty minims of the fluid extract, three times u 
day, will sometimes be sufficient, while some patients, on the other hand? 
will require twice or three times as much to produce the effect. 
The length of time required to obtain the ultimate effects of the erg 
in these doses, varies as much as the quantity required. The tumor wiy 
sometimes diminish very rapidly, but generally the decrease in size 19 
quite slow. From one month to over a year may be required to accoih' 
plish a cure when it can be accomplished at all. Ergot is sometimes 
very violent in its action, but by withdrawing it temporarily, lessening 
the dose, or combining and alternating it with anodynes, it may 136 
safely managed. Although I have given it extensively, and for a 1 od£ 
time together, I have not seen anything worse than inconvenience anB' 
ing from its use. 
It will not, of course, be expected that I should enter into a considera- 
tion of the treatment of scurvy, leucocythsemia, albuminuria, or syphib9’ 
as general conditions causing uterine hemorrhage, both for want of find 
and because they are subjects well treated of in works on the general 
practice of medicine. Our ignorance of the last of the causes mentioned 
in the first part of this paper, viz., the hemorrhagic diathesis, will 
excuse me from dwelling upon the treatment of that mysterious condi- 
tion which afflicts some unfortunate individuals belonging to our race. 
Discussion on Dr. Byford’s Paper. 
After the reading of the preceding paper, Dr. William Goodell, of Pflda' 
delphia, said:—l did not wish to begin the discussion, but as others are back- 
ward I will try to start the ball. I was not able to hear all that Dr. Byfm1. 
said, but some of the points made by him are of extreme interest. I vVIS 
to refer to the almost absolute inertness of astringents when given by b)e 
mouth in cases of uterine hemorrhage. The text-books laud them, but 1 ha' 
found most of them useless. In ray opinion, the canonical pill of acetate 
lead and opium would be inert, save for the opium in it, the latter being/* 
valuable haemostatic. A pure astringent which I have found of much value 1 
gallic acid—not administered in the ordinary dose of five grains, but in dose 
of from twenty to thirty grains every two hours, or more according to t1 
urgency of the case. I have discovered no bad effects resulting from its 
although I have given half an ounce in the course of a day. It is a bulky all 
disagreeable remedy, but I mix it with some table-syrup or with molasses, an 
have found it the only astringent of any efficacy in stopping these hemorrhageSj 
Ergot acts well, especially when used hypodermically, but I know of cases wfic 
it has increased the hemorrhage; I do not now refer to cases of fibroid tu® 
in which it will sometimes so act, but to other cases of metrorrhagia in whic 1 
have found it to increase the discharge from the uterus in a way that is inexp 
cable to me. Free dilatation of the cervix by tent's will alone often cu 
hemorrhage. The causes of uterine hemorrhage are sometimes obscure, aIH NON-PUERPERAL HEMORRHAGES OF THE WOMB. 
773 
have sometimes been humiliated by not discovering them. I have dilated the 
cervical canal, passed my finger into the uterine cavity, made careful examina- 
lolb and yet have found no tangible cause. There are other causes beside 
§ranular conditions of the lining membrane, which may be sq minute as to 
an examination by the finger. When I could find no explainable cause 
ol’ such hemorrhages, I-have treated them empirically, by introducing into the 
Cavity pure nitric acid. 1 refer particularly to the case of an unmarried lady, 
lQ which the hemorrhage lasted for weeks at a time. I fully expected to find 
f Polypus, but did not. The flow was arrested by nitric acid, but it shortly 
oegan again ; I then used intra-uterine injections of iodine, but the benefit was 
?nb7 temporary. At my request Dr, A. H. Smith also examined the patient, 
l’t failed to discover any cause. The hemorrhage finally yielded to ergot, 
Which in the first instance had failed. To this day lam ignorant of the cause 
°* this hemorrhage. 1 have found the tincture of iodine of use, though it is 
infallible. In using it, I first stretch open the os with a dilator, and then 
'pjcct about a fluidrachra. It has the great advantage of not forming hard clots. 
is a plain, homety remedy, which I have successfully used in menorrhagia 
'V jen others Imm failed—cinnamon tea, or cinnamon boiled in milk. Heat 
aPplied to the spine has also proved of benefit, though not invariably. lam 
Phased to find that the bichloride of mercury has been referred to by Dr, By- 
°i'd in high terms. This is a favorite remedy of mine, not only as an alterative, 
Cf for its property of increasing the number of red blood-corpuscles. When 
pVen for two or three weeks, but not longer, in cases where much flooding has 
laken place, it renews the blood rapidly, fattens up the patient, and is in my 
opinion a fine tonic, especially when combined with iron and arsenic. 
I Dr. J. W. Rosebrugh, of Hamilton, Canada, said:—l think that Dr. Goodell 
*as failed with the acetate of lead because his doses have been much too small. 
Ur- Workman, of Canada, has given half a drachm at a dose, and claims that 
'Dth large doses he can stop any hemorrhage at once. I do not, myself, like 
® remedj’, but in cases of extremity it may be effectual. 
Dr. Edward M. Hodder, of Toronto, said:—The subject is limited to cases 
0 uterine hemorrhage only. But such doses of acetate of lead 
as are referred to by Dr. Rosebrugh are only to be used in cases of post-partum 
lett)orrhage. I have employed the tincture of cinnamon largely, and have 
As° used the tincture of cimicifuga, as well as sulphuric acid, but always in 
with local treatment. I have injected the perchloride of iron into 
uterus until the acid has passed through the Fallopian tubes into the peri- 
neal cavity, but with only temporary inconvenience. I have also used the 
Pusulphate of iron in relaxed and flabby conditions of the uterus. I think 
|at ii astringents were used, and the uterus were kept in place, cases of hem- 
-IWage would be more amenable to treatment than is generally supposed. 
Dr. Alexander R. Simpson, of Edinburgh, said:—The subject is an ira- 
taut and practical one. It appears, from what 1 have heard, that uterine 
a®es are much the same on both sides of the Atlantic, and that no one treat- 
will suit all cases. I have a general impression as to the inutility of 
s Dngents, and yet there are cases in which 1 would use any of them. While 
freeing with Dr. Goodell as to the efficiency of gallic acid (which I prefer above 
°fhers), and in some cases of sulphuric acid, I wish to mention another 
t>eut which often acts admirably as an astringent, and that is the oxide of 
j.!ll®’ I know of cases which have been carried over by one or two-grain doses 
a llce daily. It is a truth, however, that physicians are often left in the lurch, 
. have to resort to direct local treatment. The first direct application should 
®ln tlie shape of vaginal plugging, although I have but little faith in the 
h the tampon per se. For instance, in some cases the hemorrhagic 
if is kept up by the terror and dread of the patient, but the use of the plug 
stopping the flow gives her confidence, and there is a corresponding lessen- 
menoi'rhagia. It is difficult at times to apply the tampon so as to 
ake it effective, and I therefore think that plugging the cervical canal i 774 
BYFORD, 
the better plan, especially as it opens the way for subsequent exploration anti 
treatment. As to direct applications to the uterus, nitric acid is good in some 
cases, but where a hemorrhage is in progress, 1 do not find it so effective a3 
the of iron. In cases of enlargement and of thickening of tlm 
mucous lining, it would be important to scrape off the redundant portions by 
the curette, as recommended by Recamier and Sir J. Y; Simpson. In one case, 
I simply scraped off the thickened membrane, and, contraction of the womb 
being kept up by ergot, the patient recovered. The blood at times also get® 
into such a watery condition as to tend to the continuance of hemorrhage, aim 
then special constitutional treatment is required. 
Dr. Thomas W. Gordon, of Georgetown, Ohio, said :—I think very highly 0 
the value of quinia in cases of non-puerperal hemorrhage occurring in mala- 
rious districts, or in broken-down constitutions, and think that in such cases 
it should never be omitted. 
Dr. J. A. Campbell, of Grafton, West Virginia, said :—I believe with Dr* 
Gordon in such a thing as an intermittent uterine hemorrhage, and know that 
in malarious sections of the country we could not treat hemorrhage without 
quinia. In most cases, however, the hemorrhage is dependent upon conge®' 
tion of a displaced womb. The circulation of the blood being prevented by p1’0' 
lapsus, congestion arises, engorgement follows, and then there is a hemorrhage 
at every recurrence of the menstrual period. I have in my practice insisted 
upon nightly replacement of the organ by the patient herself, for no physician 
could attend to this, unless he had but the one case ; I consider replacement 
the chief prophylactic for engorgement and the consequent hemorrhage. Tlds 
replacement can be effected by the woman herself, by first assuming the knee' 
breast position, and then by either separating the labia with two fingers, or by 
introducing a short glass tube into the vagina. I have used iced water als° 
with advantage, but of course not during the menstrual period. Or a galloll 
of water may be injected every four or five hours, not letting the tempm,£l' 
ture be much below 60°. In the water I sometimes dissolve sixty grains 0 
the sulphate of iron. The fluid extract of ergot I often give hypodermically’ 
or internally in doses of thirty or forty drops. Dilute sulphuric acid is a 
favorite remedy with me; I have known women, who from continued hem°1' 
rhage have become debilitated, and whose menstrual flow has been so length' 
ened in duration that the interval between each period has been reduced to a 
very few days. In these patients, by examination with the speculum, I have 
found polypoid granulations; but a few applications of nitrate of silver have 
changed the entire aspect of the case. . 
Di*. Thomas F. Rochester, of Buffalo, said;—Quinia should be used in 
cases of chronic hemorrhage, whether under malarious influences or not, but t 
am not in favor of full doses; quinia acts upon the capillaries, and thus exei'ts 
a good effect. Ido not therefore think that its use should be confined to case3 
of malarious hemorrhage alone. 
Dr. Edward H. Trenholme, of Montreal, said;— There are two modes 0 
treatment, the local and the constitutional. The former is adapted to chec>( 
the actual flow when the patient is in imminent danger. I employ “ Sims s 
iron cotton, prepared in proper-sized plugs. As a constitutional remedy, whQc 
it was difficult to find the cause, I have found oxide of silver, in combinatio11 
with opium, very efficient. , 
Dr. B. F. Sherman, of Ogdensburgh, 17. Y., said:—l can also recommeu 
the styptic cotton for use as a tampon, and, in granulations, a saturated sol 
tion of permanganate of potassium. In obscure cases I give internally °a 
grain of the oxide of silver thrice daily, combined with one-quarter of a gl'al 
of opium. 
Dr. Charles Shepard, of Grand Rapids, Michigan, said:—While I alO , 
warm advocate of the use of quinia, I desire to laud a mode of local treat ffiel 
which I employ. I use an elastic rubber bag into which 1 inject iced vvate • XOH-PUERPERAL HEMORRHAGES OF THE WOMB. 
775 
Tl * 
bleed;!? Up th?ugh the cervix> aud ifc applies itself so closely to the 
yUmg surface as to be very efficient in stopping the hemorrhage. 
°nlvr;erD-V??URGH7°f Ly°!lS’ N* Y., said:—Gallic acid is* I think, the 
A > astringent from which much benefit can be derived in uterine hemorrhage. 
foiJ TIC,a,vS have pet remedies, and pet plans of applying them. I ha°ve 
UteGn le orduliary solutlon of persulphate of iron effective'; I'inject it into the 
hot CuVltj hy meallS °f a gIaSS tube with a rubber bag at one end, and can- 
-1 * CaSe °f n0n’puerperal heillola'hage which has not yielded to this 
-r\ * 
I ho'* Robert Burns’ of Philadelphia, said In an experience of forty years 
sneonf SeeU many ,Cases of thlS ehiiracter. In my early practice, when the 
Sent, , W.aS bardly known’ my dePende*.ce was upon large doses of astrin- 
! ’ Wluc 1 5>ften disappointed me. But since the discovery of the speculum 
Xfb mueh less trouble* My system is a simple one, and varies but little, 
tinm attend t0 the state of the constitution—if the patient is weak, giving her 
combi’6 ?f chl(jndß of b'on’ ‘imnia, and aromatic sulphuric acid. I then use a 
of :r natlon of a di-achm each of tannic acid and sulphate of zinc, in an ounce 
iliif:3'^erine, winch I apply to the interior of the uterus, through the previously 
axed cervical canal, using cotton saturated with the mixture 7 rpnenf this 
lIT tim 6S’ and brUßh the cervix with the same, putting on 
Ord‘ 6 purgatlve treatment. There are cases of extreme hemorrhao-e where 
methods fail, but most of them are amenable to this mode of treat- 
d)r-Theophilus Parvin, of Indianapolis, said:—We must all agree from 
le discussion and from the number of remedies that have been suo-o-ested that 
e uterus is an organ which can be abused with impunity. It has been said 
at we must find the cause of the hemorrhage : true, but in the mean time one’s 
I atient may bleed to death. Stop the hemorrhage first, and find out the cause 
v There is one method which has not been referred to, and that is 
aginal injections of hot water. This is a first-class remedy. Hot-water 
11 bber bags, applied to the back, have also been found efficacious. The diffi- 
tj y °f local treatment is often due to the fact that the physician shrinks from 
e examination of an unmarried woman ; but desperate cases require modesty 
shame to be put aside. The remedies spoken of may be empirical, but 
~e.V are the best in such cases. As to local treatment, there is often some 
Sorder with the parts. Some practitioners use the curette, while others say 
at it is murder to do so. Mucous polypi in the cervical canal are irritants, 
are not the source of the hemorrhage. They cause an increased flow of 
oj.°.°d to the parts that are irritated by their presence, and there is a solution 
i e°ntinuity as the result. Remove these polypi, and then apply tincture of 
jll * I thought that I had made a discovery when I used a small forceps 
hftS’Gad op Bie curette for the purpose of pinching off small granulations, but I 
‘\e found that others had used them before me. The hemorrhage is not ai> 
tb dy !n fiat merely the expression of something else. We cannot cure 
“e patient without finding out the cause, which, in doubtful cases, I believe is 
riU aa inflammation of the lining membrane of the uterus. 
Ph r* rX°DD, °f Kansas City, Mo., said:—l wish to remove the subsul- 
i ate °f iron from the list of injurious remedies. I used it shortly after its 
lodaction b}r Dr. Barnes, and have reported eight cases, in all of which it 
Oj 8 successful, though the hemorrhages were all dangerous. I believe that 
plf bv?s bave been savod by its use. I desire to reiterate that the subsul- 
a e of iron is absolutely innocuous, 
im -le Bresidenti Dr. Robert Barnes, of London, said:—l have been much 
Se .Aessed with the great advantage of these meetings; the members of the 
neiC lon have heard a variety of expressions from all parts of this great conti- 
Va/ ’ and every expression of individual opinion has embodied much that is 
terUable- X have received several new ideas while the discussion on this in- 
-1 sting question has been going on. In London, we know but little of 776 
BYFORD, NON-PUERPERAL HEMORRHAGES OF THE WOMB. 
malarial hemorrhages; but we have found quinia a valuable means of control- 
ling bleeding, as it contracts the uterus, and is otherwise of service to the 
system. I always use it in cases of hemorrhage from subinvolution, and do 
not think a merely local treatment all that is needful in such a condition. 1 
have noticed the law of habit mentioned by Dr. Simpson, for hemorrhages 
will sometimes take place when the uterus is apparently healthy, not only in* 
dependency of ovulation, but often after the climacteric period. These hemor- 
rhages are largely attributable to regional attraction of blood to the uterus, 
for that organ is liable to regional hemorrhage, even when there is no disease 
of a local character. The treatment must be local or general, and sometimes 
it is necessary to resort to both. Topically, the best plan is to dilate the cer- 
vix and inject the perchloride of iron. Astringents by the month are of use 
at times, and, of these, 1 think with Dr. Goodell that gallic acid is the best. 
The heart-action often has an effect on the hemorrhage, and by using aconite 
and other remedies to reduce cardiac action, there will be a corresponding 
reduction in the flow of blood. In some cases in which the cause of hem- 
orrhage could not be ascertained, 1 have used, with excellent results, the 
witch-hazel, which I believe to be a native of this country. Although the 
curette has undoubtedly been of service in many- cases, yet 1 condemn its use, 
for it is often followed by furious bleeding, and the growth of small malignant 
excrescences is more rapid after using it. Besides, it is, at best, a dangerous 
instrument, and requires to be handled with the greatest care, in one year I 
lost two patients from its use. 
Dr. Byford, in reply, said:—Quinia is only second to ergot in causing 
uterine contractions, and is an admirable remedy. I have known of miasmatic 
conditions producing hemorrhage in non-puerperal cases. Quinia is of use iu 
these cases, especially in causing condensation of the uterus. In the vast 
majority of cases, hemorrhage from a non-puerperal womb is owing to one of 
two conditions, either hyperannia or a vitiated state of the uterine mucous 
lining, from inflammation or from growths. For the former condition I use 
ergot and local remedies, such as the tincture of iodine, but not as intra-uterine 
injections. In my experience, uterine hypersemia and hypertrophy need the 
application of a strong astringent to the neck of the womb alone, for the body 
of the uterus can be made to contract by applications to the external and in- 
ternal surfaces of the cervix. Local remedies can be applied in many different 
ways. The other common cause of hemorrhage is a disorganization of the 
lining membrane of the uterus. Hemorrhage becomes more easy when this 
mucous coat is not firm, because it gives way more readily. Topical treatment 
is here indispensable. When bleeding has occurred after the menopause from 
a determination of blood to the womb, I have been able to do more with large 
doses of quinia and iron than with ergot or with anything else. I do not 
consider ergot particularly valuable in such cases. The vaginal plug is of 
great use when used properly and thoroughly. It should not simply be pressed 
against the os, but firmly packed in front and behind the cervix, in order to 
compress it. I have, in my own practice, been rather timid in regard to inject- 
ing fluids into the womb, probably too much so, but I avoid such treatment 
wherever it is possible to do so. 777 
the mechanism of natural and of artificial 
LABOR IN NARROW PELVES. 
BY 
WILLIAM GOODELL, A.M., M.D., 
CLINICAL PROFESSOR OF THE DISEASES OF WOMEN AND OF CHILDREN IN THE 
UNIVERSITY OF PENNSYLVANIA. 
“ Opinionum commenta delet dies, naturae judicia confirmat.” 
In studying the mechanism of natural and of artificial labor in narrow 
.... v.es’ et us first inquire what is meant by a narrow pelvis and what 
16 its kinds. 
i:>elvis with a true conjugate (conjugata vera) measuring less than four 
of neS Collstitutes a narrow pelvis. For, although the biparietal diameter 
w average foetal head at term measures less than four inches, the 
of° Ing BPace between the promontory of the sacrum and the symphysis 
i the pubis is lessened by double the thickness of the uterine wall, and 
J double that of the vesical wall. While, therefore, the actual conju- 
j. e*B ample for an average head to pass, the virtual conjugate may be 
Po? Thus, according to our best authorities, a standard head in a 
vis measuring in its conjugate 3.75 inches—viz., half an inch less than 
Jat of the average-sized pelvis—constitutes a difficult labor, 
but BP°utaneous delivery is not impossible under such circumstances, 
-g the forceps will usually be needed; sometimes, indeed, craniotomy, 
v line below this measurement greatly increases the difficulties of 
1 turition. For instance, out of thirteen vertex presentations in pelves 
0r afSUl’ing at the least 3.75 inches, Dubois had three cases of craniotomy 
he 1 cePbalotripsy. In conjugate diameters between 3.75 and 3.1 inches, 
the ten Preseiltations at term of the vertex, and one of the face. Of 
tj two ended spontaneously, two were delivered by the forceps with 
e (^eath of one child, and seven needed the cephalotribe.1 Baudelocque 
ha pnc^8 that out of live hundred children at term and of average size, 
this r °ne be delivered alive through a pelvis of three inches. To 
i»e s’ Dezeimeris2 adds that one of 3.25 inches does not give much better 
pas *8’ one 3A hiches also offers to the child a very dangerous 
Cu Sa£e’ Joseph Clarke gives,3 as the result of an experience of 14,077 
es °f labor, that “ three and a half inches is the least diameter” through 
Cicero, De Naturd Deorum. 
* ]\ T 
trye anagement of Labor in Contracted Pelves. By Wm. H. Jones. This author, it is 
and “ i es these cases occur respectively in pelves whose conjugates measured “over 3.5,” 
these fe^Ween and 3 inches.” But since he has adopted the classification of Dubois, 
pelyes fUres seem to me incorrect. For Dubois’s first and second categories of deformed' 
(an Jn •ure those in which the conjugates measure respectively, at the least, 375 inches 
Cetltinp t*S cent>nihtres), and between 3.75 and 3.1 inches (au plus 9.5 centimetres et 8 
buboes au moins). This information I get second-hand from Cazeaux, and not from 
2 j yhose thesis is beyond my reach. 
a ( tionnaire en 30; Art. Accouchements Prematurees, p. 427. 
°atributions to Midwifery; by T. B. Beatty, p. 23. 778 
GOODELL, 
which he has known “ a full-grown fcetus to pass entire.” Chailly-Honore 
says,1 “ The forceps will frequently extract a living child through a con- 
jugate of over nine centimetres (8.54 inches), sometimes, indeed—although 
this is very rare—under this size.” From these facts, the broad rule may 
be laid down that, when the short diameter of the brim does not exceed 
the biparietal diameter of the child’s head, the unaided efforts of tbe 
mother will in general be inadequate to effect a safe delivery, and that 
even with instrumental aid the life of the child will be greatly imperilled* 
The most common kinds of narrow pelvis are three in number:— 
(1) The simple, flat pelvis, or conjugate narrowing with correlative 
transverse widening. 
(2) The generally and uniformly narrowed pelvis, in which all the 
pelvic diameters are symmetrically shortened. 
(3) The generally narrowed, flat pelvis, which combines the bone-lesion3 
of the other two, but in vaiyying proportions. 
Of these three varieties, the one most commonly met with is the 
simple, flat pelvis, in wdiich the lesion is limited mainly to the brim and 
to its posterior half. Practically the obstruction is a marginal one, and 
is confined to the sacral pole of the conjugate diameter. In the second 
variety—or the generally and uniformly narrowed pelvis—the obstruction 
is not a marginal one, nor of limited area, but diffused over every plan6 
of the pelvic canal. In the third variety, the obstruction depends upon 
the preponderance of conjugate or of transverse narrowing, and is, there' 
fore, either mainly at the brim and marginal, or mainly in the pelvi6 
canal and diffused. 
Since “Art is the imitation of Nature, and those will best succeed 1,1 
any science who closest watch her operations,”2 let us next note the 
mechanism of an unaided head-first labor in these different kinds 
narrow pelvis. 
In the generally and uniformly narrowed pelvis, the mechanism is very 
analogous to that which takes place in the standard pelvis, but is of course 
attended with more delay. The head enters the brim synclitically and 
with the normal Solayrds obliquity—that is to say it engages in one of tbe 
oblique diameters of the brim, but without lateral (Ntegele’s) obliquity. 
will also be strongly flexed (Roederer’s obliquity), because the resistance at 
the brim is equal on all sides, and the shorter hind-arm of the head-level 
must therefore descend. The heaff also begins to flex at a higher plan6 
of the pelvic cavity than in the standard pelvis. For flexion in the latter 
is chiefly brought about by the resistance of the os uteri; in the form61 
by the more highly situated brim. During the descent of the head, th6 
synelitic movement is preserved except in so far as vertical or latera 
shearing interferes with it. Since the absolute conjugate narrowing lS 
rarely great, and the general narrowing is symmetrical in all direction9’ 
the furrows or the fractures of the cranium are by no means so common 
as in the other varieties of deformed pelvis. But, when present, they 
usually start from the boss of the parietal bone and run more or |es9 
parallel to the sagittal suture, as in cases of fracture reported DI26 
and D’Outrepont,4 and one of depression of the skull by Danyau.5 -y 
must, however, be borne in mind that, while the bone-furrow alwa>b 
1 Accouchements; Paris, 1867, p. 649. 
2 The Present State of Midwifery in Paris; by A. Tolver, 1770, p. 22. 
3 Union Medicate, F6v. 1860, p. 295. 
4 Journal de Chirurgie, par Malgaigne, 1843, p. 41. 5 Ibid., p. 49. LABOR IN NARROW PELVES. 
779 
-I(lieates the transit-line, the fractures do not, as they 1114y radiate from 
111 every direction. 
a IuITI tlie u"aid®d efforts of nature, the typical mechanism of 
ead-hrst labor in the flat pelvis, or in one whose brim is narrowed 
its 1? y m lt? ,conJuSate diarneter, is as follows The hind-head offers 
ano 1 a-’ieta diameter at the 00njagate, but cannot enter. The resist- 
ee boi„g nearer to the occipital end of the head causes extension, and 
losing’-;heSdi diP- fored'ead descends, the sagittal suture, 
Beil g lts. feolayres and Rcederer obliquities, becomes transverse in two 
t\vrw,S Vlzq 14 Jies 111 the transverse diameter of the brim, and with the 
bo lontanelles on the same plane. The shorter and more compressible 
tem Pi dl.ameter~that 13 t0 sa3b the upper or vault portion of each 
uporn! region near the coronal suture—reaches the conjugate, and is 
act IT +\nt° b* tbe chfuged direction of the propelling force, which, 
dh ig through the vertebral column, is now thrown out of its perpen- 
to the base of the skull, and so bears at an angle directed to 
Bio, iT0!iead- Thus the head is niPPed’ bent in on its sacral side and 
ten dod t0 tbe Prom°utory. Sometimes it is the bicoronal (the bifronto- 
mporai) diameter which is nipped. Hence the frequency of face-pre- 
Rations in narrow pelves—a frequency, according to Michaelis eight 
t}mes greater than in normal pelves.1 Hence, also,'the ease withwhich 
m anterior fontanelle is reached, and the corresponding difficulty with 
Uch the finger touches the posterior fontanelle. 
the resistance is now at a point nearer to the fore-head than to the 
and the latter, therefore, begins to descend, but with the 
r P.ai‘ietal diameter to one side of the conjugate diameter. But the 
blßfance of the iliac margin of the brim to the descent of the hind-head 
causes that portion of the cranium to expand and to mould itself to tlie 
1 responding sacro-iliac space. It also tends to shove the whole head 
n fr-to be f°rebea(i side of the pelvis. In a generally narrowed, flat 
Jji ms_ with absolute transverse shortening, this displacement in the 
Action of the occipito-frontal diameter may go on until stopped by 
le impact of the forehead on the opposite ilium. The head, therefore, 
fosses the conjugate, not vertically in the bicoronal or the bitemporal 
anieter which first engaged, but along a transit-furrow running sorae- 
obliquely from that portion of the vault near the coronal suture to 
g0e base posteriorly, that is to say, in the resultant of three forces— 
X!°n, uterine propulsion, and occipito-frontal displacement in the 
Reverse (bisiliac) diameter of the brim. In proportion as the head 
it becomes more and more flexed, and the biparietal diameter, 
ilc 1 Passed the brim to one side of the conjugate, will, at a later stage 
ev ~ ’be bouud almost directly under the promontory. It must, how- 
cat-’ be remembered that, since all the transverse diameters of the pelvic 
thv% are also lengthened out, the head usually descends to the floor of 
rop p(dv*s Wlth less flexion than in the normal pelvis, and anterior 
rpfion of the vertex is proportionally delayed. 
from the mechanism of natural labor in this kind of pelvis, it 
Or f 1 seen *Fat the head enters the brim in a state of partial extension, 
th j !east 111 a state midway between flexion and extension, and passes 
(j- short pelvic diameter by a short and most compressible cranial 
ob]*me-er- further, the head usually passes the brim with also a lateral 
I(iuity. Before the engagement of the head, the sagittal suture in a 
Clinical Lectures by German Authors, New Sydenham Society, 1876, p. 302 780 
GOODELL, 
typical case will be found very close to the promontory. To engage, the 
head must cant over the edge of the promontory ; and during the first 
stage of descent this suture approaches the puhis. Later on, it begins to 
return towards the sacrum. This last movement is owing partly to the 
moulding of the posterior side of the head, and partly to the greater 
resistance to descent at the sacro-vertebral angle, while the pubic margin 
of the brim offers a smooth and glib surface. The head, therefore, pivots 
on the promontory as a centre of motion, and, as it were, rolls over into 
the pelvic cavity. It “doubles the promontory,” as our honored Presi- 
dent, Dr. Barnes, so happily expresses it. 
After such an unaided delivery, or after an artificial delivery in which 
the application of the forceps is delayed until the head has been driven 
past the brim, the cranium exhibits two very characteristic shears. In 
the one, there is a bending in of the sacral side of the head, and a bulging 
out of the pubic side—it is kidney-shaped. In the other, an equitation 
of one parietal bone over its fellow—usually the anterior over the pos- 
terior, The site of the pressure-furrow, or of the bone-lesion, varies with 
the size and the position of the head, and with the shape of the pelvis. 
It is not found at one of the poles of the biparietal diameter, and more 
or less parallel to the sagittal suture, as in the uniformly narrowed 
pelvis in which the vertex dips ab initio, but at the forepart of one 
parietal bone, close to and more or less parallel to the coronal suture. 
Often it lies directly over this suture, overlapping both frontal and 
parietal bones, and sometimes on the frontal bone alone. 
When the disproportion between the size of the head and that of the 
brim is relatively great, or when the conjugate is short and the bead 
unduly ossified or bullet-shaped, engagement is often delayed. Under 
such conditions the bead does not at once become fixed by the preliminary 
dip of the anterior fontanelle, but it coys at the brink of the brim without 
entering. Perched on the sacral shelf, it swings backward and forward, 
and see-saws with every foetal movement. The finger will find the sagit- 
tal suture usually close to the sacrum, and the posterior fontanelle no'v 
in front and now behind the transverse diameter of the brim; now dip- 
ping into the inlet, anon tilting up out of it. It is momentarily fixed 
by each uterine contraction, and then is the time to take the position* 
This cranial play usually ends before long, and that by the adjustment 
and moulding of the bicoronal region to the conjugate, and by its conse- 
quent engagement and descent. And this may be hastened, as the late 
Edward Martin has shown,1 by turning the woman over on to the side 
towards which the forehead looks. The breech of the child then sag 3 
over to the same side, the hind-head is lifted out of the brim by the 
leverage of the spinal column, and the fore-head sinks in more deeply* 
Whenever this dipping of the fore-head does not happen, delivery without 
artificial aid will be indefinitely delayed. 
In the foregoing description I do not pretend to have labelled all the 
natural processes involved, nor to have codified every law which governs 
the cranial movements in narrow pelves. .Nor do I contend that the 
anterior fontanelle always dips, for the head may be a small one, or the 
cranium a yielding one, or other disturbing elements may intervene* 
But from a study of the writings of Schroeder, Spiegelberg, Martin, and 
Otto de Haselberg, and also from patient bedside observation, I believe 
that the above mechanism is in the main correct—it certainly best eX- 
1 Prager Yicrteljahrsschrift, 1868, Band ii., Analect, S. 76. LABOR IN NARROW PELVES. 
781 
tnuLrfk0 behavior of the head. Since, however, the truth is not always 
bead l! i and SmCe the flexion of the head with the clip of the hind- 
Wrt 1 has hltherto been taught as the mode of engagement, a few more 
'loms on this point are needful. 
heia a pelvis narrowed mainly in conjugate diameter, the hind- 
er? a,wa^s dlps’ and the vertex first enters the brim, as contended by 
• aSe and by many others, what explanation can be offered for the 
80 o Utable fact that the anterior fontanelle, at the outset of labor, is 
a ]oOrnm°nly on the same plane with the posterior fontanelle, or even on 
sei f lerIer plane? How interPret the well-known frequency of face pre- 
iinan i?Vn nanw pelves ?ffain ifc can be shown, that, after such 
n amecl labors the pressure-marks or other coarse cranial lesions are found 
th at one of the poles of the biparietal diameter, which is alleged to be 
U 1 mpll eated diameter, but, as I have asserted, at the fore part of the 
tip V°mewhere near the coronal suture, then the burden of reconciling 
18 fact to theory must rest on those who hold to the initial dio of the 
l°sterior fontanelle. 
/jet me summon to the stand impartial witnesses, such as had no pet 
j Tories to which their facts were trimmed. And, in these forceps days 
W°Wn some difficulty in finding cases of labor in narrow pelves which 
e,’e either neglected, as we should now call it, or left entirely to the 
Raided efforts of nature. Nor are the following examples noting the 
Piessure-mark, selected ones; but the only ones which I have been°able 
0 collect within a short and busy time. 
1 n describing a natural labor in a pelvis whose conjugate measured 
,?out three inches and a quarter, Mile. Anna Puejac, midwife in chief 
j the Maternite at Montpellier, says1 that “At the anterior angle of the 
p parietal bone, there was a very considerable depression, sufficient to 
uuiit the half of an ordinary egg. It was the exact cast of the promon- 
ory, ’ griiellie writes2 that in a case of narrow pelvis he waited until 
i head was “ squeezed down to the lower part of the pelvis”—that is, 
dd passed the brim. The pains failing, he then applied the forceps 
v °ng the sides of the pelvis, and caught the head, which was still trans- 
\^Se: °ver the face and occiput. “The child’s head was squeezed into a 
Cp ®iftudinal form, flattened on the sides, with a deep impression on the 
n a,lmni above the ear.” Again he tells us that, after a woman, who was 
hVei*y much distorted,” “ had been in strong labor for four-and-twenty 
v.ollrih” he found “ the head down to the lower part of the pelvis,” viz., 
0 . 11*0 brim, and applied the forceps first over the face and the 
th and then, when the perimeura began to bulge, over the sides of 
. e head. “ The head was of a lengthened form, and contorted to one 
e5 and there was a deep impression above the ear” 
of j chapelle contends, as the result of close observation, that “ the head 
in l 16 Pectus, driven through a narrow and solid pelvis, is fractured and 
a ,ented near one of the frontal bones. This accident is not uncommon, 
i'er We B'iad c*te manT examples of it.”3 Again, she writes, “ I have 
ill ai)^ed witdl Smellie (tome ii. p. 533; that, in cases of natural labors 
ti l)elve8 considerably distorted, the depression is no longer found on the 
region {sur le front), but near the temporal region.”4 Out of a 
01 her of cases reported by her I select the following: Case I. Occiput 
1 Gazette Obst6tricale, Jain 20, 1876, p. 179. 
2 Collection of Cases, 1778, Collection xxvii., No. 2, Cases ill. and iv. 
3 Eleventh Memoir, p. 423. 4 Ibid., p. 429. 782 
GOODELL, 
to the left; the anterior fontanelle was easier to reach than usual. A dead 
child was born naturally; it had the frontal boss indented and broken. 
In another case,2 the occiput was to the right; conjugate 3.25 English 
inches; a dead child was born naturally after a long labor. “ The right 
frontal bone, although without fracture, offered a very marked depression 
which was undoubtedly due to the jutting promontory.” In a third case 
the conjugate measured 3.25 English inches; position of the child’s head 
not known ; after six and twenty hours of labor the forceps was applied 
along the sides of the pelvis; “ extraction prompt and easy.” The left 
frontal and parietal bones were found fractured.3 A fourth case4 was a 
primipara, with a conjugate of about 3.5 English inches, and with a 
second position of the vertex. The forceps was applied to the sides ot 
the head, but failed to extract; the blades were, therefore, withdrawn 
and applied in each ilium. There was now no further delay in delivery* 
The child weighed five pounds,and died twelve hours after birth. “The 
right frontal was depressed and fractured by the sacral promontory.” In 
a fifth case,5 the conjugate measured 3.25 English inches. The occiput 
looked to the left ilium ; the sagittal suture lay transversely and on the 
sacro-vertebral angle, with the right parietal affronting the inlet. 
Siebokl describes a typical case of unaided labor in a pelvis of 3.5 
inches.6 At the first labor, a dead child was delivered by the forceps* 
At the second labor, the head presented transversely, with the occiput 
to the right ilium. By means of ergot a dead child was expelled. It 
had lesions and furrows at both temporal regions. At the third labor, 
the head presented transversely “ with the small fontanelle to the left 
and the large to the right.” “It was also greatly extended to the right, 
viz., the forehead dipped. After many hours of hard labor, the head 
was driven past the promontory, and then the vertex rotated anteriorly 
to the first position. Thereafter the child was soon delivered. B 
weighed seven pounds, was dead, and had the left temple denuded of it 9 
cuticle, at a point on a level with the small anterior inferior fontanelle 
(Casserius’s fontanelle). At the autopsy, four fissures were found ; one 
on the left side of the coronal suture (on the frontal bone), and three oU 
the parietal bone. In the same journal, Carus reports an analogous case, 
in which there was a furrow of the parietal and a fracture of the frontal 
bone. Schdller, of Berlin,7 relates a unique case of labor in a primipara 
with a narrow pelvis. At the end of three days the woman was delivered 
of a living child. “In the middle of the left parietal, and in the neigh' 
borhood of the left temple, the skin was abraded and the bone depressed. 
“ The bone beneath died, and a portion as large as a sixpence of the whole 
thickness of the parietal bone exfoliated, leaving the dura mater exposed. 
The destruction of the frontal bone was less considerable.” The Transac- 
tions of the Medical Society of Erlangen contain the history of a case ot 
spontaneous delivery in a narrow pelvis, reported by W. J. Schmidt* 
The child was still; its skull had a fracture and a depression on the leß 
frontal region. In the same paper analogous examples are given by H* 
Hirt and Jdrg. Another case of natural labor, in a pelvis measuring 
1 Fourth Memoir, p. 154. 2 Eighth Memoir, p. 189. 
3 Eleventh Memoir, p. 475. 4 Ibid., p. 4G9. 
5 Ibid., No. i. p. 463. 
6 Revue Medicale, 1833, tome i. p. 301; from Siebold’s Journal fur Geburtshlilfe, B. xl- 
- 404. 
7 Berlin. Medicinische Zeitung, September, 1841. 
8 Jdrg, Schriften zur Kentniss des Weibes, Bd. ii. S. 123, 130. LABOR IN' NARROW PELVES. 
783 
ab°ut three inches, is given by Osiander.1 After the most violent expul- 
Ve pains a dead child, weighing six and a half pounds, was born, with 
lacture of the left parietal and frontal bones. Danyau, whose excellent 
Paper 2 has furnished me with some of these references, gives the following 
history of a woman whose pelvis was found after death to 
jbeasure 2.75 French inches; Her first child was delivered dead by the 
°rceps. In five succeeding labors each child ottered by the breech, and 
°ne was born alive. In her seventh and eighth labors the head presented, 
ail(;l the children were born without aid, but dead. In her ninth labor 
r^e Avas brought to the Maternitfi. The head came first, and for four 
°urs stayed locked at the brim. Its sacral side was then felt suddenly 
0 bend in, and the same pain drove it down to the vulva. The child 
as dead. Its skull had a deep depression overlapping the left coronal 
future, and shelving obliquely backward to the boss. The death of the 
pother on the fourth day permitted a careful measurement of the pelvic 
diameters. 
Levret3 writes of a natural labor in a narrow pelvis in which the “ face- 
alf” of the head was obliquely furrowed. Antoine Dugds contends,4 
hat “ The bones of the skull are often fractured with depression by the 
Bacro-vertebral angle of the mother. It is one of the frontal, or, indeed, 
?lle of the temporal regions, which is the most ordinary site of these 
jesions.” As a voucher for this statement, he gives an example of a 
Wing child born spontaneously, after a labor of thirty-six hours, through 
a.Pelvis measuring 3.25 English inches. The occiput presented to the 
lMght, and the right temple showed a red and contused furrow,5 In 
Mother case, the left frontal bone was so depressed as to push the corre- 
sponding eye nearly out of its socket. Velpeau declares,5 that “the 
| epression of the parietal or of the frontal, with or without fracture, has 
een observed at the Maternite of Paris.” Budin, a most careful observer, 
biet with a case of spontaneous delivery in a flat pelvis measuring about 
(*4 English inches in its conjugate.7 The occiput presented to the left, 
ail(l a small living child was born twenty hours after the rupture of the 
Membranes. On the left frontal region it had a deep furrow, which 
parted from the coronal suture at the anterior fontanelle, and ran 
obliquely backward toward the base of the skull. Chailly-Honore holds8 
hat “ The depressions of the skull have their site ordinarily on the 
.lQntal or the parietal bones,” and are often the result of natural labor 
lri a reniform pelvis. Casper, after giving a list of writers on this subject, 
'yhose works are unfortunately beyond ray reach, says that the 
Jactures caused by unaided labor arc commonly on the parietal bone 
and usually transversely to the sagittal suture.” Sometimes they are 
?Und “ stretching from the frontal bone more or less parallel to the sa- 
pttal suture.”9 From these citations, it follows that the site of the bone- 
®Sl°ns caused by a natural head-first labor in a fiat pelvis, is found, not 
a °ne of the poles of the biparietal diameter, but either directly over the 
1 Handbuch der Entbindungskunst, Bd. ii. Abth. 2, fe. 206. 
2 Journal de Chirurgie, par Malgaigne, Janvier, 1843, p. 42. 
3 Accouchements Laborieux, Paris, 1762, p. 119. 
4 Manuel d’Obstetrique, Montpellier, 1840, part v. sect. i. p. 306. 
5 Thbse, No. 64, 1821, pp. 51, 54. 
6 Accouchements, Paris, 1835, tome ii. p. 588. 
7 De la Tete du Foetus, Paris, 1876, p. 58. 
8 Accouchements, Paris, 1867, p. 950. 
9 Forensic Medicine, New Sydenham Society, vol. in. p. 118. 784 
GOODELL, 
track of the coronal suture, or on either side of it, and generally parallel 
to it, and at right angles to the sagittal suture.1 
After turning in a flat pelvis, or in one narrowed mainlj’ in its conjO' 
gate diameter, a very analogous cranial mechanism takes place. The 
partial extension of the wedge-shaped head throws the biparietal diameter 
to one side of the promontory, and places in the conjugate of the brim 
the small bisauricular (bimastoid) diameter—viz., that portion of each 
temporal region lying directly in front of the ear. FTow, upon traction? 
if the occipito-frontal diameter of the head be short, or the occipital 
portion of the pelvis roomy, the head will pass in the transverse (bis' 
iliac) diameter of the brim, and in a state midway between flexion J|)(* 
extension, while the transit-furrow will be vertical, running directly 
upward from the smaller bisauricular diameter to the larger bitemporal 
diameter, close to and parallel to the coronal suture. If the head be 
large or the brim shortened in its transverse diameter, the resistance to 
the descent of the hind-head tends to bring about two movements; the 
one of flexion, and the other of occipito-frontal displacement towards the 
forehead side of the pelvis. The head should, therefore, pass in the 
resultant of these forces and of traction ; viz., in a line running some- 
-what obliquely from the front of the ear, or from the anterior interim’ 
angle of the parietal bone, to the vault posteriorly. But this transit-li'l6 
is more vertical than in the given case of unaided head-first labor, being 
very generally found very near and almost parallel to the coronal suture? 
sometimes indeed in the very gutter of this suture-track. For the sacral 
side of the head being, under traction and propulsion, quickly bent 
and fixed by the promontory, resists occipito-frontal displacement; whik 
free lateral bulging at uncompressed points prevents any exaggerated 
lengthening out of the occipito-frontal diameter. Furthermore, supt’a' 
pubic propulsion together with two movements of unremitting traction? 
first in the axis of the outlet and then in that of the inlet, cants the bnse 
of the skull over the edge of the promontory, causes its sacral side to he 
nipped high up, and makes its pubic side revolve around the promontory 
as a centre of motion, and descend over the glib under-surface of the 
pubis; in other words the head is, as I have elsewhere expressed ib 
warped around the promontory.2 
Now, since this mechanism of a head-last labor in a narrow pelvis is 
yet mooted, I shall try to prove it by such clinical histories as note the 
site of the pressure-furrow. Smellie,3 after turning in a narrow pelvis? 
and making traction on the child’s body “ with all my strength,” delivered 
a living child, which did well, although it had “ a depression of the 
temporal bone before the ear, and the frontal and parietal bones pushes 
outwards.” Madame Lachapelle4 advises turning in narrow pelves 111 
1 In order to facilitate the work of others in this direction, I append the following refe ' 
ences to papers on fractures of the foetal cranium, which I have not been able to consul • 
Proems verbal de la distribution des prix, June 20, p. 64, etseq.; London Medical an 
Surgical Journal, March, 1834, p. 145 ; Charles West, in Medico-Chirurgical 
2d series, vol. x. 1845, p. 404; Siebold’s Journal fur Geburtshiilfe, 1825, B. v. S. 224, ' 
xi. S. 400; C. F. Hedinger, über die Knochenverletzungen bei Neugebornen in Me( • 
gericht Hinsicht, Leipzig, 1833. The following authors have also written on the sain 
subject: Chaussier, Meissner, Siegel, Ollivier, D’Angers, Viardel, Haller, Bose, Bercho -? 
Deventer, Dionis, Roederer, Baudelocque, and Stein. 
2 Philadelphia Medical 'times, March 20, 1875, p. 386. 
3 Cases in Midwifery, Collect, xxxiv., No. ii., Case ii., p. 237. 
4 Pratique des Accouchements, Paris, 1825, Eleventh Memoir, p. 429. LABOR IN' NARROW PELVES. 
785 
so Make the head descend midway between flexion and extension, 
sev S g6t the “temPor(>-auricular diameter” in the conjugate. From 
cases of head-last labor in narrow pelves, which she narrates, I 
vert tbG followinS: Case L 1 Frimipara; conjugate 2.75 French inches; 
ext X Presentatlon 5 forceps slipped ; prolapse of the cord ; version ; head 
lar •C! Wlth dlfficulty and Wlth a sodden jerk {secousse brusque). A 
ge girl was born alive, but did not live long. The head had a deep de- 
fua to 011 tbe left frontal bone- Case n-2 Second position of breech; con- 
fer 6 2,5 French inches; child weighed five pounds and had been dead 
itsn T6-tlme- The bead had “a deeP dePression of the right parietal in 
Cn. TTrrorportlon and nearthetemPle> caused by the sacral promontory.” 
hear! 111,3 First Position of breechi “For more than ten minutes the 
Chin rf-Tted tbe most vlolent fractions” {aux efforts les plus violens). 
the dld well for twenfy-four hours and then died in convulsions, from 
Par' CJanial lesions- An autopsy revealed the separation of the’rio-ht 
1 1 total bone from the temporal along its whole inferior border. 
Pel F Fhillips4 reports three cases of successful version in contracted 
u Ves after failure with the forceps. In one of them the child had a 
t niarbed depression on the left parietal and frontal bones.” Here* the 
g.ansit-lme followed the course of the coronal suture. Carl Huge5 gives 
* cases of fracture of the frontal bone, and one along the temporo- 
sMure, after version. In the seven of my own cases6 in which 
rj, e Pressure-furrow is noted, the site was near or on the coronal suture, 
in 6 at.e Frof. E. Martin, of Berlin, says7 that, after version, “These 
jApressions or depressions of the respective parietal bone are always to be 
jjllnd upon its anterior portion, more or less near the coronal suture.” 
tj1 ‘ A* Fames avers8 that “Tbe mark of pressure or indentation against 
® Jutting promontory is always seen at one end of this short diameter:” 
azy fbe bitemporo-frontal. Dr. I. E. Taylor, of Hew York, in describing 
case of labor in a pelvis measuring 2.5 inches in its conjugate diameter, 
es that “By version and propulsion from above the pubes, the head 
?at.teiied or iudented at the junction of the parietal and frontal bones, 
furtn *s be usuaX place.”9 Many other examples could be cited, but 
per evidence is needless, 
ces rorri this mechanism it is clear that version closely imitates the pro- 
its S^S uature, for by it the head enters and passes the conjugate by 
shortest diameter, where four yielding bones meet; where four wide 
0v U,res converge; where the fontanelle is large and always open ; where 
tper aPping is most free, and where compressibility is greatest. Since 
Pas InS^ance *s Fmi ted mainly to’the margin of the brim, that once 
tp Sed (and generally with a well-marked jerk), there is usually no fur- 
J °hstacle to the descent of the head. It is now brought into relation 
lJa } new pelvic diameters, and the greater friction of the broader and 
c.ei' surface of the hind-head brings about the needful movements of 
1011 and of rotation. To effect this the line of traction must be 
to that of Carus’s curve, and finally to one at right angles to 
mother’s body. 
3 !pP- cit., Eleventh Memoir, p. 481. 2 Ibid., p. 486. 
5 Fourth Memoir, p. 157. 4 Lancet, March, 1871, p. 404. 
6 "Blletin General de Therap., Aotit 15, 1875, p. 130. 
7 iynerican Journal of Obstetrics, August, 1875, p. 197. 
8 -Richmond and Louisville Medical Journal, April, 1870, p. 421. 
9 ~, tetric Operations, London, 1871, chap, xvi., p. 237. 
ransactions of the New York Academy of Medicine, September, 1875 
50 786 
GOODELL, 
But there are mechanical advantages which turning possesses over a- 
cephalic presentation in a narrow pelvis. Outside help, that of traction 
and of propulsion, can be invoked without in the slightest degree inter- 
fering with th natural mechanism. Again—and this must not he 
overlooked—by turning, the head enters the brim by the very short bi- 
auricular (bimastoid) diameter of its base, and passes the conjugate by 
the larger but more compressible bitemporal diameter of its vault; that 
is to say, the small end of the wedge is first nipped. In the correspond- 
ing head-first labor, the reverse to this takes place; for the head enters 
the conjugate by its bitemporal, or the vault portion of its bicoronal 
diameter. From repeated measurements taken shortly after birth, I find 
that the average length of the bisauricular diameter is 2.6 inches, and 
that of the bitemporal diameter 3 inches—a difference of nearly half an 
inch. 
From this description of the cranial movements, it follows that turning 
should be limited to cases of antero-posterior shortening of the brim. For, 
in other kinds of narrowing, the previously described mechanism, so essen- 
tial to success, could not take place. In the generally and uniformly nar- 
rowed pelvis, the transverse (bisiliac) diameter of the brim would probably 
be too short to permit the after-corning head to pass in a state midway 
between flexion and extension; while, on the other hand, if the head 
were forcibly flexed, a longer diameter than the bitemporal would bn 
jammed into the short diameter of the brim. Again, from the narrow- 
ing of all the diameters of the whole pelvis—brim, bony canal, and ouf' 
let—the after-coming head would be detained at every stage of 
descent, and could not, therefore, be delivered soon enough to avert 
fatal asphyxia. To save the life of the child, then, the.forceps, and no* 
turning, is here needed. As a corollary to this, less power and time am 
needed after version to deliver an average head in a flat pelvis, than il 
large head in an average pelvis ; for, in the former, the resistance is mar- 
ginal, and limited to a single osseous point; in the latter, diffused niom 
or less, not only over the whole bony brim, but over the pelvic canal and 
outlet. 
How to tell a uniformly narrowed pelvis from one narrowed maiul) 
in its short diameter, becomes, then, an important question. Apart from 
careful digital examinations, much may be learned from measuring th® 
distance between the anterior-superior spinous processes and that between 
the crests of the ilia. In a standard pelvis these distances average i‘e' 
spectively 25 cent. (9.8 inches) and 28 cent. (11 inches).1 But what shook 
mostly be relied on is the position of’the head. When conjugate narrow' 
ing alone exists, or when it preponderates, the occipito-frontal diainetm 
lies parallel to the transverse diameter of the brim, with the antei’101 
fontanelle low down. A head so situated implies conjugate narrowim? 
and transverse amplitude of the brim. When the pelvis is uniformly 
narrowed, or when transverse (bisiliac) narrowing preponderates, BJ° 
head will be found high up and very strongly flexed. This happeI1t 
because the resistance at the brim is equal on all sides, and the shorty 
arm of the occipito-frontal lever must therefore descend. The sagiß 
suture, for the same reason as in a standard pelvis, will be found runumb 
more obliquely than transversely. Such cranial conditions show_ tba 
the transverse diameter of the brim is too short to admit the occiplto 
1 Carl Martin, Mounts, fur Geburtsk., Dee. 1867. LABOR IN NARROW PELVES. 
787 
frontal diameter of the head, and that version is consequently inadmis- 
Turn now to the mechanism of labor when the forceps is used at the 
. rirn of a flat pelvis. If the blades are applied to the fronto-occipital, or 
0 the fronto-mastoid diameter, the head, which is lying midway between 
eXion and extension, is—unless firmly nipped in the conjugate—forcibly 
eXed, and either the biparietal diameter, or some diameter longer than 
bitemporal, is made to enter the short diameter of the brim. Again, 
be fronto-occipital compression to which the head is subjected, not only 
Prevents the natural lengthening out of the long diameters, but it causes 
of all the cross diameters. This is, of course, a mechanical dis- 
‘bjvantage, one which increases the difficulty of the head’s transit, and 
|yhich can be overcome simply by a brute tractile force—such as puts 
°etal life in jeopardy. In addition, the fronto-mastoid application tends 
force a premature anterior rotation of the hind-head. Also, the line 
0 traction on the forceps-handles will invariably be at an angle to the 
axis of the superior strait, and the brunt of the traction is wasted on the 
Pubis. Finally, such an application, by flexing the head or by shortening 
| 8 fronto-occipital diameter, so widens the iliac spaces that prolapse of 
lbe cord is very liable to occur., “Statistics show that out of five appli- 
cations of the forceps above the superior strait, no fewer than two are 
by a prolapse of the cord. I,” continues Chailly-Honord, 
have met with it in the ratio of twice in three cases.”1 
1 On the other hand, when the blades are applied along the sides of a 
®ad at the brim of a narrow pelvis and lying in its transverse (bisiliac) 
jpunieter, flexion is inevitable.2 So essential, indeed, is this movement 
°r the accurate adjustment of the blades, that some practitioners try 
2 1867, p. 643. 
ti i 16 statement often appears in foreign medical works, that this application is imprac- 
pc_ le whenever the head lies in the transverse diameter of the brim, this is a mistake; 
rJi’ the long curved forceps then becomes virtually a straight one in so tar as the 
** curve is concerned, this application can be very generally made with a propeily con- 
c jlc^ed instrument, provided the head be not locked. With the Hodge or the Davis for- 
fr’P® I have frequently made this application, and have repeatedly seen others make it. 
Aodg« and Meigs, it is true, condemned it; but they denied, not its practicability but, its 
Utility. Baudelocque, Capuron, and Gardien, warmly advocated it, and it is now the 
itual practice of some of the best obstetricians of Philadelphia. It possesses the gieat 
an V^S securing the firmest grip, of compressing the head in its least vulnerable diameter, 
riPf. lessening the pressure on the bladder. Since the mode of making this application is 
ilin lar’ a description of it may not come amiss. If the occiput look directly to the lolt 
is and this is the most common cephalic position in the simple flat perns—the woman 
r; yf over on her back, and her coccyx made to project over the edge of the bed. he 
(female) branch is first introduced in the right side of the pelvis, with the convex sur- 
As blade looking obliquely to the sacrum. By a rapid downward sweep ant a spiral 
finrG it® handle, together with upward pressure on the convex edge of its blade by the 
of*5®/8 ln the vagina, it is rotated very nearly half of a circle over the forehead to the side 
thechjjd’s head under the pubis/ The left (male) branch is now so held at its lower 
Wi,Vfx odge by the tips of the fingers of the right hand, that its handle hangs down. 
ri,,/6 held in this position, the blade is introduced, as far as it can be made to go, in the 
blaT Sule also of the pelvis, over the child’s left temple but under the shank ot the female 
"'hi u' ■ right hand is next carried to the still pendent handle, which it raises, and upon 
tlipfl makes upward pressure. This movement, combined with a guiding pressure from 
tlip i n£ers °f the left hand in the vagina, makes the blade glide up over the sacral side of 
the i When the branches are united, the lock should press firmly on the tuberosity of 
be nk ISchium. Should the occiput look to the right ilium, the same, general rules are to 
]ejv , Served. But now both blades are to be introduced in the left side of the pelvis—the 
I’hp i ale) hlade first, and under the pubis; the right (female) with its handle pendent. 
°c'k should now press firmly on the tuberosity of the right ischium. 788 
GOODELL, 
first to flex the head, either by the hand, by the vectis, or by one blade 
of the forceps. In my own experience, however, the act of locking and 
that of grasping the handles, usually bring about the needful amount ot 
flexion ; for success in such an application of the forceps presupposes a 
certain amount of mobility of the head, which insures its flexion. 
Hence the large biparietal diameter, or one of its congeners, mnst 
inevitably pass directly through the narrow conjugate. But, apart from 
its width, the hind-head is the least compressible portion of the cranium- 
The parietal bosses, being projections, as their name indicates, and being 
also the centres of ossification, are the most unyielding points of the vault* 
They are in fact eburnaceous when compared with other portions of the 
parietal bones. The posterior fontanelle is small, not open, and not infr®' 
quently ossified. The sutures are narrow. Only three bones meet there? 
the occipital and the two parietals. But the occipital bone goes to form 
the hard cranial base, and is incompressible. The compressibility of the 
hind-head is therefore limited to the equitation of the parietal bones- 
But being shored up and buttressed by the unyielding occipital bone 
underneath them, they cannot readily overlap or bend in. Hence the 
tedious traction needed for forceps-deliveries, when compared with that 
required after turning. Transit-furrows are rare, but, when present? 
they run anteriorly from the boss either obliquely toward the cranial 
base, or parallel to the sagittal suture. In a recent case of forcep9' 
delivery this was very strikingly shown. The diagonal conjugate, noea* 
sured by the rule and finger, gave a length of four inches. The sagittal 
suture ran transversely to the left ilium, with the large fontanelle dipping 
down so low as to make it almost the presenting part. The blades of the 
forceps were applied to the sides of the head, which flexed on bringing 
the handles together. After strong traction of about two hours’ duration? 
made alternately by the attending physician and myself, the head wa9 
finally delivered. It was much flattened, and presented on its sacral side 
the well-marked furrow of a fracture running from the parietal bone 
obliquely to the mastoid process behind the ear. The child was still; tbe 
mother died four days afterwards from peritonitis, and I now regret not 
to have turned. Duges1 also describes such a fracture of the parietal bos9 
in one of his forceps cases. Fractures and furrows at this site would fa*" 
more frequently happen in instrumental labor, were it not that the ham 
boss so resists the direct pressure upon it as either to flatten the whole 
parietal bone, or to cause lesions of it at weaker, although unirnplicateo? 
points. 
But there are mechanical objections still stronger against the forcep9 
when compared with version. The base of the skull being unyielding’ 
the head cannot be compressed so readily by catching the vault with th 
forceps. For the effect is then to direct the compressive power towai 
the unyielding base. But by turning, the compressive power is directe 
toward the yielding vault. Further, from the peculiarity of constructing 
of the forceps, the compression exerted by it is necessarily diffused ove 
the whole surface covered by the blades. How, in a bilateral application? 
tbe tips of the blades cover the bones of the cheeks, which are incompreS 
sible and so narrow as to need no compression whatever. Hence, n° 
only is this amount of compressive power misapplied and sheer waste? 
but it detracts by so much from that applied to the offending diameter 
tbe biparietal. Thus tbe surface covered by tbe blades not only involve 
Manuel d’ObstMrlque; Montpellier, 1840, part v. sect. i. art. i. p. 306. LABOR IN NARROW PELVES. 
789 
'implicated diameters, but it is too broad to be very materially reduced 
ffain°?pre?ion' -Even when the handles are lashed, but little more is 
s ’ and that little at the expense ot a prolonged, disorgauizino’ pres- 
win UiP°,n the brain- Faudelocque’s exceptionally powerful forceps°were 
Parif iied bandies, found by their inventor barely to reduce the bi- 
g0 etal diameter as much as four lines, although the force applied was 
]ou?rea1t and 80 prolonged as to spoil the three instruments used. It fol- 
bler • berefore’that the HodSe or the Davis forceps, which are much fee- 
d instruments than the French one, cannot compress the biparietal 
meter as much as three lines, and the operator is therefore compelled 
narrow pelves to make the anterior portion of the brim and the pro- 
shel!toryi0f the Bacrum do most of the compressing work; and that by 
tfofand prolonged dragging force, which, as in the case just narrated, 
‘eatens injury to the mother and death to the child. 
alsn ain’- Eie forceps-blades being of equal length and breadth, and beino- 
con apPbed to corresponding surfaces of the child’s head, make equal 
j.l nipression upon the pubic and the sacral side of the head. But from 
e imitation of the bone-lesion in these pelves to the posterior half of 
vle brim, the pubic side of the head needs no compression ; for its con- 
-0^Xlty naturally adapts itself to the smooth concavity of half 
jg “be brim. Therefore just one-half of the effective compressive power 
abs°lutely thrown away. For granting that, in a given case of conju- 
m narrowing, the forceps reduces the biparietal diameter by three lines 
ls diminution does not facilitate to the same extent the passage of the 
th • > for supjiosing that it actually reduces the width of the head by 
le® lines, yet it does not virtually so reduce it. This is evident from 
t G met that the pubic side of the head needs, not compression, but adap- 
lofo and the bulging tissues around the periphery of the blades will 
0f separated by their width still impinge on the pubic concavity 
Li , . brim, making the clamped portion of the head subtend the sym- 
bi/818 Pllbiß bkc the chord of an arc. In all the narrow pelves belong. 
to the museum of the Philadelphia Obstetrical Society, and one of 
c ertl I® under two inches in its conjugate diameter, the pubic side is con- 
di museum of the University of Pennsylvania, I find that the same con- 
to h'1 °btains in all that were not affected by osteomalacia. Turn now 
the sacral blade of the forceps ; it is the posterior half of the brim 
ajolc 1 is distorted; and to its irregular configuration must the sacral side 
to fif the head be moulded. Since also the distortion is mainly owing 
.le descent of the sacrum as a whole, and to the anterior projection 
ar ds Promontory, the portion of the head needing moulding is a small 
a of_surface corresponding with the sacro-vertebral angle. In other 
Uiet 8’ 8’ wpen flexion is forced by the forceps, the biparietal dia- 
-Bac _ei’ alone that needs shortening, and that by the indentation of its 
tjji . Pple. But the very width and length of the sacral blade thwarts 
\llcbcation. This blade flattens the whole sacral surface of the head, 
fifttt °eS not moldd ib The whole head and included brain are in fact 
So Glled out by the two blades. And this excessive bilateral compression 
eveUllnecessardJ lengthens out all the other diameters of the head, that 
Physician has seen forehead bulging out, eyeballs starting from 
to whets, and bfe destroyed by the violent and prolonged compression 
late - Vcb tbe vybole brain has been subjected. In one word, by the bi- 
cessla c°mpression of the forceps the pubic blade interferes with the pro- 
°t adaptation ; the sacral blade prevents the utilization of the roomy 790 
GOODELL, 
concavities on each side of the promontory, and the whole brain is, there- 
fore, subjected to an unnecessary amount of compression. 
The catch-word “ moulding;,” which is so much used to designate the 
o/ # o 
action of the forceps, is a misnomer. Moulding here means an outline 
conformity of the cranium to the kidney-shaped configuration of the 
brim. To attain this end, it is needful for the pubic side of the head to 
adapt itself to the smooth concavity of that portion of the pelvis, for 
the occipito-frontal diameter to be moderately lengthened out, for n 
limited area of the sacral side of the head to be bent in by the promon- 
tory, and for lateral bulging to take place around it in the very roomy 
sacro-iliac spaces. No moulding of the head, in its true obstetric sense, 
can possibly occur, unless, as in natural labors or by version, the pelvis 
itself acts the part of the moulder. Look at a head in the grasp of the 
forceps applied bilaterally. How is it possible for this steel-ribbed head 
to alter its shape to that of the brim? How can any bending-in take 
place within the fenestra of the sacral blade, whose iron rim, by firm 
pressure, acts as an abutment to the included parietal boss? How can 
the pubic side of the head adapt itself to the anterior portion of the pel' 
vis? How can the head bulge out at points clamped by iron ? The 
forceps, thus applied, indeed moulds the head, but to its own shape, and 
not to that of the brim. For how can bow-shaped blades mould a head 
to a kidney-shaped brim? The thing is an impossibility. Who ever 
saw a head kidney-shaped which had been delivered in such a manner 
through a narrow brim ? The truth is that the head then passes the 
brim by being flattened out, and not by being moulded; and, what lS 
worse, since the blades do not exert the needful compressive power, tbe 
promontory itself is made to do most of this unnatural work—the work 
of flattening and not of moulding. When the head is squeezed sum' 
ciently flat, it is delivered by being dragged straight past the promon- 
tory, without revolving around it as it does in natural or in version 
cases. 
So true is this that, when a head has been delivered through a smmL 
conjugate by the forceps applied bilaterally, never will it exhibit a cast 
of the promontory by a spoon-shaped depression, and only once have I seen 
a slight furrow. The whole head is flattened, the bones are separated at 
the sutures, sometimes so much so as to seem loose in a scalp-bag, but no 
lesion of limited area is found by a surface examination. Post-mortem 
examination will, however, reveal fissures and fractures radiating fa°n 
the base of the parietal boss. 
It follows that the hackneyed term of “ wire-drawing” the head b) 
the forceps, is also a misnomer. In “ wire-drawing,” the pincers whmr 
seize the end of the wire do not pass through the graduated holes in tn 
draw-plate, but work outside of them. But when the head is seized by 
the forceps, the pincers, so to speak, must also pass through the bon) 
draw-plate itself. So great a disadvantage is this, that there are 011 
record far more remarkable cases of successful natural deliver}7 in very 
small pelves, than there are by this use of the forceps. For it stands t° 
reason that when a forceps, whose blades lie from two and three-quart®1, 
to three inches apart, is applied to the sides of a head at the brim of 
pelvis with a conjugate of less width, the blades will need wire-drawing 
as much as the head, before they can be made to pass. 
So far the use of the forceps. Mark now what happens when tn 
child is turned in a flat pelvis. The wedge-shaped and semifiexed hejx 
enters the conjugate by its small bisauricular diameter, and passes it n) LABOR IX NARROW PELVES. 
791 
lts Very compressible bitemporal diameter. The very cause of the conju- 
gate deficiency—the jutting promontory—becomes itself the moulder, 
the plastic head, unhampered, unclamped, unribbed by bars of steel, 
,eing also drawn upon by outside traction, accurately moulds itself to the 
VaPe of this small bony barrier. Meantime the pubic side of the head, 
,ea<Jy presenting its convexity to a concavity, is made by lateral pres- 
?,re to St snugly the anterior half of the brim. Bulging takes place at 
1 the uncompressed points, and the whole head becomes concavo- 
onvex, being rapidly moulded to the kidney-shaped configuration of 
4le whole brim, while backward traction and supra-pubic propulsion 
aus.e the pubic side to revolve around the promontory as a centre of 
Joti°n. To my mind nothing can be plainer. How, otherwise, is the 
whence of vesical disturbance, after version, explainable? How the fact 
as I have seen and others attest, it will take as many minutes, less 
nilnufes indeed, to deliver the head by version, as it has taken hours of 
Unsuccessful traction with the forceps? Even without these facts and 
w,thout a cloud of witnesses to sustain them, an d priori reasoning would 
e°mpel me logically to the inevitable conclusion that version possesses 
§l'eat mechanical advantages over the forceps. 
One word in regard to the obliquely ovate pelvis. If the hind-head 
Present in the less roomy side, by turning, the soft and voluminous breech 
Js very likely to adapt itself and"pass through the more roomy side. This 
e,|dency, together with a knowledge ot the fact that the foot drawn on 
dually rotates to the pubic arch, ought, very generally, to enable the 
Practitioner to place the occiput in the larger halt. Yet so great an 
jlclvantage is it to turn, that Barnes and Strassmann declare1 that they 
>ave Bavec[ t]ie children-, even when they had failed by this operation to 
the desired change of position. 
, The use of the vectis, or tractor, in narrow pelves has been so highly 
aaded by Boddaert, of Brussels, Batfaele, ot Naples, Fabbri, of Bologna, 
' jarehant, Herbiniaux, Coppee, Beytter, Frayes, and other Dutch, Bel- 
gian, and Italian writers,2 that a few words in regard to the action of 
118 instrument are needed, 
q hen the head is transverse, this instrument should be passed over the 
Pttoic mastoid region ; when oblique and anterior, over the pubic side of 
le occiput; and when oblique and posterior, over the pubic fronto- 
ornporal region. At first it is used as a lever of the “first kind,” the 
e f hand on the shank representing the fulcrum, and the right hand be- 
°ming the power by raising the handle toward the pubes. In other 
vOfds, each hand acts in opposite directions—the left one mainly to pro- 
fect pubis from pressure. As soon as the handle is raised high enough 
°l the blade to secure a good hold, the right hand kept at rest to be- 
-oloe the fulcrum of a lever of the “third kind,” while the left acts as 
1e power. This compound action of traction and leverage, peculiar 
1 °ne to the vectis, here meets several important indications. As a lever, 
118 instrument compresses the head from before backward in its lateral 
1 Jarneter, and aids the moulding of its free sacral surface to the posterior 
lstortion of the brim. By its action as a tractor, it hooks down the 
Pvibic side of the head, making it revolve around the promontory of the 
aci'Uni as a centre of motion, and roll over into the pelvic cavity. 
’ Obstetric Operations; by R. Barnes. 1871, chapter xvi. p. 241. 
*feaux, edited by Tarnier, 1874, p. 998; Congres Medical de France, 1865, pp. 584, 
cf i’aite des Accouch., par Hyernaux; Bruxelles, 1866, p. 699; New Sydenham So- 
s Biennial Retrospect, 1869-1870, p. 409. 792 
GOODELL, 
From the close resemblance of this mechanism to that of an unaided 
head-first labor, and to that of an aided head-last labor, I am led to think 
that the vectis, in skilled hands, will be found more efficient than the 
forceps in dislodging a head from the brim of a pelvis narrowed mainly 
in its conjugate diameter. Below the brim, and in the generally narrowed 
pelvis, it cannot of course compete with the forceps excepting in certain 
anomalous positions and presentations. But in selected cases this neglected 
single-bladed instrument is, in my opinion, destined to take rank over its 
double-bladed fellow. For instance, in 1863, the late lamented Fabbri, 
of the University of Bologna, quickly delivered with the vectis, through 
an artificial pelvis, a head which S. Tarnier,1 although using all his 
strength, was not able to budge with the forceps. The head was then 
replaced, and the forceps re-applied, but with the same want of success. 
Professor Tarnier, who is the narrator, then resorted to the lever, and, 
much to his surprise, delivered the head “with astonishing ease” [avec 
une etonnante facilite). This experiment was repeated, and invariably 
with the same result. 
To sum up then the mechanism of natural and of artificial labor in a 
flat pelvis:—Nature makes the first-coming and the after-coming head 
enter the brim by extension ; the forceps by flexion. With the former 
the head engages in the short conjugate by its shortest and most com- 
pressible diameter; with the latter by its largest and most unyielding 
diameter. By nature and by version the head revolves around the pro- 
montory as a centre of motion; by the forceps it is dragged straight 
past, over this osseous point. By the former the head is moulded to the 
outline configuration of the brim; by the latter, when applied to the 
biparietal diameter, it is moulded more to the shape of the blades than 
to that of the brim. By the one the brain lesion is local and limited to 
the area bent in by the promontory; by the other the area of undue com- 
pression is increased. By nature and by version the compression is that 
which is needed and no more; by the forceps it is more than is needed. 
Regarding then alone the mechanism of labor in narrow pelves, to 
which the scope of this paper is strictly limited, the following conclu- 
sions are reached;— 
I. The unaided first-coming head and the aided after-coming head 
observe in a flat pelvis precisely the same general laws of engagement 
and of descent. Hence, version here means art plus nature. 
11. The forceps, however applied in a flat pelvis, antagonizes more or 
less with the natural mechanism of labor. Hence, the forceps here means 
art versus nature. 
111. The aided and the unaided first-coming head observe in a uni- 
formly narrowed pelvis precisely the same laws of engagement and ol 
descent. But version violates these laws. Hence, the forceps here 
means art plus nature; version, art versus nature. 
IY. At or above the brim of a flat pelvis, the fronto-mastoid or even 
the fronto-occipital application of the forceps interferes less with the 
moulding of the head, and violates less the natural mechanism of labor, 
than the biparietal application. 
Y. In the flat pelvis, the vectis aids the natural mechanism of labor, 
and, therefore, meets the indications better than the forceps. 
1 Cazeaux’s Obstetrics, 1874, p. 996. LABOR IN NARROW PELVES. 
793 
Discussion on Dr Goodell’s Paper. 
-After the reading of the preceding paper, the President, Dr. Robert Barnes, 
London, said:—The paper is now open for discussion. I desire, however, 
to say that it is the ablest paper that I have ever heard or read upon the 
s^*)ject. lam aware of the difficulty in treating this question, for the passage 
the foetus through the pelvis, and the obstructions to its progress from de- 
are not only to be studied clinically, but, as the conditions are me- 
by a priori reasoning. Yet, after all, experience is the best guide, 
the method proposed is clinical or empirical. I shall be glad to hear 
I(>m the members of the Section, and may suggest as heads for the discussion 
G) the mechanism of labor when unaided, and (2) its mechanism when aided 
y art. I am glad to see in the room Prof. Barker, who has possibly more 
sPecial knowledge on this subject than any one I know of. 
Lr. Fordyce Barker, of New York, said:—l believe that Obstetrics has 
)egun to make itself an exact science, and I am sure that investigation and 
. le presentation of papers such as we have heard will have a tendency to make 
ft more and more exact. I am sorry that I did not hear the first part of the 
Paper, for I should feel like studying it carefully before commenting upon it. 
| think that the vectis in certain cases of contracted pelves is preferable to the 
0,’ceps, and lam pleased to find that Dr. Goodell agrees with me upon this 
Point. 
Lr. William H. Byford, of Chicago, said:—-I have greatly enjoyed the 
reading of Dr. Goodell’s paper, but as to criticism, I think mine would be 
I have in my writings advised the use of the vectis in cases of the 
after-coming head, where it lias not entered the pelvis; but I use the forceps 
'jGere the head is fully in the pelvis. Since hearing Dr. Goodell’s paper, I feel 
c lsposed, in the case of kidnej’-shaped pelves, not only to turn, but to use the 
instead of other instruments. Obstetrics is a science that is almost en- 
,ll Gy mechanical, and for that reason I think, with Dr. Barker, that it will ere 
°ffg become an exact science. I regret very much that I have not had the time 
®f the opportunity to study the valuable paper which has been presented, and 
® subjects treated of in it. 
the President, Dr. Barnes, said:—lt must be apparent that in certain cases 
?, Harrow pelves one must resort to the induction of prematuie laboi ; but 
ffft point has not been referred to. The value of this operation has been 
in question of late years, and it may be well to inquire how does the 
echanism of labor bear upon those cases in which lives are thus saved . I 
ould like to have the experience of those familiar with cases in which the 
' ftd has lived after the induction of labor. _ 
Dr. William Lusk, of New York, said:—ln the main I agree with the coll- 
isions of Dr. Goodell. I have, however, applied the forceps along the sides 
the pelvis, and have, in some cases, dragged the head down to the floor of 
le pelvis, without flexing it, both fontanelles being nearly on a level. It has 
*rays been my habit, after the conjugate diameter has been passed, to wait for 
J?e jiead to flex and the occiput to rotate, before renewing traction and com- 
P eting the delivery. If continuous traction be kept up, then all the statements 
the paper are justified; but if occipito-frontal compression be applied at the 
Urn, and traction made only during the pains, the child’s head will generally 
I ass without being flexed, and delivery will be effected in accordance with the 
echanism described by Dr. Goodell. When the head is fixed in the brim, I 
°T'lLl use the forceps with no apprehension of flexing it. 
: L r* Goodell, in reply to a question, said;—l have no experience with the 
Nstrurnent of Chassaguy. But all the distinguished obstetricians in France 
Ge leaning in the very questionable direction of importing the labor-saving 
G Laments* the straps, pulleys, and capstans, of veterinary obstetrics, into 
Ulllan obstetrics. In 1872, Chassaguy bore off the Montyon prize for his 794 
GOODELL, 
appa,veils de traction soutenue, and since then many others have been invented* 
It is a significant fact that these instruments have originated in France, where 
version is bitterly opposed. It is also a significant fact that the only eminent 
French obstetricians who oppose them are Blot, who practises version to save 
the life of the child in narrow pelves, and Pajot, who turns in order to crush 
the base of the skull by his cephalotribe. 
Dr. Alexander R. Simpson, of Edinburgh, said The flat pelvis presents 
peculiar advantages for version. One would expect the greatest advantag0 
when the base of the skull, which is the narrowest part, comes in relation to the 
narrowest part of the pelvis. I have seen this, in my own practice, again an] 
again. Reference has been made to Budin and his series of mechanical expel'l' 
raents on the comparative force needed by version and by the forceps in drag' 
ging the child through the pelvis. These experiments have somewhat stag' 
gered me. In some of them the long diameters were shortened, and in others 
they were elongated. In Dr. Goodell’s conclusions I see allusions made to 
the application of the forceps to the sides of the head at the brim. But it is 3,11 
impossibility for the forceps to grasp the sides of the head in the case of a 
flattened pelvis ; for there is no room, and the operation is simply impracticable* 
It might be possible for one blade of the forceps passed over the occiput and tfie 
other over the forehead to so grasp the head as to produce elongation and thi’s 
cause the head to pass through a narrow brim, but version is preferable in 
these cases. 
The President, Dr. Barnes, said :—I have practised version for twenty 
years in preference to using the forceps, and am becoming more partial to 1 
the more I practise it. From the forceps there can be but little benefit except 
in minor contractions, but in great contractions, where there is any chance 0 
saving the child, I should use all means in preference to the forceps. As to th® 
mechanism of labor in a “ head-first presentation,” it has been well explain® 
in the paper of Dr. Goodell. I can only add force to those deductions by 
referring to the frequency of occipito-posterior positions in contracted pelves 
a frequency which enforces Dr. Goodell’s arguments. Under such circumstance3 
version is the best mode of delivery, but there are occipito-posterior presenta- 
tions in which, the head having passed through the narrow brim, and the woman 
being exhausted, the forceps will finish the labor. I have delivered one la(v 
five times, all with the same difficulty of occipito-posterior presentation* ** 
another case in which there was a slight contraction of the pelvis, the child 
lost by the use of the forceps, but on two occasions when I turned, the cln 
was saved. It requires practice in these cases of version in a narrow pelviSj 
and the mechanism, in head-last presentation, will be much better understoo 
by careful study. In turning, there is the danger from dragging on the chin* 3 
neck, and from the traction on the medulla oblongata, or in some cases 
the injury to the brain pulp. I have seen a child’s head pulled off by inju 
cions traction. There is in these cases often a misdirection of force on t 
part of the physician which jeopardizes the child’s life. 
[Dr. Barnes explained by a diagram on the blackboard the method of getting the hea 
around the sacral promontory by backward traction.] 
The force needed can be augmented, and the mechanism facilitated if sol 
one pushes from above while the physician pulls from below, as this will ta 
off a great deal of the strain on the neck, and the propelling hand can glll 
the child’s head in its rotation around the promontory. I lay great stress 
supra-pubic propulsion by the hands of an assistant. The use of forceps 
the fore-coming head in contracted pelves, is not based upon sound raecha.ni. <■ 
principles. In cases of minor contraction, it aids delivery by elongating 
head. The direction of thought in obstetrics is now tending to a greater p 
cision in this question of the mechanism of delivery. Sometimes it is i°l^e 
impossible by any mode of delivery to save the child alive; sometimes 
woman is too much exhausted for an attempt at version to be made. In tIL LABOR IN NARROW PELVES, 
795 
ases, after perforation and the escape of a few ounces of brain, the forceps can 
>e used for breaking the skull from behind, and it will be found to collapse at 
ollCe- It cannot be said under such circumstances that the child has been 
sacrificed, but that all endeavors to save the life of the mother have been used, 
llnd that the child has been abandoned only when it has become absolutely 
Pessary. As to the vectis, I deem it of service only in cases of minor con- 
duction ; but it has been greatly lauded by some provincial practitioners, who 
Pi’efer it to the forceps. 
, -Br. Goodell, in reply, said :—I was glad to hear Prof. Simpson refer to 
Budin’s paper. Its conclusions in favor of the forceps at first staggered 
also, but, upon an examination of the experiments, three sources of fallacy 
became manifest. In the first place, the pelvis used by M. Budin was not 
originally flat one, but an iron cast of what was supposed to be a normal 
Pelvis. To narrow the conjugate of this metallic pelvis, Budin had a movable, 
alse promontory so constructed that a sacral screw forced it towards the 
Pubis. Hence the conjugate diameter of the brim was shortened without 
a proportional lengthening out of the transverse diameter, and every turn 
the screw converted the *pe^v's a uniformly narrowed, flat pelvis, and 
into a simple, flat one. Thus, as his experiments abundantly showed, there 
M'as not room enough in the transverse diameter of the brim to admit the 
°c<dpito-frontal diameter of the head. But when he experimented with chil- 
dren born before term, and consequently with a shorter occipito-frontal dia- 
meter. far less tractive-force was needed to deliver them by turning, than by 
the 
use of the forceps. Again, this movable and metallic, false promontory 
"as cast from a mould taken from the broad, blunt, and rounded promontory 
of a normal pelvis, and not from the narrow, sharp, and jutting promontory 
°f a flat pelvis. Hence the needful indentation of the head was gained by 
lhis broad and blunt knob of a promontory with very great difficulty. In the 
third place, Budin’s iron pelvis was placed on a table and near its edge, to 
the dorsal decubitus of a woman when artificially delivered, while 
the tackle used by him for these experiments was fastened to a staple driven, 
Uot into the floor near the legs of the table, but into the wall. Consequently, 
fiot only no backward traction could be made on the legs ot the child, but the 
traction was so directed as to cause the head to revolve around the pubis, and 
a°t around the promontory, as the centre of motion. In reply to Hi. Lusk I 
say that, if the head be well nipped in the conjugate, the fronto-mastoid 
?v Hie fronto-occipital application of the forceps will not ordinarily flex it. But 
111 other cases it commonly flexes the head, and always tends to do so. *\ hen 
JJe blades are applied to the sides of the head, the vertex always dips, and 
biparietal diameter enters the conjugate, because such an application could 
n°t be made if the head were tightly nipped. I wish finally not to be mis- 
understood as recommending version to the exclusion of the foiceps. Ihe 
oi'eeps is for obvious reasons generally my first choice ; besides, veision can- 
always be made ;in some cases, indeed, should not be attempted. Jut in 
tlle paper which I have read, I have avoided all such side-issues, and have 
approached the subject from a purely mechanical stand-point. 796 
THE MANAGEMENT OF CONVULSIONS, IN CHILDREN, 
DEPENDING UPON A HIGH TEMPERATURE 
OF THE BODY. 
BY 
T. K HOLMES, M.D., 
OF CHATHAM, ONTARIO, CANADA. 
Gentlemen : 
I purpose, in this short paper, to ask your attention to the manage- 
ment of convulsions, in children, depending upon a high temperature of 
the body. The subject will not be thought unworthy of consideration 
by any one who has seen this complication resist various plans of treat- 
ment, and prove fatal after hours of intense anxiety on the part of all 
concerned. The great frequency and fatality of convulsions, in children, 
should be a strong incentive to all physicians to avail themselves or 
every mode of reducing the mortality. In this city during the five 
years from 1844 to 1848 inclusive, 1729 children, under fifteen years of 
age, died of convulsions ; a higher mortality than attended either cholera 
infantum, marasmus, pneumonia, or hydrocephalus, during the same 
years. It is neither possible nor desirable, in this paper to enter into a 
lengthened discussion of all the phenomena connected with this subject. 
This has been done by most modern authors, and by none more lucidly 
or ably than by your distinguished countrymen, Meigs and Pepper. 
It is admitted by all that eclampsia is a frequent complication m 
many febrile diseases, as scarlatina, measles, pneumonia, malarious 
fevers, etc., and by nearly all writers great prominence is given to the 
particular poisoning of the blood in these affections, as the chief factor 
in the causation of the convulsive fits which so often complicate them- 
While admitting that certain septicaemic conditions may not be without 
influence in producing the convulsive attacks, I believe that the simple 
elevation of temperature, accompanying these diseases, is sufficient, m 
most cases, to account for them. In this connection it is worthy of noto 
that those febrile diseases in which convulsions are common, are those 
usually marked by a high degree of temperature, although the specific 
poison in each may be quite different ; and that in other diseases, as 
smallpox, syphilis, and diphtheria, in which the blood-poisoning is very 
virulent, but the temperature not very high, convulsive seizures are 
comparatively rare. The experiments of Dr. Brunton prove that heat 
acts as a direct excitant to the heart, causing it to beat more frequently? 
directly as the elevation of temperature, and that cold has the opposite 
effect. These results are due to the influence of heat and cold upon the 
cardiac nerves, and from the extreme nervous irritability accompanying 
fever, as evinced by restlessness and liability to convulsions, it is fan 
to conclude that heat and cold act similarly on the cerebro-sj3inal sys- 
tem. While an elevated temperature causes increased frequency in the 
heart’s action, it weakens the force of its contractions, a fact that shouU 
not be overlooked in the administration of some therapeutic agents 
which, however useful under other circumstances, become highly dan- CONVULSIONS IN CHILDREN. 
797 
gcrous when the heart has become weakened from any cause. This is 
especially true of aconite, veratrum viride, chloral hydrate, and bromide 
°f potassium. 
From observations upon thirty cases, of which I have preserved notes, 
following propositions may be deduced; (1) That the nervous sus- 
Ceptibility of children under ten years of age strongly predisposes them 
convulsions; (2) that in children of that age a temperature of 103° 
vahr., and upwards, is very liable to excite an attack; (3) that the 
severity of the attack bears a direct ratio to the intensity of the fever ; 
(4) that convulsions are more liable to occur during the first few hours 
ef the pyrexial seizure, than at any subsequent period of its course ; and 
1°) that whatever reduces the temperature, modifies or arrests the con- 
vulsions. 
Regarding the first four propositions, few will differ, but while the 
may be generally admitted, there is great diversity of opinion as 
the best manner of accomplishing the reduction of temperature. The 
111 eans at our disposal may be classed as internal remedies and external 
applications; the former including veratrum viride, aconite, digitalis, 
Quinine, and salicine, with probably some others not as much used nor 
as Well understood, and the latter consisting of cold applications to the 
BUrface of the body. Most of the remedies of the first class exercise a 
Very depressing influence on the heart, and so are not applicable to these 
eases, quinine being almost the only one upon which any reliance can be 
safely placed. It generally happens, moreover, that in all severe cases of 
convulsions the child cannot swallow, and then remedies of the first 
class must be dispensed with altogether unless we resort to their adminis- 
tration hypodermically, a proceeding not warranted by the results ob- 
tained. 
Ror the antipyrexial action of quinine, veratrum viride, aconite, and 
ty.gitalis, I would refer to the experiments of Dr. Roberts Bartholow, of 
Cincinnati, which have been published in one of a series of clinical lectures 
edited by Dr. Seguin, of New York. From a study of the physiological 
Action and therapeutic influence of these remedies, it is plain that their 
rn°dus operandi, in reducing the temperature, is quite different from 
Cat of cold applied to the surface of the 
snlt is accomplished by interrupting the conditions which render rapid 
Cnemico-vital change in the capillary system possible; in the latter, it is 
accomplished by the simple abstraction of heat already generated. _by 
le former, it is accomplished slowly, imperfectly, and with gieat risk 
t° the patient; by the latter, the same is done rapidly, perfectly, and, in 
a least the great majority of cases, without risk. It is chiefly with the 
jew of illustrating the curative influence of remedies of the second class 
Dat X have ventured to ask your attention even for a few minutes. 
°r tliis purpose I have transcribed from my case book the following 
cases; 
Case I._— July 3, 1876. M. Arnold, two years of age, strong and well devel- 
i l>eck was taken suddenly ill last evening with dysentery and high fever which 
all night, and at seven o’clock this morning had a pretty severe convul- 
?!0n- At eight I saw him for the first time, and found the temperature 108° 
and the child restless. I gave a large dose of castoi oil, and also one-third 
a drop of tincture of aconite, to be repeated every horn while fever lasted. 
nother convulsion occurred at ten o’clock, and a third at half-past ten, when 
a-1 rived in time to check its violence with chloroform. At noon, the castor 
11 had operated well. At 2 P. M., convulsions returned, and continued for 798 
HOLMES, 
two hours with no intermission, although the patient w-as partially under the 
influence of chloroform during the time. At 4 P. M. they were as violent as 
possible, the temperature was 105° F., the pulse 150 and very weak, and death 
seemed imminent. I now put the child into a tepid bath, and rapidly cooled 
it to 50° F. by the addition of ice and iced water. At the end of ten minutes 
the breathing became easier, in fifteen minutes the temperature was 103° F-? 
and in twenty minutes it had fallen to 99° F., and the pulse to 110 beats pc1’ 
minute, I then dried the child and wrapped him in a blanket. He was very 
much better, but the breathing was still somewhat noisy and labored, and there 
were two slight fits during the first half hour succeeding the bath ; the tempC' 
rature also began to rise again, and had reached 101° when I again put him 
into the same cold water for five minutes. The temperature now fell to 
and the pulse in the same time to 100 beats per minute. The child slept 
naturally for half an hour, and awoke apparently quite well. There was n° 
return of fever, and no further treatment was required. 
One can scarcely avoid the conclusion that the convulsions in this case 
were caused by a high temperature alone. The previously healthy state 
of the child, the freedom of the alimentary canal from anything irritating? 
for the castor oil had acted thoroughly two hours before the most violent 
attack came on, the absence of any other appreciable, centric, exciting 
cause, and the almost instantaneous cessation of the convulsions when 
the temperature had fallen below 99°, all support this conclusion. 
Case IT.—Sept. 26, 1872. P. T., set. 8 years, was never ill until noon to-day? 
when he had a chill for a few minutes, followed by fever and convulsions, which 
still continued when I arrived at one P. M, His temperature was 106°, and 
his pulse 140, full, and regular. The attendants had just removed him from a 
warm bath and wrapped him in a blanket. It was impossible to get him t° 
swallow anything. lat once applied cold to the head, administered an enermb 
and put him under the influence of chloroform. This modified the violence of 
the spasms, but they returned immediately when the effects of the ansesthetm 
were allowed to pass off". The enema acted well, and the chloroform was con- 
tinued, but the temperature was unchanged, the pulse became gradually weakm 
and more frequent, and after three hours the patient died. As this boy ha*1 
been well until now, and as no other exciting cause could be traced, it is not 
unreasonable to conclude that the high temperature led to the fatal result. 
Case lll.—July 12, 1876, 10 A.M. C, S., a well-nourished male child, five 
months old, has had diarrhoea for three days, and the mother thinks fever also? 
but was not very ill until yesterday afternoon, since which time he has neithm 
nursed nor slept, but has constantly uttered half suppressed cries. The cbin 
is pak, the hands and feet quite cool, and the skin dry. Gave a purgative dose 
of rhubarb and soda. 
3 p. M. The rhubarb has acted on the bowels three times, the last evacuating 
having been quite natural in color. The hands, feet, and legs are quite cold ? 
the pulse almost imperceptible; the pupils not larger than pins’ heads; 
thumbs contracted ; the face pinched, and of a leaden hue ; and the thirst mos 
intense. The axillary temperature, to my surprise, was 105° F., for I had been 
deceived by the coldness of the extremities and the general appearance of fj10 
patient, and did not expect to find the temperature so high. I now gave tue 
child half a drachm of brand}-, and placed it in a tepid bath, adding water from 
the well until the whole was quite cold. In ten minutes the temperature fell to 
103°, and the child went to sleep for the first time in thirty hours. When 1 
temperature had fallen to 100°, I wrapped the child in a blanket, and he con 
tinned to sleep most of the afternoon and was not thirsty. As the temperate1 
fell, the pulse became slow-er and fuller, and the pupils larger. . 
BP. M. Temperature 103°, pupils natural; the child sleeps well and 100 v 
placid. Bath repeated, and temperature reduced in five minutes to 99°. CONVULSIONS IN CHILDREN. 
799 
13th, 10 A.M. Child rested well all night; nurses; temperature 103°. As 
e appeared quite easjq I merely ordered a dose of castor oil. 
. A. M. Child has had two severe convulsions in the last ten minutes, and 
ls insensible, and the temperature has risen to 1 Repeated the cold bath, 
an<l reduced temperature to when the child became quiet and slept. After 
the temperature never rose above 101°, the bath was not repeated, and in 
a few days the child was well. 
The coldness of the extremities and the weakness of the pulse in this 
ease made me hesitate before resorting to the cold hath, but as death 
Reined imminent, and as the axillary temperature was so high, I coll- 
ided that any other means would fail, and that some risk was justi- 
lt is remarkable that during the hour preceding the convulsions, 
he temperature rose from 108° to 105J°. I could cite a number of cases 
lesembling the three here detailed, halt of which would go to show the 
Superiority of the treatment by cold baths over every other, when the 
.enaperature is high ; and my friend and co-delegate here, Dr. Murphy, 
informs me that his experience with this plan of treatment entirely 
c°bicides with mine. 
Wliere other indications for treatment exist, as malaria, teething, 
accumulation in the alimentary canal, etc., it of course becomes 
Uecessary to attend to these also. In pursuing the plan I here recorn- 
[liei)d, I have always been guided by the thermometer, never resorting to 
hath when the temperature has been below 100°, and always removing 
tlie patient from the water when the axillary temperature has fallen to 
Uearly the normal standard of health. 
It is much better to have the water tepid at first, on account of the 
and alarm produced by sudden cold. I have not ventured 
7 use the cold bath in convulsions complicating pneumonia, my expe- 
tience being chiefly confined to those occurring in connection with 
ysentery, diarrhoea, cholera infantum, and malarious fevers. In these 
11§eases, when the fever is high, although there be no convulsion, I 
found no remedy that approaches the cold bath in its power of 
u laying nervous irritation and procuring quiet rest, and I am fully 
I'ersuaded that all who resort to this mode of treatment once, will do so 
u§aiu. 
Discussion on Dr. Holmes’s Paper. 
After the reading of the preceding paper, the President, Dr. Robert Barnes, 
• London, said:—Where there is an increased temperature in childieu, tneie 
)S alvrays some trouble with the blood, poisoning, or something e se, w uch 
eads to convulsions. The question is, what develops convulsion, what is the 
*Bt cause? It has been found that as the temperature rises, there is an 
liability to convulsions, and that as the temperature sinks, there is a 
cci'ease in this liability. Do we find that high temperatures always produce 
cuvulsions? In children, there is an exalted nervous irritabilty like that in 
Regnant women. Do they always have an increase of tempeiatuie . I have 
atehed cases in which there has been no rise whatever in uiaeraic convulsions 
ci scarlet fever, for instance. In simple pyrexia I believe that cold water 
aR be used to reduce the temperature; I have wiped the suiface of the body 
,lth it, and found it to act well. The cold water acts by evaporation, and 
°Rsequently reduces the temperature. The cold bath is a powerful remedy; 
s use by the Germans is a revival of a remedy first employed by Dr. Currie. 
r* Thomas F. Rochester, of Buflfalo, N. Y., said:—l have paid consider- 800 
HOLMES, CONVULSIONS IN CHILDREN. 
able attention to infantile disorders, and think I can corroborate the views 
advanced by Dr. Holmes in respects. The subject is one which requires 
more attention than is paid to it. The reduction of the temperature by water* 
I regard as more safe than by the use of drugs. In my own city there have 
been many children lost, during the hot season, from what is called summer- 
complaint, which is ascribed wholly to the elevation of the temperature, but 
this 1 deem an error. The thermometer rises to 90° or 100°, the sky is blue 
and the sun bright, and yet the mortality is not as great as it is when the 
atmosphere cools off. Some years ago we had, in my city, a hot, dry spell* 
with but little sickness among the children ; a hail storm came without any 
premonition, and at once infantile disorders set in. The diminution in the 
heat had caused the whole trouble. I have not examined the temperature 
before and after such atmospheric changes, but to me it seems conclusive 
that the fall in the temperature produces more diseases of children than the 
rise. I speak of convulsions as associated with the diseases of children, anti 
make my remarks only in that connection. 
Dr. Holmes, in reply, said :—I have lost a good many children from high 
temperature; and now think it well to reduce the frequency of the heart beats, 
for, as they become slower, the exhaustion lessens, and the beat becomes more 
forcible. My views are embodied in the short paper presented, and are based 
upon experience gleaned from my own practice. 801 
OVARIOTOMY BY ENUCLEATION. 
BY 
JULIUS F. MUSTER, M.D., 
professor of special and clinical surgery in the medical department op the 
UNIVERSITY OF BUFFALO. 
0 It is now about seven years since I announced to the profession that 
sio ri?n umors could be removed bJ enucleation, and invited my profes- 
j nal friends to make trial of the proposed plan, describing, as well as 
°uld, what I had done and the conclusions I had forraedp5 The idea 
c/at a tumor having such large arterial supply, could be removed without 
ligature, or cautery, though at first startling, received considerate 
ha entdon, and, both Li this country and in Europe", its successful results 
t -Ve led some of the most distinguished operators, not only to make 
]al of it, but to speak of it in high terms of commendation, 
h fom the numerous reports and papers upon the subject, I discover 
at the exact manner of enucleation is not yet distinctly understood; 
cvrM bave sP°heu of a clamp after enucleation, others have spoken of 
pj^lng, the very thing that is to be avoided, while others still have 
1 anted the detachment of the pedicle to two or three inches above its 
USe’ thus showing me that I have never been fully understood as to the 
e thod of removing ovarian tumors by enucleation, a plan which, my 
Perience convinces me, if properly understood and executed, possesses 
■yardages over aH others, and is of almost universal application. 
c 0 Is weH known that the ovarian tumor is surrounded by a peritoneal 
£ e,ring; that the pedicle, proper, usually divides into three or four parts, 
c;s"lng up over the walls of the tumor in bands of variable width, which 
llfi1 V 11 vesse^s’ often of large size, and which gradually diminish in 
and in the size of the contained vessels, until finally they are 
h ln thickened portions of peritoneal covering. The peritoneal 
is not closely attached to the cyst, but separates readily, just 
(p ,h<r peritoneum separates elsewhere in the pelvic cavity, being imme- 
Sjc| ev lined by the subserous cellular tissue; thus no vessels of any con- 
size enter the cyst. The tumor separates from its attachments 
ren 1 rernurkable readiness, so much so that, in several instances, it is 
ousi ! to have escaped the grasp of the operator and fallen spontane- 
Pi’o rom the pedicle, accident thus plainly indicating the natural and 
biebU' Method of removal.2 The capillary vessels thus broken do not 
bror ’bor the band contracts, and corrugates the larger trunks, while the 
* --off capillaries ooze a little for only a rainute or two, and a dry 
heb vll1’ applied for a short time, is all that is required. The fear of 
the ?rrbaSe is wholly unfounded, and I now say, without hesitation, that 
the (janoer of bleeding after this mode of proceeding is vastly less than 
anger of slipping of clamp or ligature, in other methods in which 
2 Bhim0 Medical and Surgical Journal, June, 1869. 
p. 212 tIS l Medical Journal, Nov. 26, 1870, p. 577; Braithwaite’s Retrospect, July, 1871 802 
MINER, 
the vessels are divided in their trunks. In this they are separated only 
in their extreme branches, and cannot give troublesome hemorrhage; it 
is seldom that any vessels are torn large enough to be seen as vessels or 
points of hemorrhage, and torsion is all that can be required in almost 
any case. If care is taken not to wound the vessels with either trocar, 
knife, or scissors, there will be no bleeding. 
The tumor being removed, the operation is completed; there is no 
clamp to be used, for there is nothing to clamp; the pedicle requires no 
attention except to be carefully handled, and to be restored, as nearly as 
possible, to its original place; if the usual conditions are present, no 
drainage is necessary; and the incision may be closed as accurately as 
possible. 
The bands referred to are to be grasped where they commence to 
diverge, raised from the cyst, and traced out to their terminations, often 
nearly around to the opposite side; the cyst is thus separated from its 
vascular supply, which is contained in these bands, other attachments 
being separated in the usual manner. Care must be taken not to wound 
or divide the vessels in their trunks, and, although the attachments will 
be found at points very strong, they can be forced off, or even with care 
a small piece of the cyst may be left attached to the pedicle, and no 
harm result, for it has a vascular supply, and is living tissue like the 
pedicle itself. 
The method of enucleation has the further advantage that if upon 
trial it is for any reason thought impracticable, a clamp may be still 
applied, or the pedicle may be cauterized or tied with a ligature just as 
well as if enucleation had not been attempted. Tew rules in surgery 
have no exceptions, and, though I believe that all ovarian tumors can 
be, and should be, removed by this simple method, supplemented when 
necessary by torsion or ligature to small vessels which bleed, still, to 
provide for all possible contingencies, I would assure the operator that a 
trial of enucleation is no hinderance to the subsequent adoption of any 
other plan that may be preferred, so that, while everything may thus be 
gained, nothing can be lost. 
The accompanying cut, from a drawing by Dr. Edward ~N. Brush, who 
has several times assisted me in operating, will give a very fair idea ox 
the procedure. The fingers of the operator are represented beneath a 
vascular portion of the pedicle, separating it from the walls of the tumor* 
This separation, as has before been observed, is to be carefully made, until 
the vessels are traced to their termination. To make the illustration 
plainer, the tumor is represented as raised from the abdominal cavity 
and supported by the hand of an assistant, but, of course, where extensive 
adhesions are present, this is impossible, and the risks of removal are 
greatly augmented. Formerly the operation in such cases was abandoned* 
When adhesions exist, they are to be separated, and the process continued 
to the pedicle. 
There is no need to point out the advantages of this plan. Those who 
have studied the history of ovariotomy, and who are familiar with the 
difficulties and objections which may fairly be urged against the ordinary 
methods of procedure, will at once perceive that, if enucleation is success- 
ful, there is no pedicle to keep open the lower angle of the wound or to 
drag upon the parts—no unfavorable adhesions of the pedicle, no wix’eS 
to be discharged by suppuration, and no crusts of burned tissue to oe 
provided for. The abdominal cavity has simply been opened, and the 
diseased part removed; all that is left behind is capable of life. OVARIOTOMY BY ENUCLEATION. 
803 
has been supposed that enucleation was designed exclusively for 
j^ses of extensive adhesion or short pedicle, in which no other plan could 
thus lessening the number of incompleted operations. Cer- 
a 11 y the method is adapted to such cases, but, instead of being reserved 
hi a resoui’ce, it should be chosen first, and the case regarded as most 
fr- orahle in which it can be successfully accomplished. My surgical 
iave seen °Perathm, unite in regarding it as the most 
eri..Ural surgical procedure possible. To see it, is to be convinced of its 
re lr.e feasibility and safety, while its advantages are too apparent to 
llllre a moment’s consideration. 
wing case first attracted my attention to this mode of treatment, 
invited to remove an immense tumoi; from the person of Mrs. Foster, of 
re.) araugas County, N. Y, It was of many years’standing, and had been 
tapped, but at length its contents became too thick to be drawn 
djjj. ll§h the largest sized cauula, and the patient’s distress too great for en- 
o°u The tumor was multilocular and very large, weighing, as nearly as 
out ii ae ascei'tained, almost one hundred pounds. It was attached, through- 
aud entire circumference, to the omentum, intestines, walls of the abdomen, 
Dot ll °ther parts with which it came in contact. These attachments were 
WasS° rin hut that they could be broken up, and, with great care, the tumor 
p)>ocSel)arated from the surrounding parts until the pedicle was reached. The 
eucon8.8 enucleation had been carried on so extensively and successfully that 
ia£ement was afforded for its continued trial; the pedicle was large, and 
fro"* ovei' a wide surface, but by gentle and patient effort it was separated 
Witp. s eu^re attachment to the tumor, and the immense growth removed 
°ut tlle use of a single ligature. The terminal branches of the vessels of 804 
MINER, 
the pedicle gave out no more blood than issued from the vessels of the adhe- 
sions, and none of them required ligation. All hemorrhage soon ceased, and 
the incision was closed by the interrupted suture. The success of this proce- 
dure was complete, and the patient for nearly two weeks did not present a 
single untoward s}rmptom, so that her recovery was considered almost certain- 
But she then began to lose her relish for food, grew weak and desponding, 
and died on the twentieth or twenty-first day after the operation. The fatal 
termination of this case detracts nothing from the success of this mode of treat- 
ing the pedicle ; indeed, so remarkable were the size and attachments of the 
tumor, that any attempt at recovery was surprising, and yet the feeble, emaci- 
ated, exhausted patient, continued to improve long enough to show that the 
manner of treating the pedicle was, at least in her case, unobjectionable. 
On the fourth of June, 1813, I was called, in consultation with Dr. Mixer, 
of Buffalo, to see a patient, aged twenty-three, in whom he had diagnosed an 
ovarian tumor. After careful examination, Dr. Mixer’s diagnosis was con- 
firmed, and an operation was decided upon. The patient had suffered from 
pain in the right iliac region for about a year, but had menstruated quite 
regularly, though not to the usual amount, and had not noticed any enlarge- 
ment of the abdomen until about six months previous to my seeing her, since 
which time the tumor had grown quite rapidly ; she had never been tapped. 
On Monday, June 11, I operated, assisted by Drs. S. F. Mixer, C. C. Wyckoff 
and son, E. K. Barnes, and E. N. Brush. Dr. Mixer administered chloroform, 
which was afterwards replaced by ether. An incision about four inches in 
length was made in the abdominal wall, when the tumor was found adherent 
to the anterior surface of the abdominal cavity for a circumference of about 
nine inches. The attachments -were carefully separated, but the walls of the 
tumor in this localit}' were so thin that it was accidentally ruptured, and some 
of its contained fluid escaped, whereupon a large trocar wras immediately 
plunged in, and the contents of the cyst evacuated. The mass was now lifted 
from the abdominal cavity, and the pedicle brought into view. It was found 
to be of medium length, and its vessels were spread out over the tumor. I next 
introduced my finger beneath the central portion of the pedicle, at its least 
vascular part, between it and the sac, and by gentle manipulation separated it 
from the cyst. Two vessels only bled sufficiently to attract attention, and 
these were easily controlled by torsion. All further hemorrhage soon ceased 
on exposure of the part to the air, and, the cavity of the abdomen having been 
sponged out, the pedicle was returned without the application of a single liga- 
ture or other mechanical means to prevent bleeding. The slight oozing of 
blood caused by the separation of the adhesions from the abdominal wall ceased 
spontaneously. The .wound was closed with the interrupted silver suture, sup- 
ported by adhesive plaster, and warm flannel cloths were applied with bandages 
over the abdomen. The tumor was multilocular, and weighed eighteen pounds- 
On recovering from the anaesthesia, the patient complained of nausea, and 
vomited frequently. One-fourth of a grain of morphia was administered by 
hypodermic injection, and repeated once in four hours, and the patient was 
also given brandy and beef-tea. The following is a report of her condition as 
I found it on seeing her occasionally with Dr. Mixer. The temperature was 
not taken. 
June 11, evening; pulse 120. 
June 18, morning; pulse 108; vomiting at night. 
June 19, morning; pulse 108; less vomiting. 
June 20, morning; pulse 98; no vomiting; slept well; urinated without the 
use of the catheter ; no swelling nor tympanites ; wound was healing rapidly- 
June 21; pulse 94; no symptoms of constitutional disturbance; slept and 
ate well. 
June 24 ; pulse 84, 
June 21; stitches removed ; patient well. 
During the whole course of recovery the patient declared that, with the ex- OVARIOTOMY BY ENUCLEATION. 
805 
Ception of the nausea experienced during the first two or three days after the 
°peration, she felt better than at any time just previous. 
The pedicle in this case was of medium length, but too short to admit 
T' its being brought out of the wound and secured by a clamp, without 
dragging upon the uterus, especially if any portion of it had been taken 
aWay with the tumor, as is the case when it is severed by the knife in 
the ordinary mode of performing ovariotomy. The vessels of the pedicle 
tVere large, and could be felt to pulsate plainly ; and it is doubtful whether 
fevering these with the cautery would have controlled the hemorrhage. 
and metal ligatures have been employed successfully in many cases, 
Prid have been left in the cavity of the abdomen without producing any 
I'l effects. Their employment, however, leaves within the peritoneum 
foreign substance, which in most cases cannot but produce more or 
less inflammation, and any method which will allow the return of the 
Pedicle to the abdomen, free from sources of irritation, must meet with 
approval. The question has been asked: “Can the pedicle be easily 
Separated from the tumor?” In the case just narrated, the separation 
accomplished with as great facility as attends the separation of cys- 
tic growths from surrounding parts in other portions of the body, and 
bras easier, in fact, than was the detachment of the adhesions from the 
aMominal walls. 
. krof. Logan, of the Medical Department of the University of Loui- 
sa, in a" private letter, speaking of an operation which he had per- 
fumed for the removal of an ovarian tumor, the solid portion of which 
Weighed sixteen and a half pounds, says:—“ I was surprised at the 
lability with which the enucleation was effected not a single vessel of 
Efficient size to throw a jet of blood presented itself, and no ligatures 
irere, of course, required.” In this case also, there was a rapid conva- 
escence, with not a single bad symptom. > 
Upon these and similar facts is based the suggestion that the pedicle 
Caih in ovariotomy, in some cases at least, be separated without ligature 
cautery, thus avoiding many ot its dangers. At first, this pioposition 
111 ay appear startling, and surgeons who have tied large vessels in the 
operation, or who have witnessed the fearful hemorrhage which some- 
.bßes takes place from the slipping of the clamp or ligatures, may legaid 
U With some surprise, and may perhaps, without trial, look upoip it as 
lolly impracticable ; I should myself, probably, hold such an opinion, 
„ad X not paci tpe opportunity of demonstrating to myself its entire 
feasibility. 
. An ovarian tumor is generally composed of a firm dense cyst, contain- 
fluid of varied color and composition. It may, or may not, have a 
s°lid portion, but usually it does have more or less of a body, the rem- 
lla,it of an enlarged or degenerated gland. Upon the surface of this 
is spread out the vascular, fibrous, cellular, and othei tissues which 
compose the pedicle, but only the terminal branches of the vessels enter 
he cyst wall; the vessels may be quite large at their origin, but soon 
ey are numerously divided, and enter the cyst, if at all, only when of 
Papillary size. The attachment of the pedicle to the cyst is more easily 
. 10ken than any one would imagine who had not tried the experiment 
the manner described, and I am confident that the same efforts which 
nia(lc to break up the adhesions to the peritoneum, omentum, and 
°ther parts, would, if extended to the pedicle, many times be equally 
Suceessfuh 806 
MINER, 
If this method can he adopted without hemorrhage or other difficulty, 
its advantages are apparent. The pedicle can then be returned to the 
abdominal cavity without any of the objections which have been urged 
against this procedure. There is no ligature to be discharged by ulcera- 
tive process, or to become encysted, or to induce inflammation. There 
are no purulent or inflammatory products to be in any way removed of 
provided for ; the pedicle is wholly living tissue, and has no irritative 
qualities which render its return to the abdominal cavity 
My object will have been wholly accomplished if the feasibility of 
enucleation in ovariotomy has been shown with sufficient clearness to 
insure a trial of the method by other surgeons. 
Discussion on Dr. Miner’s Paper. 
After the reading of the preceding paper, the President, Dr. Robeb? 
Barnes, of London, said:—l am glad to hear the paper, as I was the first to 
introduce the method of enucleation into England. I think it a good method, 
but it cannot wholly supersede other modes of dealing with the pedicle. 111 
some cases, enucleation is the only mode of removal practicable ; but these 
are exceptions to the rule. I must say that Ido not share Dr. Miner’s 
dread of leaving silk and silver ligatures in the peritoneal cavity, for I have 
frequently seen them left there without mischief. I have also seen the per- 
chloride of iron used to sponge bleeding points left after the sundering of 
strong adhesions, and without any of those formidable results which some 
writers attribute to its passage through the Fallopian tubes after intra-uterine 
injections. In ovariotomy, the great thing is security against hemorrhage; 
and that, I think, is best gained by the use of the clamp or the ligature. The 
operation of ovariotomy demands still more study than has been given to it, 
and I congratulate Dr. Miner upon having very materially added to the stock 
of knowledge regarding it. 
Dr. James P. White, of Buffalo, said:—l am cognizant of twenty or thirty 
cases in which enucleation has been used. It is not a very difficult operation, 
but in some cases it is impossible—for instance, where the growth of the 
tumor has been rapid and the pedicle is short and large. In these cases, the 
cyst cannot be safely enucleated. I have no doubt, however, that enucleation 
is often the best method of treating ovarian tumors, but the subject merits » 
great deal of study and consideration, and the cautery, the clamp, the ligature, 
and enucleation, all deserve attention, and should be severally used according 
to the special indications of individual cases. 
Dr. E. R. Peaslee, of New York, said:—We should not confine ourselves 
to any one method of treatment in the removal of ovarian cysts. Nor is 
enucleation always feasible. In some cases, short and large vessels enter into 
the cyst directly from the pelvis, and do not become capillary. In these, 
enucleation will not answer, because it cannot arrest the hemorrhage. Such 
an instance I have met with, and the patient bled to death. Again,"owing to 
the thinness and the friability of the cyst-wall, it will sometimes break 
before the adhesions can be broken up. But I feel under great obligations to 
Dr. Miner for introducing this method, for I have removed tumors by enucle- 
tion, which I am confident could have been removed in no other way. 111 
most cases the ligature can be used, and I then see no particular advantage to 
be gained by enucleation. But I would adopt it in cases of cysts adherent to 
the liver. lam myself inclined to the use of the ligature, which I genera fly 
cut close. As I have only once seen the pedicle slough, I do not share Pr* 
Miner’s fears on that score. 
Dr. G. Kimball, of Lowell, Mass., said:—l have tried enucleation but once? 
but believe that I might have saved some lives had I known of this method OVARIOTOMY BY ENUCLEATION". 
807 
earlier in my practice. I feel very much indebted to Dr. Miner for his sug- 
gestions on this subject. Dr. Keith’s great success has been obtained with 
D*e cautery, and I think that the profession is still at sea as to the proper 
Method of dealing with the pedicle. I myself generally use the clamp, but I 
adapt the treatment to the particular case. 
Dr. White said:—As a rule, I prefer cauterization, because it leaves fewer 
foreign bodies in the cavity of the abdomen; and I am sure that, in my 
Practice, I have seen as many children born from women who have lost one 
°vary as I have lost cases of ovariotomy. I think that the treatment of these 
tumors should be eclectic, and that each case should be separately studied with 
a view to its treatment. 
. Dr. Alexander K. Simpson, of Edinburgh, said :—ln regard to the applica- 
tion of the cautery, Dr. Keith has used it very successfully; personally, lam 
ready to use any method that the case may demand. The great strength of 
Dr. Keith lies in the thorough preparation of his cases, and in the care which 
he takes with them. There is always a difference in operators, and Dr. Keith 
does not consider minutes wasted that will prevent hemorrhage into the peri- 
toneal cavity. 
Dr. Theophilus Parvin, of Indianapolis, said:—Enucleation is of use 
Vdien the pedicle is too short for the clamp. I have had two cases: one 
implicated with pregnancy was attended by considerable hemorrhage. This 
I checked by the application of flannels dipped in hot water. In such cases I 
can recommend hot water, and I referred to the same agent in the discussion 
of yesterday on uterine hemorrhage. I think, contrary to Dr. Miner’s state- 
ment, that it is settled that there is no peritoneal coat to an ovarian tumor, as 
there is no peritoneal covering to the ovary itself. Enucleation is of value 
V'here there are peritoneal adhesions, but I believe that it can be very often 
dispensed with by the use of hot water. I recognize its advantages, but do 
V°t think that it is the only treatment for ovarian tumors. 
Dr. Miner, in reply, said:—l agree that possibly in some cases enucleation 
*ay not be of service, and that torsion, the ligature, and even the cautery may 
have to be used. But in ordinary cases of ovarian tumor, I deem it to be a 
Plain piece of surgery ; and I have myself never seen a case in wuc i ic cys 
could not have been removed by enucleation. Where theie is iee ing, 16801 
f° torsion; but enucleation does not interdict the subsequent use o ie c amp, 
ff>e ligature, or the hot iron. 808 
THE TREATMENT OF FIBROID TUMORS OF THE UTERUS. 
BY 
WASHINGTON L. ATLEB, M.D., 
.OP PHILADELPHIA. 
In opening the discussion on The Treatment of Fibroid Tumors of the 
Uterus, a question that has for many years engaged my attention, it wiH 
be imposssible to present the subject properly in the short space of time 
allotted to me; and I must, therefore, ask your indulgence if, in adhering 
closely to the text and compressing my material, I should fail in satis* 
factorily elucidating the several points in this paper. 
I beg, also, to premise that, in bringing this subject before the Section 
on Obstetrics, I shall not go into the detail of every method of treatment- 
This I think would be out of place before an assembly of such enlight- 
ened men, who are already familiar with its written history. I shah 
merely refer to my own experience. Every gentleman, who will engage 
in this discussion, has an experience of his own, and if each one win 
bring his personal contributions, able architects of our profession wih 
rear a structure out of these materials which no individual could erect 
from his own observations, and which will stand as a lasting memorial 
of this day’s work. In this way we will be likely to arrive at the best 
practical results for the benefit of Science, Art, and Humanity. 
My methods of treatment have been surgical and medicinal. In the 
use of medicine I have principally confined myself to iodine, ergot, and 
muriate of ammonia. Many years ago I lost faith in iodine, and 
seldom use it, and only as a local application. As early as 1845,1 intro- 
duced the use of ergot in the treatment of uterine fibroids, and have evet 
since employed it. In proof of this I may refer to ray essay on Fibrous 
Tumors of the Uterus, published in the Transactions of the Americau 
Medical Association for the year 1853. Ergot, no doubt, acts in two 
ways in influencing the nutrition of fibroids of the uterus: (1) on the 
muscular tissue of that organ, and (2) on the capillary circulation of tbe 
tumor itself by contracting its smaller vessels. Notwithstanding thd 
action of the medicine, I have never been so fortunate as to see a fibroid 
quietly disappear under its sole influence, although in many cases the 
size has been diminished, while in others-no effect has been produced- 
The reason of its variability in action may be explained in the course oi 
this paper. Recently, Hildebrandt has introduced the hypodermic use 
of ergot, and with results, in his hands, quite extraordinary. I cannot* 
however, conceive how this agent can accomplish more by its subcutane- 
ous employment than by its administration by the natural passages. H 
certainly acts more promptly through the cellular tissue. But it is ques- 
tionable whether this increased speed of action is a sufficient compensa- 
tion for certain inconveniences to the patient from this mode of ds 
application, as well as for the greater tax on the time, convenience, and 
patience of the medical attendant. 
In the consideration of the treatment of uterine fibroids, it must also 
be kept in mind that spontaneous cures may result in consequence <d FIBROID TUMORS OF THE UTERUS. 
809 
degeneration; that diminution in the size of the tumors is often 
observed in advancing age, through senile atrophy of the muscular fibres; 
oiat fibrous induration sometimes occurs, the muscular tissue becoming 
scarcer as the connective tissue hardens, and that this induration is fol- 
lowed by calcification and an arrest of growth. 
With these preliminary remarks, I will proceed to discuss the subject 
treatment more definitely. In doing so understandingly, it will be 
Necessary to keep in view the relative position of the tumor with the 
uterus. Hence I will make the somewhat arbitrary division into the 
following heads: 
I- Tumors usually accompanied with hemorrrhage, embracing (1) 
bbroids occupying the vaginal canal; (2) fibroids within the cavity of 
uterus; (3) interstitial, submucous fibroids; (4) interstitial fibroids 
Proper; (5) recurrent fibroids. 
. 11. Tumors usually not accompanied with hemorrhage, including (1) 
interstitial, subperitoneal fibroids; (2) sessile, peritoneal fibroids; (3) 
pedunculated, peritoneal fibroids; (4) interstitial, cervical fibroids; (5) 
Myomatous degeneration of the uterus; (6) fibro-cysts ot the uterus. 
I. Tumors usually accompanied with Hemorrhage. 
T (1) Fibroids expelled from the Cavity of the Uterus, or occupying the 
paginal Canal—The treatment of these tumors will vary according to 
their size. "When small, with a slender pedicle, the tumor may be 
gasped as high as possible on its neck by means ot Luer s polypus for- 
?eps, or a similar instrument, and twisted off, or, in other words, removed 
W torsion. _ . 
When larger, with a pedicle not thicker than a finger, it may be seized 
a,]d brought down with some force so as to stretch the pedicle, which 
P?ay then be severed at as high a point as possible with Coopei s heinia 
istoury, or a probe-pointed bistoury properly wrapped and piotected. 
When quite large, distending the vagina or filling up the pelvis like 
head of a child, a small obstetric forceps may be applied to it, and 
then placing the patient under the influence of an anaesthetic, with the 
Assistance of supra-pubic pressure, the tumor may be gradually biought 
hr°ugh the os externum. Having accomplished this, one or se\eial 
P,ans may be adopted for the purpose of detaching it: (a) By means of 
the bistoury the proper coat of the tumor may be severed all around, about 
aa inch or so beyond the insertion of the pedicle, and then the upper end 
the tumor enucleated from its peduncular attachment, if) the sub- 
stance of the pedicle may be directly severed by the knite, (c) the 
pedicle may be divided by the ecraseur. I have used all these methods, 
ai)cl it is best to be prepared for either operation, as the surgeon must be 
governed by the circumstances of each case. When it can be acconi- 
Pished, I prefer the first method, or that by enucleation ot the peduncu- 
ated end of the tumor. , 
Immediately after the removal of these large tumois we should use a 
tampon, charged with persulphate of iron or other efficient haemostatic 
?bd antiseptic, adapting it well against the amputated stump, and allow- 
it to remain from twenty-tour to forty-eight hours. Ihe raw and, 
Usually, inflamed surfaces should afterwards be treated through the 810 
atlee 
condition Bulta,:>le applications until they are brought into a normal 
m^wf/HT4108? that-1 haV? not referreillo the ligature as one of the 
ablation of thcTtumorf BmCe abandoned this Plan- Paring immediate 
m ioiufZnLKf-Wltn the Camty °f the Uterus.—The treatment of 
tibronls inclosed within the cavity of the uterus must depend somewhat 
on their size and locality. When large and of long duration, havino- dis- 
-1 chilli hi fhdyioVhe UtIrUS/nd dllated the cervix as does the head of 
,-? d 111 the last m°oths of gestation, an examination by the finger 
will discover a mere uterine ring, through which by firm pressure, ]> 
he detl^Jt^hemhC.oUnte7c^ed by supra-pubic support, a tumor within W 
fibroid whfphThlln° d°U )- f tbe eon(lltl°n precedent to the first form of 
fAlic T hiaiVtCmSldered,and the laPse of time in all probability 
It i« w should hold out, would accomplish the same state of things- 
imStfZ+T' alwa^8 Safe t0 wait’ but safer to facilitate measures by 
processes of nature. To make the tumor more accessible, 
1 should be dilated by the usual means, and at the same time 
T t0 excite and maintain the contraction of the expol' 
siye fibres °f the organ, and in this way also aid in opening the uterus. 
instead o using dilators to open the os uteri, the action of ergot ma}f 
fiist be established, and afterwards the tense edges of the os may be 
nicked wfih a bistoury, thus successively dividing the circular fibres, and 
accomplishing the object in much less time. As soon as the mouth of 
the womb is sufficiently expanded, a small obstetric forceps may be intro- 
ohd? aTd aPPlied to tho tumor in the same way as it is to the head of » 
child, fraction should now be made on the tumor under the influence 
of an anaesthetic, and if the circular fibres, as will probably be the case, 
should resist its escape, the bistoury must be employed until all resist- 
ance is overcome, and the tumor is brought into the cavity of the vagina 
it is now in the position described under the first head of our subject, 
and may be managed accordingly. 
. fhm’e is, however, a very important difference between a tumor pass- 
fr?m th® uterus mto vagina spontaneously and one brought 
?ie. yiole.nce, and that difference involves a very grave practical 
point 1 his will be at once apparent when it is stated that in the former 
case the tumor alone occupies the vagina, and that in the latter it is very 
apt to be accompanied by an inverted uterus. This is particularly liable 
to occur when the pedicle is attached to the fundus. Usually too, in vagi- 
nal fibroids, we find a moulded and elongated pedicle which is readily 
and safely managed, but in the tumors under consideration the pedicle is 
usually sessile, and affords but small space for any surgical appliance. 
Hence, the inverted fundus uteri is in great danger of injury and muti- 
lation, and unusual care is required in amputating the tumor. I believe 
the safest mode is to enucleate the upper portion of the tumor from its 
proper coat, and thus free it from its uterine connections. Of course, after 
ns is done, the inverted uterus should be at once replaced after proper 
styptics have been applied to the raw surface, and the case treated upon 
general principles. 
These fibroids, however, are not always as simple and as easily 
managed as has been just described. From some cause or other the tumor 
may have formed adhesions to the surface of the uterus, independent of 
i s original, peduncular attachment. These adhesions may be so situated 
as to interfere materially with the dilatation of the os uteri, or with the FIBROID TUMORS OF THE UTERUS. 
811 
introduction and application of the forceps. It is necessary, under these 
circumstances, as soon as they are recognized by the finger, to sever them 
with the bistoury until the surface of the tumor is free. It, in consc- 
ience of such adhesions, or of a lateral origin of the pedicle, the ordi- 
nary forceps cannot be applied, Museux’s forceps, or appropriate hooks, 
niay be substituted to seize and bring down the tumor after the os uteri 
i§ sufficiently dilated. . 
Besides the fibroids referred to, there are other tumors in the cavity ot 
the uterus which are entirely concealed, and, either from their diminutive 
size or a very adipose abdomen, cannot be detected. The cervix uteri 
may be intact, and there may be no bulging of the uterine wall recog- 
nizable by the finger in the vagina. Yet the symptoms may be so diag- 
nostic of their presence that we are bound to be governed by them alone. 
11l such cases we must dilate the. cervical canal by sea-tangle, sponge 
tentg etc until we are able to pass the index-finger and explore the in- 
terior of the uterus and get access to the tumor. The dilatation must 
now be carried further, so as to admit, in addition to the finger, the 
necessary instruments for the removal of the growth These are usually 
a strong, slender forceps, or hook, and a long-handled, probe-pointed bis- 
toury, or a probe-pointed, semicircular knife. A small wire ecraseur. 
Passed above the forceps, will answer the same purpose. If the tumor 
lave a small pedicle, it may be removed by torsion. . • 
(3) Interstitial Submucous Fibroids.—These are tumors which, originating 
in the wall of the uterus, develop mainly towards the mucous surface, 
like the two preceding forms, they more urgently demand the surgeon s 
/• . F rsf wwino- uterine hemorrhage. When the 
attention m consequence of in awnnt » body h 
CerviX is not implicated in this class <di iuiuuib,t riqnrtino- 
Uterus alone is involved, it is best not to be too precipitate . ■ 
ms aione is uxvuiveu, hemorrhage can be controlled, 
to surgical means for relief. As ong as 5 • di - ’ 
and blood saved to the patient, it is best to depend upon tl: 
nniployment of ergot and other remedies, ra ei j walls on 
ous use of the knife. A tumor thus situated, with 
one side of it and a mere mucous covering on the ot ' “ bed 
favorable condition for ergot to gradual y exp t f u accom’ 
and force it into the uterine cavity, and, m prop uterine 
Plisbed, we secure the aid of all the longitudinal fibres ■ot the uteune 
in propelling the growth .against the 
Jpd in causing a gradual opening of the °s uteri w j 
this form of tumor to the second variety beloie c j , and faml 
If, however, exhausting hemorrhages canno must be adopted 
threaten, other tt 
The os and cervix should he well dilated, so | the surface 0f the 
of the uterus, and to be able to co adminis- 
nmor. As soon as this is done efficient dosesi of ergot mu 
vd* WhGn TitS af°n 18 ftSefthand should be passed up flat- 
W* ttfth eutenYasffi'usf g a sound, over the of the 
so as to slit open both 
its mucous covering and its proper coat, burying the well in the 
fibrous mass Ind carrying it downwards until it makes its exit at the 
lower border of the tumor. As the knife passes through the dense tissue, 812 
ATLEE, 
a decided grating is perceptible. It is a remarkable and interesting fe?1 
that, if hemorrhage have existed before this incision, it will cease after m 
has been made, and it will sometimes be found that when nothing else 
will arrest hemorrhage, a free use of the knife will accomplish it. Inl' 
mediately after the section, an attempt should be made to enucleate tbe 
tumor from its bed, which can often be accomplished if the tumor he 
not too massive. Should it not be removed at once, it is apt soon f° 
become disorganized and dead, throwing off a very offensive, dirty? 
watery discharge, and endangering septicaemia. Ergot must be con- 
tinued, to maintain the contraction of the uterine tissue, antiseptic? 
administered by mouth, lungs, and vagina, and the patient sustain6*1 
until the tumor is removed by the surgeon, or is discharged in a soft' 
ened mass resembling wet tow. The danger to be apprehended aft6l 
this operation is blood-poisoning from dead matter. This is very much 
diminished when the tumor is removed by one operation, but, even then? 
the extent of raw surface remaining after the tumor is taken away, some- 
times causes toxasmic symptoms. 
(4) Interstitial Fibroids Froper.—These are tumors which originate 
deeply in the substance of the uterine wall, and during their growth aim 
development are surrounded by a pretty uniform coat of uterine or mus- 
cular tissue, neither impinging on the mucous lining on the one side u°r 
on the peritoneal covering of the organ on the other. As a general rule? 
the demand for active treatment in these cases is not as great as in the 
submucous varieties. These intra-mural tumors, however, are the very 
ones most amenable to the mode of treatment that has recently claimed 
the attention of the profession, viz., the hypodermic use of ergot. I cap 
understand how the tonic contraction induced by ergot can impede nuti’1' 
tion in a tumor so located, but I cannot conceive how absorption coin*1 
be promoted under a similar amount of compression obstructing the 
absorbent vessels. In the treatment of interstitial fibroids I think i 1 
best to use ergot periodically and not constantly; employing it in anti- 
cipation of and during the menstrual periods, and associating with it the 
continuous use of an alterative sorbefacient, such as muriate of ammo- 
nia. If ergot acts mechanically in destroying the life of a tumor, them 
when that is accomplished, the stress or pressure should be removed, so 
that this dead matter may be absorbed. As long as this dead material 
is hermetically encased in living tissue, unaffected by atmospheric inflU' 
ences, it is not likely to become offensive or toxic, and may be carried on 
by the absorbents like other molecules of dead matter in the regular pr°' 
cesses of repair, without infecting the general system. As there is*1 
tendency for fibroids to increase in size before each menstrual period, ill 
consequence of the greater determination of blood to the organs of gene- 
ration, so there is a diminution in their size after menstruation subsides- 
Hence ergot is calculated to act beneficially, when given in time, irl 
arresting this supply of blood to the tumor; and yet we must not ahvaj78 
attribute the diminution in size, which usually follows menstruation, 
the influence of ergot, as it is a natural physiological sequence. 
These interstitial fibroids often assume a great size, and in doing s0 
stretch the cavity of the uterus to an unusual length, increase the vascu- 
larity of the organ and the size of the vessels pervading.the correspond' 
ing mucous covering, and, during the menstrual period, these unsupported 
vessels are rendered turgid and congested, and, giving way, produce copio°s 
and dangerous hemorrhages. When this is the case, and danger cannot be 
averted by medication, surgical means are demanded. A bold, free m°1' FIBROID TUMORS OF THE UTERUS. 
813 
C throu£h the rnuco-muscular envelope of the tumor, and through its 
hv coat’ burying the knife into the fibroid substance, will be attended 
of arrest of the bleeding. This may be followed by an enucleation 
Sam 6 tumor—the several steps of the subsequent operation beino- the 
ae as detailed under the head of Interstitial Submucous Fibroids? 
the BtlmeS tlie interstitial bbroid, even when very small, may produce 
most violent symptoms, both local and reflex, leading even to death; 
ola ITlay be so situated that, under certain circumstances, its existence 
T not be suspected, and that, even if correctly diagnosticated, it could 
be removed by any ordinary operation. This is particularly the case 
been the.tumor orlginates m the lateral part of the fundus uteri and 
ernes mtra-ligamentous. Such cases, fortunately, are extremely rare, 
pro q l]l endeavorto Castrate them by the detail of one which recently 
Phi] G‘ S’’ aged 34 years’ was brou»ht from the interior of the State to 
Bivpielphia’ and Placed under my care. She was small irf stature, but exces- 
siiff c°rpulent, particularly in the abdominal wall. For a long time she had 
Co ered. the greatest agony and distress, and had had frequent and most violent 
lvulsions. All the symptoms were distinctly traceable to the uterus. There 
teV? decided endo-metritis, and the slightest touch of the sound would cause 
hi sPasms- There was also extreme tenderness confined to a small spot 
toj e hypogastric region, on the right of the linea alba, so that she could not 
re]eiate 4,10 most gentle pressure. The treatment during the winter of 1814-75 
the endo-metritis and several of the reflex symptoms, and, although 
i'e» • d not billy convalesced, she went home with the expectation of gradually 
li baming her health. But she again became worse, and her husband, an intei- 
t fcent physician, conducted the treatment, but without controlling the symp- 
tfis* I visited her several times during the winter of 1875-76, and I never 
a greater sufferer. The spot in the hypogastrium was the point of trouble. 
gee bad not been able to lie down for months, and the right thigh was kept 
a Xe(l all the time. Her suffering was so constant and intense that both she 
tj u her husband begged me to open her and remove the womb. She required 
p.e c°nstant use of the most powerful anodynes to afford the least comfort. 
Wly symptoms of cerebral congestion supervened, and in a few days after, 
ab ] . twenty-third of March last, death came to her relief. In exposing the 
h cavitjr after death, about four inches in thickness of adipose tissue 
Cav‘ t0 be Penetrate(b The uterus was enlarged and highly congested. Its 
In ti?7 as three and a half inches long. The lining membrane was normal, 
in pl 6 laSht wall of the fundus was an interstitial fibroid, not over two inches 
lanieter, surrounded by a dense wall of uterine tissue, and so closely adhe- 
hal 4o?ts capsule that it could not be shelled out or enucleated. The capsule 
Ca[ eviflently been in a state of inflammation, and this was thought to be the 
>se °f the intense and fatal suffering. Both openings-of the Fallopian tubes 
le obliterated. 
p .11 reference to this interesting ease I wish to state that I had ap- 
t the very day on which I witnessed the post-mortem examination 
Vlsit the patient to decide upon the feasibility ot extirpating the 
by 6^8" In consequence of the extreme amount of abdominal fat, as shown 
cal i e examinatiou, this would have been very difficult, it not irnpracti- 
ho '6* or 4be same reason it was impossible to make a correct diag- 
°f the case, and the fibroid discovered after death was not at all 
rbad>eCted 4o exaßt before. Of course the case might possibly have been 
the ? °Ut by the barbarous practice of exploring with the hand through 
rectum. If such an extreme case were again to present itself to me, 814 
ATLEE, 
particularly in a thin patient, I should think it my duty to remove the 
diseased organ. 
(5) Recurrent Fibroids.—The recurrent fibroid is polypoidal in charac- 
ter, and is supposed to be reproduced, after its removal, from the sanie 
pedicle. These cases are very troublesome, because, after one tumor ft 
removed, there may be repeated recurrences of others, resembling 111 
this respect, and in this only, the several forms of malignant disease- 
The operation for their removal is the same as for that of the ordinary 
uterine polypus, but, as this is a much more grave trouble, I wish 
submit to the Section a proposition embracing more extensive surgical 
interference. This proposition is based upon the treatment of two cases 
of very great interest, which I beg permission to relate. 
In the first case I removed eleven successive tumors, after which the 
patient recovered and had no return. 
On December 27, 1860, I visited Mrs. T. W. S., aged 31 years. Menstrua- 
tion for the first four years was small in quantity and free from pain, but after- 
wards was accompanied with extreme agony during the first day. She married 
at the age of 24 years, in one year after gave birth to a child, and had a mis- 
carriage afterwards. The menses were regular, having only missed the hist 
period. In April, 1858, she first discovered something wrong in not being able 
to pass water. A large quantity was drawn away by the catheter, which opera- 
tion had to be repeated. Several physicians saw her, and diagnosticated mpl' 
position of the womb, and very violent efforts were made to restore it to ft® 
normal position, but without effect. June, 1860, she had a sudden attack 
severe pain, which so entirely disabled her that she could not walk for several 
weeks, suffering much of the time with the most dreadful bearing-down pains- 
After a period of intermission the expulsive pains again returned with extreme 
violence, and, on November 28, 1860, while using the catheter, she felt a 
tumor in the vagina which she supposed to be the womb. The pain now dimin- 
ished, but the size of the tumor gradually increased, and it finally protruded 
through the os externum. During the above period she had copious discharge8 
from the vagina of bloody clots and a greenish, slimy, and offensive fluhb 
changing usually about twenty-five napkins in a day. 
When I saw the patient she was perfectly blanched and anaemic, with a small 
thread-like pulse, and evidently in a state of toxicohsemia. A tumor, as large 
as a small adult head, protruded from the vagina, and was lying between the 
thighs. It was in a gangrenous condition, and gave off' a most offensive odor- 
The index finger, passed into the vagina in front, came against the anterior hP 
of the os uteri about two inches up. It was stretched across the front face ot 
the tumor, which was continued into the uterus as far as the finger could reach- 
The sound struck the fundus uteri one inch above the anterior lip. The vagina 
behind the tumor was also explored. A cul-de-sac was reached at the distance 
of one and a half or two inches, formed apparently by the inverted vagina 
coalescing with the tumor. The growth had clearly been developed in the p°s" 
terior wall, and had been extruded by the uterine efforts from the cavity °* 
the organ. The circulation was still maintained in the posterior portion o 
the mass. The pedicle was about two inches thick. With the assistance o 
Drs. Drysdale and Burpee, I removed the mass by means of the ecraseut- 
Although much decomposed, its weight was one and a quarter pounds. 
several weeks the patient continued to be very ill with septicaemia fever, bu 
finally fully recovered. _ , 
April 17, 1862, the patient consulted me again, stating that she had remained 
well until three months before, when she had had a copious puruloid discharge 
and that one week before seeing me another tumor had begun to protrude, bin 
examination, I found that the relative positions of the tumor and uterus were 
now different. The former, instead of being behind the os tincse, was anterior to 
it, and the expanded posterior lip could be distinguished in the hollow of the FIBROID TUMORS OF THE UTERUS. 
815 
in second tumor increased to a considerable size, and was removed 
Pop-n fS^me way' the same time a har(l tumor was felt occupying the hy- 
folW T1regl°n* A few Weeks after the removal of the second tumor it was 
hVnZ. by a third’ which was also taken away. A mass still occupied the 
Jugastric region. 
the n following December she was taken with excessive hemorrhage, requiring 
the v!- the Itampon- Subsequently quite a large tumor was expelled from 
the f" glnla’ and at tbe same time the supra-pubic tumor disappeared. This, 
the n Vth tumor’ WaS reraoved b-fthe ecraseur on the 9th of January, 1863, and 
tD*r?tl(in™ followed b3r a raPid recovery. June 1, 1863, another large 
tu |he Mth\ was removed in the same way. Januarv 21, 1864. the sixth 
of tless ln size> was removed. I could plainly trace this one into the cavity 
terin Uterus’ and the anterior lip of the 08 stretched over it, the sound en- 
HizJf anterior to the mass two and a half inches. At the same time I recoo-- 
the 1 a hard turaor in the riB‘ht inrf amal region. August 24, the same year, 
quenfi nth tumor was removed. Ihe eighth, ninth, and tenth were subse- 
avv *Uy removed up to the 20th of May, 1866. The eleventh tumor was taken 
Ch • °.n tbe of August, 1867, with the assistance of Dr. J. Nicolaysen of 
Dstiania, Norway, now Professor of Surgery in the University of Norway. 
ler this no tumor could be detected anywhere. J 
kev i 6r tbe e^eventh operation there was no return, and the patient regained 
health, at least for two or three years, after which I lost sight of her. 
{.• reviewing the above case—its extraordinary features, its lono’ dura- 
n,its imminent perils, and its almost endless recurrence—the question 
aas °Den presented itself to me: Would not extirpation of the uterus at 
early period have been not only justifiable but preferable? 
question also of great interest—the pathology of the so-called Recur- 
v!] djr°ids—might be discussed with profit, but this is not compatible 
our present subject. Both questions will be in a measure involved in 
j ® detail of another case, which I think would have exhibited the same 
ire res as that above narrated, but which was terminated quickly and 
c Ppily by a different mode of treatment:— 
fol°n May 15, 1874, Mrs. C. T. was brought from the interior of Pennsylvania 
ye treatment. She was 30 years of age, had first menstruated at the age of 14 
for 1S’ and bad continued to be regular until her marriage in 1870. Two years be- 
and ri'air^age she began to suffer from a burning sensation in the pelvic region, 
i'ia dorn bearing-down pains, which gradually grew worse. Soon after mar- 
SeCj became more copious, and, eighteen months after, she was 
she^t( whh great pain, accompanied with excessive flooding. Subsequently 
feri Was confined almost constantly to bed by copious hemorrhage, intense suf- 
tra.ng’ and constant nausea and vomiting. She had never conceived. Pros- 
t')011’ e*naciation, and anaemia were very strongly marked, 
full /e U^erus was enlarged to the size of a four-months’ pregnancy, the cervix 
tlie ‘T expanded, and the os, round and ring-like, merely admitted the point of 
puWldex Auger. A hard, smooth tumor could be felt within. I immediately 
typ , lG.r °n the use of iron and ergot, but, notwithstanding, she had an over- 
tjje miug attack of flooding and pain. By the 22d of June the condition of 
ope Patknt and of the os uteri was such as to warrant me to proceed with an 
iuto ay|011. Assisted by son, Dr. W. Lemuel Atlee, I introduced a forceps 
Pati 16 CavitT °f the uterus, and, grasping the tumor, made traction while the 
cieii?iNt Was under the influence of an anesthetic. As the os was not suffi- 
dt f °pen to allow the tumor to escape, it wTas nicked by the bistoury as 
Vaoig lten.ed over the descending mass, which finally was delivered into the 
ec^Ula tvith a sudden slip, and afterwards through the os externum. The 
PediS?%r >Vas now aPpbed, but, proving to be faulty, was removed, and the 
was severed by the bistoury. While preparing for this part of the 816 
ATLEE, 
operation, I was struck with what appeared to be an unusual elongation of 
the pedicle, which was dotted over with several molluscum-like bodies. Ap* 
prehending that this might be the uterus itself inverted, I was careful to make 
the section close to the tumor. Im mediately afterwards I tamponed the vaghlfl 
with strips of muslin wet with Monsel’s solution of iron. 
The operation was followed by intense pain, and in the course of two or 
three hours by hemorrhage, which was controlled by removing the first tarapo11 
and substituting small sponges. There were also incessant sickness and vomit- 
ing, which, the patient said, always followed the loss of blood or the use of 
anaesthetics. These symptoms were subdued by opiates in the course of twenty- 
four hours. The pulse increased in frequency, and the case looked rather 
alarming, Next day the sponges were removed, an examination was made, and 
a rough, irregular, tumor-like mass still occupied the vagina. I could not divest 
myself of the apprehension of its being an inverted uterus. The parts were 
so very tender that a satisfactory examination could not be made. This sore- 
ness continued for eight or ten days. 
The regular menstrual period came on the first week in July, accompanied 
with very little pain and a moderate discharge. On the 13th I repeated the 
examination, and found the same state of things. The os grasped the tumor, 
and a sound passed up entered the uterine cavity the normal distance of two 
and a half inches. From this examination I inferred that there was no inver- 
sion, and that there still remained a portion of the original tumor. Pressure 
over the pubes did not enlighten me. Perhaps a finger in the rectum would 
have disclosed the true state of the case. I seized the body with a strong 
double tenaculum, brought it partially through the os externum, applied the 
ecraseur, and on working the instrument found the tissue unusually 
requiring much force and time in getting through it, and indeed having to finish 
the operation with the knife. On examining the mass, after its removal, I was 
surprised to find it to be the body of the uterus. 
[The specimen was then exhibited. The mucous surface was dotted over with several 
small tumors in different stages of development.] 
Great pain and sickness of the stomach succeeded the operation as before 
but did not last so long. Much less bleeding accompanied the 
and none followed it. The patient had a rapid and excellent recovery, grew 
fat and hearty, and, with the exception of slight coccyodynia, has been in the 
continued enjoyment of perfect health. Menstruation has not occurred since- 
The speculum reveals a perfect os tincse, and the sound enters only one inch* 
Although the treatment of the above case was ultimately conducted 
on an error of diagnosis, does it not teach a valuable practical lesson ? li- 
the history detailed to you this day explains and illustrates the patho- 
logy of the so-called recurrent fibroid of the uterus, and if each abnormal 
body on the surface of the womb is liable to be successively developed 
into a life-endangering tumor, will not the amputation of the body or the 
entire removal of such a diseased organ be the best mode of treatment 
keeping in view the comfort and life of the patient? 
IT. Tumors usually not accompanied with Hemorrhage. 
(1) Interstitial iSubperitoneal Fibroids.—These are tumors having the 
same relation to the serous coat of the uterus as the interstitial subm11' 
cous fibroids have to the mucous coat. They are imbedded in uterm6 
tissue except where they present towards the abdominal cavity, and there 
they are covered only by peritoneum. Their locality renders them much 
less serious in their consequences to the patient, and does not call so FIBROID TUMORS OF THE UTERUS. 
817 
imperatively on the surgeon for interference. Still, circumstances might 
arise in which relief would he demanded. Treatment in these cases will 
accomplish a oreat deal, either with or without reference to an ultimate 
Slll'gical operation. I have just hinted at the action of ergot in the sub- 
mucous fibroids. It is the same, in an opposite direction, in the sub- 
Peritoneal tumor. The tendency of any foreign body, when actedupon 
h the contractile efforts of uterine tissue, will be towards the point o± 
least resistance. Hence ergot, acting forcibly on the muscular substance 
of the uterus, in which the fibroid is deposited as in a closely-fitting nest 
covered merely by a delicate serous membrane, must, as a necessary re- 
sult, gradually diminish the bed of the tumor, and as gradually cause the 
mass to encroach upon the abdominal cavity. I have no doubt that nature 
Wself sometimes converts this kind of tumor into a sessile or even pe- 
dunculated fibroid. And hence, by following her teachings, by means of 
ei’got we are able greatly to aid her in accomplishing such results, bup- 
f°sing, however, that this result has been reached, the tumor has not 
been destroyed nor diminished, but only changed in its locality, for I 
vcry much doubt whether ergot has influenced its growth in this situa- 
tion. Still our patient has been benefited by relieving a very sensitive 
aM irritable organ of a troublesome tenant, and by placing the tumor m 
a Position more accessible to the resources of surgery if the case should 
rilttemtlttal subperitoneal fibroids, it be prions 
to invade them by the knife from the interior of the uteius, and in this 
atte™V* t^e'^enuc B^g^s^^ehabarr^rIto1to protect 
pdlCrlkria"ZSbeing entered. which 
fetalresolts. 
rh °?eu *l6 cavlty of tiie a „ Vnifp and enucleate the mass from its 
dlvule its peritoneal coat with the knife, < , d be secured 
muscular bed. Should bleeding occur, the vessels readily b^secured 
J? they are in ovariotomy, and to guard again » carefully placed 
lons in the abdominal cavity a siphon-diain 1 same time 
S* brought out of the lower angle ofof^"mofand 
deemed necessary, a communication bet ®th h the cervlcal 
be cavity of the uterus could be made, and t insist in carry- 
P«al with the vagina, and a siphon introduced so as to a^slst i y 
"Set fluids also in that direction. These precautions would go vc y 
ar in preventing septicaemia and fatal inflamma ton. , t bodily 
, (2) Sessile Peritoneal Fibroids-These are tamor. whrel 
S*?,the abdominal cavity but are l,£|'deep™ Mo the 
* the uterus, and have a broad base. They * cavity. 1 They may 
vterine tissue itself, and do not elongate tl • t but the same 
e removed in the same way as the A ut^ne bed which 
1 ecautlons need not be exercised with & uliar]y formed tube 
reives the tumor. Indeed, in both| va h £hePcietached coats of the 
tUnSIVer’ &dass, or hard rubber, aro , secured with one end in the 
herilo^ec?uld be fastened or liga et,» carried out of the lower end 
offo tUmT’ Wlnl? pi 6 as a siphon in drawing off the fluids, 
or L abdominal wound, daction ©Antiseptic washes from with- 
as a conductor for the intioducmu T Inrmpnprl tUp d™in 
ut- By the time the ligatures should have become loosened, the diam- 
a§e tube could be removed, and a fistulous track would remain to fill up 
aml heal by granulation and cicatrization. 
52 818 
ATLEE, 
In cases of ovariotomy, when complicated with small sessile fibroids 
I have not hesitated to enucleate them before closing the incision, being 
careful, if there were any oozing, to carry a tent from the raw surface to 
the lower angle of the wound. 
(3) Pedunculated Peritoneal Fibroids.—These are fibroids having a dis- 
tinct pedicle, either membranous or myomatous, attached to the exterior 
surface of the uterus, and contained within the cavity of the abdomen* 
These tumors, being beyond the limits of uterine action, are not usually 
influenced by the use of ergot, but do sometimes yield to the sorbefacient 
action of muriate of ammonia uninterruptedly maintained for a long 
time. If they fail to yield to medical treatment, and induce such sever® 
symptoms as to destroy personal comfort or jeopard life, they may b0 
removed, as are ovarian tumors, by abdominal section, and the pedicl® 
secured by the clamp or ligature. The operation need not be described* 
I may, however, remark that, in proportion to the size of the tumor, the 
incision through the walls of the abdomen must necessarily be larg®1* 
than that required by ovariotomy, and that the pedicle will need nioi’e 
careful attention. Should the pedicle be short, we can add to its length 
by incising the proper coat of the tumor around its base, two or tin’®0 
inches beyond the stem, and shelling it oft' and making it part of the 
pedicle. I have several times removed these tumors in this way. 
(4) Interstitial Cervical Fibroids.—These tumors occupy the vagina, bn 
are not ejected from the cavity of the uterus, and consequently are n<ft 
pedunculated, and are not capable of being treated in the same way gS 
uterine polypi. They are surrounded by7 the tissue of the cervix, and ai’e 
imbedded within it. When small, resembling a bullet submerged in tb® 
7 m O o 
cervical structure, a simple incision carried through the tumor, so as £ 
bisect it, will often be sufficient to lead to its decay and destruction. rbo 
make its disorganization more certain, the surfaces of the cut fibroid naaY 
be touched through the speculum with a pencil of vegetable caustic or 0 
potassa-cum-calce ; or, better, the small mass may be entirely enucleated b}r 
the point of the finger after opening its capsule. When the tumor is lai’go’ 
swelling out a portion of the cervix to the size of a walnut or an orang®’ 
it will be necessary to make a free slit in its envelope and enucleate tb® 
mass at once. These tumors are so accessible to the finger that this pr°' 
cedure can readily be accomplished, provided their capsule has nev®r 
undergone inflammation. In all of these cases the vagina should aft®1' 
wards be kept carefully cleansed by antiseptic washes, and the inflamm®' 
tion of the cervical mucous membrane, which usually7 accompanies th®s® 
tumors, should receive proper treatment. 
(5) Myomatous Degeneration of the Uterus.—The uterus sometimes seer®® 
to be overwhelmed with fibroids filling up the interstices everywhere, a®0 
even to harbor at the same time every variety of tumor heretofore ®°rl' 
sidered. When such a condition exists, it is not to be expected tb® 
medicinal means alone will be of much use, nor can the surgical trea ' 
ment of each, individual, diseased mass be contemplated, but if 
is to be done, it must be the entire extirpation of the affected organ. & 
these cases cannot always be clearly diagnosticated, the surgeon must n 
prepared to vary his original course of action during the progress of all 
operation. He may commence with the expectation of removing only ® 
pedunculated fibroid, or even an ovarian tumor, but will sometimes en 
by extirpating the entire uterus and its appendages. I will relate tn 
following case:— FIBROID TUMORS OF THE UTERUS. 
819 
g,^n August 8, 1815, I visited, with Dr. Kurtz, Mrs. J. A. D., of Reading, Pa. 
r eyas 44 years old, had menstruated 'at 15 years of age, and had always been 
egular. When 21 years old she had married, and had had two children, and 
ri€j miscarriage between them. In 1812 menstruation had become more free, 
Ilc' in the summer of 1814 she had had two or three attacks of bleeding during 
e menstrual intervals. In 1812 she had first noticed a tumor in the right 
s>l°in. it was hard and movable, and fell over on turning her body. For 
''° years its increase in size had been gradual, but during the last twelve 
.. olAhs very rapid. As the tumor enlarged, her general health failed, and she 
apiclly emaciated. 
At the time of my visit, the abdominal enlargement was equal to that of an 
pregnancy. It was irregular in shape. There appeared to be two 
mnors, or one with a deep sulcus dividing it. The mass was hard, but slightly 
Dstic, and upon the left side of its fundus there was a harder knob the size of a 
i amut. The two lobes were movable on each other. The uterus occupied the 
a(A part of the pelvis, admitted the sound two-and-a-half inches, and was not 
. 11 ch influenced by manipulating the abdominal growth. While the sound was 
the uterus, I discovered still another and much harder mass in the superior 
‘ mit of the pelvis, which I diagnosticated as an intra-mural fibroid, but had 
°me doubts in consequence of the abdominal enlargement having masked the 
lamination. The diagnosis was obscure, but I inclined to the opinion that 
m abdominal tumor was pedunculated, and hence rather favored an operation. 
, jA® patient’s health continuing to fail, she solicited relief. September 1, 
p (5, I visited Reading, and met Drs. Kurtz, Brooke, Ulrick, Dundor, Kuhn, 
.°hlentz, Cleaver, Weidman, Brodhead, and student Ellis Kurtz. The divi- 
®l(m of the tumor had now disappeared, and the mass was more consolidated. 
n incision seven or eight inches long was made below the umbilicus through 
Wry attenuated abdominal wall. On exposing the tumor, the characteristic 
, ahogany color at once disclosed its uterine nature, and further examination 
eloped its real character: fibroid degeneration of the bodjr of the 
lei’e being no adhesions, the whole mass was easily rolled from the cavity of 
llle abdomen. The body of the uterus was now found to be occupied by intra- 
Ural fibroids, while the cervix was normal. Both ovaries weie seated on the 
°Wer portion of the enlarged uterus; the right one being healthy, and the left 
IA8 tic, and as large as a walnut. A strong needle was now armed with a double 
Mature of strong plaited English silk cord, and with it the ceivix uten was 
Aai)sfixed just above the insertion of the vagina and below the oyaiies. Each 
*§ature was securely tied on its respective halt of the cervix, and each 
as again made to encircle the whole cervix and firmly secured. The tumor, 
, ollsisting of the uterus and both ovaries, was now cut away, leaving a huge 
. l)tton beyond the ligature. To make it doubly safe the stump was embraced 
1 Atlee’s clamp, and maintained outside. The cervical canal was plainly seen 
p tlle face of the cut pedicle, into which a probe was passed about three-eighths 
Pan inch, and a finger introduced into the vagina entered the os tmere and 
p(! the grasp of the clamp. The return circulation of the tumor, which 
®CaPed on excising it, was prevented from entering the abdominal cavity by 
°tecting sponges. The wound was closed with iron-wire sutuies. Ihe patient 
a(le an excellent recovery, and now enjoys good health. 
■hi considering the propriety of extirpating the uterus by abdominal 
ection, we must judge each case by itself. The condition of the pelvis, 
aguia, and cervix uteri, is of primary importance. It the cellular tis- 
K is indurated in consequence of inflammation or other cause, or the 
agUia shortened and rigid, or the cervix occupied by fibroid deposits, it 
p 1 not be a case favorable for operation. If, however, the pelvis is free 
°ni morbid deposits, the vagina long or extensible, and the cervix in a 
JArnal state, the chances of life may be considered almost equal to those 
°variotomy. 820 
ATLEE, 
(6) Fibro-cystic Tumors of the Uterus.—The fibrocystic tumors of f^e 
uterus, as far as my observations go, are developed upon the exterior snl' 
face of the organ, and are usually pedunculated. They are constitute01 
of fibrous tissue, and are more or less cancellated in structure, and ill 
consequence of their greater impressibility are called soft fibroids in coU' 
tradistinction to the hard tumors heretofore considered. They grow so#16' 
times to an enormous size. These tumors, in my opinion, are entirely 
beyond the influence of ergot, while they seem at times to be control!60 
in their growth by muriate of ammonia. I have had no experience 111 
the treatment of uterine fibroids by means of galvanism, but I should sup' 
pose that this would be the kind of tumor most amenable to such an agent- 
There are, however, surgical means, both palliative and radical, which 
have employed with benefit. The palliative treatment consists in pen 6' 
trating the abdominal wall with a long, large-sized trocar and canula,thru3 
into the centre of the tumor, withdrawing the trocar and passing a strong 
sound through the canula, and with it breaking up the interior, cancellated 
structure in every direction, and drawing off all the fluid possible. Usually 
after such a proceeding the tumor will diminish in size to a considerably 
extent. The operation, at proper intervals, may be repeated. As thj 
treatment is original with myself, I must ask permission to illustrate 1 
with a case:— 
On April 22, 1868, I was consulted by Mrs. A. E. S., of Washington Oh}’ 
D. C. She was 42 years old, had commenced menstruating at 14 years of agc’ 
and had been married at the age of 17. She had had three children, tb® 
jmungest then 18 years old. About four weeks before seeing me, she had beel| 
seized with very acute pain in the right groin, which lasted for twenty hours, ai 
was only relieved by strong opiates. This was followed by an enlargement 0 
the right side. She was a fine, healthy-looking lady, disposed to corpulenc}’ 
and exhibited no unusual abdominal prominence. An elastic, cyst-like, smoot 
tumor was detected occupying the hypogastric and right inguinal regions, 
rising above the umbilicus. It was at that time diagnosticated to be an ov‘a' 
O O 
rian tumor, and she was advised to let it alone. 
September 24, 1868, she consulted me again. The abdomen then was v 
much larger than that of a woman at the full period of pregnancy. It 
smooth, elastic, compressible, semi-fluctuating, and of uniform shape. rfhe 
uterus was normal in size, and movable, independently of the mass. In co'11 
pany with Dr. David Burpee, I passed the large trocar into the tumor bel°' 
the umbilicus, but no fluid escaped. The sound was then introduced throng1 
the canula, and passed round in several directions. It was very evident that 
manipulating with the sound many fragile septi were broken up, which 
to be the walls of cells containing fluid. Two or three gallons of fluid, stain6 # 
with blood, were removed in this way, and it coagulated on exposure to 
The operation was followed by no unpleasant symptoms, and afforded Sr,e 
relief. Up to this time the case is reported in detail in my work on the DUb? 
nosis of Ovarian Tumors, page 285. Subsequently the tumor was 
the same way at distant intervals three times, and each time with benefi61® 
results—the last being in March, 1871. I saw the patient in November, UUj 
when her general health was good, and her size very much diminished, althoug 
the tumor was still there. During all this time she had used the muriate 0 
ammonia internally, and the combined treatment had had a very happy effect o 
her condition. Letters from her assure me that she still remains in conrfiff 
ble health, that the size of the tumor is not nearly so great, and that its tn 
ther development is probably arrested. 
I have treated other cases of fibro-cystic tumor of the uterus in th® 
same way with similar results, but have never entirely cured them tv FIBROID TUMORS OF THE UTERUS. 
821 
hese means. In one case, I cut up the interior structure with a small 
vl|ife introduced through the large canula, and afterwards injected acetic 
fCI(T This was followed also by a decided diminution of the tumor, and 
I no unpleasant consequences. 
The only radical cure for these tumors I believe to be extirpation. In 
heir removal, the surgeon must keep in mind their peculiar pathological 
1 Rations with the uterus and with the peritoneum, as these differ mate- 
tiully from those of ovarian tumors. As far as ray observations have 
£°ne, the fibro-cystic tumor originates from the wall of the uterus at the 
Junction of the cervix with the body, at or just below the point where 
peritoneum is reflected from the uterus to form the recto-vaginal 
?Ulde 
-sac. As the tumor enlarges it raises the pelvic peritoneum above 
and, dissecting it from its natural attachments, elevates it into the 
cavity far above the pelvis, so that a real peritoneal cul-de-sac 
surrounds tire enlarged tumor between the umbilicus and pubes. 
tumor now is covered by a peritoneal coat above, wlrile its pelvic 
P°rtion is free from peritoneum. The reflected peritoneum, therefore, 
like a coronary ligament in binding the lower portion of the tumor 
the pelvis. To illustrate the operation, I will relate the case of Miss 
S., acred 57 years. The same case is detailed for another purpose in 
tlle work referred to above, page 279, but the manner of operating is 
fitted 
.On June 5, 1868, in the presence of Drs. Mitchell, Brinton, Thompson, and 
[wen, and assisted by Drs. Drysdale and Burpee, an incision seven inches in 
eilgth was made throimh the linea alba down to the tumoi. my hand 
trough the incision, I "found the tumor to be adherent to the abdominal wall; 
. llt these adhesions were readily broken up. I now particularly explored the 
Interior of the left side, in the previously ascertained locality of the elevated 
Utei’us, but soon encountered an additional tumor, resembling an hypertrophied 
fpeen and filling up the whole left side from the hypochondnum down into 
fhe iliac fossa. In carrying on the investigation downwards, over the large 
*Un?or, my band was interrupted in its descent by a cul-de-sac of reflected 
extending around the tumor midway between the pen 1 IGlis an 
and firmly fixing it in position. It was, therefore, plain that the fundus 
Jf tumor was covered by a coat of peritoneum which had been lifted from 
le pelvis by its development upwards. The membrane was vascu ai am nc i- 
I next cut boldly into the tumor, in the line and to the extent of the ex- 
dual incision, and, passing my hand into the gap thus made, io Te up e 
interior of the mass, freeing it of one or two gallons ot yellowish fluid, 
bch coagulated on exposure to air. After thus reducing ® slze 0 16 
I succeeded in shelling off' the whole peritoneal coat, to which were at- 
defied several folds of intestines, and by this means relieved it of all pomtsot 
JJtachment in the abdominal cavity. The entire mass was now readily dis- 
rated and turned out of its bed. It was found to be attached by a ibious 
cdiele, an inch to an inch and a half thick, to the uterus on ie ng 1 SK Gi a 
rp Point between the insertion of the vagina and tliat of the u enne pen oneum. 
]• e pedicle was short, almost sessile. It was transfixec )} as 1 on» cop [ e 
gature, which was tied both ways and also encircled the whole pec ic 
Hio1’ was then excised, so as to allow a large button beyond the igature. 
Ihe remaining tumor now presented itself at the opening. _ sprang from 
16 Posterior surface of the left broad ligament just where it joins the posterior 
of the uterus. The Fallopian tube coursed along m front of the pedicle, 
Wrapped around it, and its fimbriated extremity rose up on the tumor, and 
ias attached to it. Several adhesions to the walls of the abdomen were 
ai'°kefi upi and the tumor was turned out. The pedicle was very short, but 
as clamped, the Fallopian tube being included, and the tumor was removed. 822 
ATLEE, 
The abdomen was afterwards carefully cleansed with soft sponges, as well as the 
pelvis, which was nothing but a raw surface having no peritoneal lining. Tb® 
right ovary was found to be healthy, the left being absent and evidently in' 
volved in the small tumor. A large amount of loose peritoneum, which had 
been removed from the large tumor, now occupied the lower portion of tbe 
abdominal cavity. It had contracted very much, and appeared more thickened- 
It was allowed to arrange itself. The uterus was enlarged to more than twice 
ts normal size. On its anterior wall was a small sessile subperitoneal fibroid- 
I opened its capsule, enucleated, and removed it. 
The clamp was arranged across the middle of the wound, the ligated pedid6 
in the lower end, and five wire sutures were introduced above and five below the 
clamp ; the fundus uteri occupying a position-against the interior surface of the 
wound between both pedicles. Several ounces of blood were lost, but not suffi' 
cient to affect the pulse. One vessel was controlled by torsion, and one by silk 
ligature, cut short and dropped in. The large tumor was fibro-cystic, weighing 
thirty-five pounds. The small one was an ovarian fibroid, and weighed ovel 
five pounds. The patient made an excellent and rapid recovery, and is now m 
the enjoyment of perfect health. 
In presenting this subject for discussion, I am aware that I am op6ll 
to criticism for having made such an arbitrary subdivision of fibroid 
tumors of the uterus. It is, however, apparent that this has been don6 
for practical reasons. A much simpler classification would have been 
into subserous and submucous, or extra-muscular, and interstitial °r 
intra-muscular. But as the question to be considered was the treating 
of fibroids, I preferred arranging these tumors as we find them 111 
patients, so as to make the paper purely clinical and practical. 111 
making the above division, it must not be inferred that each case can 
be classified under one or other head, for several or even all forms cl 
fibroids may be present at the same time. According to my observation? 
however, the intra-muscular tumor is most likely to be solitary, whil0 
the extra-muscular is more frequently multiple. 
As a consequence of the limited time allotted to this paper, and which 
has already been exceeded, I have viewed this subject only from a p61*' 
sonal stand-point. In omitting to mention the various modes of treat' 
ment of which I have no experience, I mean no disrespect or di spa rag 6' 
ment to any of my medical brethren, who, perhaps, may have had better 
success than myself. These methods, it is hoped, will be stated by then’ 
advocates. With regard to the use of one agent, which has recently 
been extensively used, I may be excused for repeating that I commenced 
the use of ergot in 1845 in the treatment of fibroid tumors, and havo 
continued to employ it beneficially ever since. I have, also, for many 
years, used muriate of ammonia alone, and in connection with ergot? 
and with such results as have satisfied me of its value. The dose is ten 
grains three times a day. A solution of one drachm to one pint 
water is used twice a day as a wash to the abdomen and to the vagina 
and an apron of silk oil-cloth is worn next to the skin. Neither patient 
nor physician should tire in its use, using it for months and even yeai’9? 
if the tumor does not disappear. lam satisfied that it often arrests tb6 
growth ; so does ergot. It sometimes causes its entire disappearance ? 
I have yet to see this result from ergot alone, except in mechanically 6*' 
polling polypi. It sometimes fails to produce any appreciable results; 9° 
does ergot. I attribute the influence of muriate of ammonia to its alter01' 
tive, resolvent, and sorbefacient power, as well as to its alkaline properties* 
I am well aware that the remedial power of muriate of ammonia has been FIBROID TUMORS OF THE UTERUS. 
823 
denied on the ground that inflammatory or plastic deposits have been 
Mistaken for fibroids. I do not pretend to possess any more diagnostic 
than others, but the same remark will apply to all other remedies 
ail(I to all other persons. Even if it accomplishes so much under an 
eiTor of diagnosis, it certainly is a great boon to suffering humanity. 
I now present the following propositions, which will throw the whole 
Object of treatment open to discussion;— 
I- Fibroid tumors of the uterus, although frequently unaffected by 
treatment, are sometimes cured, and often controlled in their growth, by 
Medicinal and other agents. 
11. Fibroid tumors of the uterus which are entirely harmless to the 
Patient, should never receive surgical treatment involving the least 
danger. 
111. Extra-muscular, submucous tumors usually demand surgical 
treatment. 
IV. Hemorrhage, caused by a fibroid, uncontrollable by other means, 
Aay be, and should be, arrested by the knife. 
V. In the surgical removal of fibroids, it is of the greatest importance 
V extirpate the living tumor. 
Vi. When the living tumor cannot be removed, as is usually the case 
the capsule has undergone inflammation, antiseptics must be dili- 
gently employed. 
. VII. Extra-muscular tumors of the subperitoneal variety, when involv- 
es health and life, should be removed_by abdominal section. 
VIH. In cases of recurrent fibroids, it is justifiable, under certain cir- 
Cumstances, to amputate the inverted uterus, or to remove the organ by 
abdominal section. 
IX. lii exceptional cases of uterine fibroids, extirpation ot the uterus 
V abdominal section is warranted. 
X As a general rule, in all cases of fibroids which destroy the cora- 
°l't of a patient, or hazard life, and are not amenable to othei tieatment, 
sbi'gical interference is to be commended. 
Discussion on Dr. Atlee’s Paper. 
After the reading of the preceding paper, the President, Dr. Robert Barnes, 
of London, said:—This is a very important subject, and one upon which we 
lle«d all the light possible to get. We need not care so much about the suc- 
eessful cases as about the failures, and also the reasons tor the failuies. he 
should not rush into an operation when there is no hope ot benefit, fiom the 
distinguished physicians present, I think that some ideas may be developed 
lil a surgical way that will be of use to humanity. . , . „ 
+l Dr. JohN L. Atlbe, of Lancaster, said :-I believe that abdominal section for 
tlle removal of fibroid tumors has been decided upon as a necessity in some 
Cases. I once met with a case in which the enlargement of the abdomen was 
equal to that of an eight months’ pregnancy, and was hard on the light side. 
J diagnosed an ovarian tumor. Two days afterwards the operation was per- 
Armed. On opening the abdomen I encountered a dark-brown cyst, such as 
A had never noticed in cases of the kind. I drew oft six pounds ot fluid, 
J’Ach looked like an infusion of coffee-grounds, and succeeded, with some dif- 
"unity, in surrounding the pedicle with a clamp. n examining the tumor, 
f f°und it to be of unusual character, and uterine. It weighed, in addition to 
Ve six pounds of fluid drawn off, about as many pounds of a solid mass, 
hemorrhage had occurred in the tumor on one side, and had bent it over the 824 
ATLEE, 
uterus until it was of a half-moon shape. I confess that I was disappointed 
in my diagnosis, but the patient did well. If through an error in diagnosis 
I was successful in removing such a tumor, I do not see why it is not a legitl' 
mate operation to perform abdominal section for fibroid tumors, as well as 
in ovariotomy. In another case there was an ovarian cyst on the right side? 
and a subperitoneal uterine fibroid weighing six pounds on the left. Both 
pedicles were included in the same clamp, and the woman did well. 
Dr. Alexander Dunlap, of Springfield, Ohio, said:—The treatment of fibroid 
tumors is now on trial before-the profession. I have been watching the ques- 
tion for thirty years, and ray experience does not entirely coincide with that 
of the author of the paper which has been read. Many tumors require n° 
operation at all, for after attaining a certain size some disappear, while others 
stop growing, and give us no further trouble. I think that if the mind be 
withdrawn from the diseased organ, in nine cases out of ten the tumor will 
remain quiescent and give no annoyance. I have known of cases in which the 
tumor was as large as a uterus at full term, without giving much inconve- 
nience. Fibroids often cause hemorrhage, a thing to be guarded against- 
I have found that ergot contracts the muscular coat, and cuts off the source ot 
blood from the tumor. I differ also as to methods of operation. Dr. Atlee 
uses the knife to remove the tumor; I prefer the ecraseur, because it prevents 
hemorrhage. In some cases enucleation is effective, but I have lost two cases 
from want of proper drainage, septic inflammation having supervened. I 
would propose a new method of dealing with the pedicle in cases requiring 
the removal of the uterine tumor. This consists in dissecting the peritoneum 
off of the lower half of the tumor, and in removing the latter by the ecraseuf 
very close to the os internum. Strong silk threads are then passed at various 
points through the edge of this cup-shaped peritoneal covering. Next the 
cervical canal of the uterine stump is dilated, and a small speculum introduced 
per vaginam. Through this the ends of the silk threads are passed, and the 
peritoneal coat is drawn by them through the uterine canal into the vagina* 
Thus no raw surface can remain within the abdominal cavity, for the stump 
covered by peritoneum, and all discharges become external. In some cases ot 
hemorrhage I have found it of advantage to lay the patient on an inclined 
plane, with the head low down, so that the tumor can be pressed from the 
pelvic into the abdominal cavity; the proceeding is very easy in these cases- 
I have never been able to stop the growth of a tumor by ergot, but it is ot 
use in checking hemorrhage. 
Dr. G. Kimball, of Lowell, Mass., said:—l concur in the opinion of Dr* 
Dunlap, that these tumors should be let alone, except when it is absolutely 
necessary to use the knife. They sometimes disappear spontaneously, and it 
requires good judgment to tell what cases need operation. Such as do not 
involve the vagina or the neck of the uterus are the only ones that can be 
operated upon. A surgeon would be almost guilty of homicide who should 
attempt an operation in some cases in which the fibroid fills the vagina and 
invades the cervix, and in which hemorrhage would inevitably result, for there 
would then be no pedicle which could be ligated. In one case I removed the 
womb on account of a sessile subperitoneal fibroid, and secured the pedicle 
with a silk ligature the ends of which were brought out externally. F°x 
eighteen months the ligature ends remained in situ, and then disappeared in- 
ternally, as the patient averred. Instead of the ligature I now use the wire 
ecro,seur, which I fasten externally by adhesive straps, after searing the stump 
with the hot iron. In this manner lam able to control all hemorrhage with- 
out having much of a pedicle left. Very few cases authorize extirpation o 
the uterus. I have seen good results from ergot, but none from the muriate o| 
ammonia in subperitoneal fibroids. But one of my cases got entirely wen 
after using for a year intra-uterine injections of a solution of eight grains d 
iodide of potassium in an ounce of water. 
Dr. E. K. Peaslee, of New York, said;— Fibrous tumors should be consi- FIBROID TUMORS OF THE UTERUS. 
825 
c erecl apart from other tumors. They either produce hemorrhage or they do 
0l,5 and this depends greatly on their site. When there is no hemorrhage Ido 
ll°t consider that we have any right to interfere. In the treatment of these 
growths, I have used the muriate of ammonia with good effect, but I do not 
hink that we can expect much from ergot, except in cases of interstitial tumor. 
I might, possibly affect the uterine muscles, and cut off the nutrition of a sub- 
bmitoneal fibroid, but I have little faith in most of the ways suggested for its use. 
ivould reject the use of ergot entirely except in cases in which contraction 
as an absolute necessity. There is no hemorrhage so great that it cannot be 
stopped for a time, and this time is important, as it gives a chance to think 
the case really needs a surgical operation. Women very rarely die 
lQtn hemorrhage in these cases, but more frequently from septicaemia. In 
mdinary cases of hemorrhage I give ergot in combination with the tincture of 
le ferric chloride. In severe cases I introduce a tent into the cervix, and keep 
lin situ by means of a vaginal tampon. When septic symptoms show them- 
®*“'ves, I consider repeated, intra-uterine, disinfectant injections as of para- 
j °Unt importance. I regard it as a safe rule not to interfere with fibroids. 
II regard to cutting into a fibroid, I have found that an incision through its 
11111 cons capsule is valuable in arresting hemorrhage, but I have never used 
®bUeleation because lam afraid of subsequent bleeding. In such cases I use 
.. e ligature and antiseptic washes. I would suggest to Dr. Atlee instead of 
l'Je term “recurrent fibroid,” which he has used in his paper, that of “ mnlti- 
II e fibroid.” In the discussion of this subject, should be separated 
lom fibroids proper; the former generally spring from the posterior wall 
.Hie uterus, and drag the organ upward, elongate it, and bend it forward; 
11® does not occur in cases of simple fibroma, and constitutes a diagnostic 
P°int. Ido not, think that we are justified in removing a fibroid unless the 
Patient is in such a condition that she will die without the operation. With 
ro-cygts, the operation is often necessary, and if, in a case of ordinary 
r°icl, life were threatened, I should not hesitate to extirpate the uteius. 
Hr. pp Penox Hodge, of Philadelphia, said:—No reference has been made 
b* What I consider very important, namely, accurate statistics of opeiations 
°l the removal of these tumors by abdominal section. It would be of gicat 
abie if each surgeon would state how man}r times he had opeiated, in how 
?aily cases the operation had been successful, and in how many it had been 
atal. This has been done in regard to ovariotomy, and the same least ms 
f.Pply for doing it in this case. Dr. Pean, of Paris, has published such statis- 
}lcs- His results are very favorable. They as yet stand alone. No one else 
as approached the success which he reports. I have myself, as yet, nevei 
grated in a case of this kind, and have never met with a case which seemed 
0 require it. On the other hand, it would also be of value to know the lus- 
,ovy of cases which have not been operated upon. I have seen many ot these 
juniors of the uterus, and have the record of some of my father’s cases, dating 
' a°k many years, which are still under my observation. In my experience, 
le number of deaths resulting from such tumors when let alone is very small; 
rIH as the patient approaches the age of fifty years, the tumors often icgin to 
Dninish. In some of my cases, no trace of the old tumors can now be 
effected. One of the dangers, dreaded by some, is inflammation, icsulting in 
ePticaemia; this I remember to have seen in only a single case. I not ici dan- 
Gl is hemorrhage; this I have always been able to contiol. I have seen veiy 
results follow the use of hypodermic injections and suppositories of 
lgop qpc ergop according to my observation, acts well in all the varieties 
. these tumors, including the subperitoneal. I believe that it acts by con- 
Acting the bloodvessels, rather than the muscular tissue, of the uterus. There 
s a remedy, however, which is far superior to ergot. It is a suigical one, and 
°bsists in pushing up the tumors out of the cavity of the pelvis, and maintain- 
them, by proper pessaries if need be, above the biim of the pelvis. rlhis 
elloves the dysuria and tenesmus so common from pressure of the tumor on 826 
ATLEE, FIBROID TUMORS OF THE UTERUS, 
the bladder and the rectum; but more than this, it lessens in a most remark' 
able manner, or arrests, the hemorrhage. The cause of this haemostatic effect 
is somewhat obscure and difficult to explain. It seems probable, however, 
that there being no longer pressure from the firm pelvic walls, the circula- 
tion becomes unembarrassed, and, the blood returning by the veins, the con- 
gestion of the uterus is diminished. 
The President, Dr. Robert Barnes, of London, said:—We must have ade- 
quate reasons for these operations. The question is, whether w7e should 
patients to die, or use all the means at our command to save life. This discus- 
sion will be a help to all of us. In my own practice I last year lost three 
patients from a sort of necrosis which supervened upon the incision of the 
capsule of submucous tumors, and an attempt to enucleate them. This un- 
fortunate experience has made me very shy of undertaking any such procedure 
unless the whole tumor can be removed at one operation. If the tumor were 
too large to be approached by the vagina, I should advocate gastrotomy as 
soon as the woman’s life was threatened. 
Dr. Atlee, in reply, said:—l beg to return thanks for the attention given 
to my paper. All of the points which I have advanced have been sustained 
by the very distinguished gentlemen who have taken part in the discussion- 
Physicians are bound to aid a patient when in extremity, and should employ 
the means which they know to be of use; we have no right to let a disease 
alone; our business is to relieve the patient. 827 
THE THREE MOST IMPORTANT OBSTETRICAL 
INSTRUMENTS. 
BY 
T. LAZAREWITCH, M.D., 
professor of clinical midwifery and diseases of women, and director of the 
GYNAECOLOGICAL CLINIQUE, IN KHARKOFF, RUSSIA. 
[Communicated by the Secretary.] 
A blunt hook,1 a parallel forceps, and an embryotome, devised by Prof. 
Lazarewitch, and presented by him to the Congress, under this title, are 
°trered to the Section on Obstetrics. 
The Blunt Hook is bent at both ends in the same direction, and has 
a hole drilled in one end, and two holes in the other. Apart from the 
Uses to which the ordinary, obstetric, blunt hook is devoted,-this one pos- 
Sesses the important advantage of enabling the practitioner to replace a 
Prolapsed funis, and to carry a fillet around the thigh of the child, or a 
tlQose around its ankle. 
The Parallel Forceps weighs only one pound, has narrow blades, is but 
eleven inches in length, and when closed gives a divergence of two and 
a half inches at the hollow of the blades. The handles lie parallel to one. 
pother, and are locked by lateral contact. The lock, consisting of a 
and mortise, is so loose as to permit freedom of movement to the 
child’s head. By the shortness of its handles, this instrument cannot 
®Xert much compressive or extractive power. To compensate for this 
deficiency, a strong silk loop is attached, either just above the lock when 
oppression is needed, or at the ends of the handles when merely power- 
llT traction is called for. By this loop, traction can be made also in any 
direction, and the.forceps converted into a lever whose fulcrum is repre- 
Seoted by the hand at the handles. The inventor attributes the following 
advantages to his parallel forceps:— 
“ Either half may be introduced first with equal facilities for locking. 
“After the first blade is introduced, the way is not obstructed against the 
®econd, as it is with the crossing forceps, which is especially important in cases 
111 which the head is high up in the pelvis, and the vagina imperfectly dilated. 
c The locking is effected with perfect ease, and without risk of pinching the 
s°fi parts of the mother, which are quite clear of the lock. 
Whatever force of traction may be applied, in all cases immediate pressure 
0 the head with the blades may be avoided on account of this possibility of 
themselves to the head and the mother’s parts. This cannot 
e so perfectly effected by any other forceps.” 
The Embryotome consists of a hollow shaft, armed with a steel beak 
f one end, and with a screw at the other, which opens and closes the 
oak. The instrument is introduced closed. The beak is then opened 
[An abstract, only, of Professor Lazare witch’s paper is here inserted. The original 
lna;|UßCriPt, with elaborate illustrations and samples of the instruments described, is deposited 
the Museum of the Obstetrical Society of Philadelphia.—Editor.] 828 
LAZAREWITCH, OBSTETRICAL INSTRUMENTS. 
and made to bite into the cranium. By turning the shaft on its longi- 
tudinal axis a portion of the skull is then torn off. By repetitions of 
this process the whole vault is broken up. For this instrument, Prof. 
Lazarewitck claims not only the property of lessening the bulk of the 
head, but that of acting as an efficient tractor, and of being available for 
severing the neck, or any portion of the body, in a difficult cross-labor. 829 
ON THE NATURE, ORIGIN, AND PREVENTION OF 
PUERPERAL FEVER. 
BY 
W. T. LUSK, M.D., 
pSOFESSOR OF OBSTETRICS AND DISEASES OF CHILDREN IN THE BELLEVUE HOSPITAL MEDICAL 
COLLEGE, NEW YORK. 
The total number of deaths in the city of New York for the nine 
years from 1868 to 1875, inclusive, was 248,533. Of these, 8342. were 
deaths either from diseases complicating pregnancy, from the accidents 
of child-bearing, or from diseases of the puerperal state 5 or, in other 
Words, very nearly one in seventy-five of all the deaths occurring during 
that period, was the result of the performance of what we are in the 
Labit of regarding as a physiological function. 
A careful study of the records preserved by the Health Department of 
the city has enabled me to classify these 3342 deaths into;—- 
(1) Those due to child-birth proper, under which head I would place 
deaths from shock, from protracted and unusually severe labor, from 
convulsions, from flooding, from rupture of the uteius, and, foi the 
of convenience, those from extra-uterine pregnancies , 
(2) Deaths from eruptive diseases, from phthisis, and from the various 
*on-puerperal, inflammatory disorders complicating child-birth. _ A few 
cases recorded as typhus, typhoid, and intermittent, I have included 
Under puerperal fever, on account of certain inherent difficulties in the 
differential diagnosis. Should exception be taken to this action, I have 
°nly to state that the entire number thus recorded is much too small to 
Palpably affect any conclusions, which this report may contain , 
(3) Deaths from a variety of diseases, occurring during pregnancy in 
Which the pregnant state was, in all probability, an active cause o e 
Unfavorable result: __, ~ •, , , 
(4) Deaths from miscarriage (I use the term as I fin 1 emp y y 
Re majority of physicians, in their reports, to designate all cases of inter- 
rupted pregnancy during the first six months), in which either mtercur- 
reut affections, the lack of proper medical assistance, actual want, or 
priniinal malpractice, have been the chief factors in determining the fatal 
issue. To be sure, in many of these instances, death is due to the super- 
vention of peritoneal complications, septicaemia, and pyaemia, assirai ating 
Rem closely to cases of puerperal fever. _ I do not, however, include them 
Under puerperal fever, because their origin is not in velvet in mystery, 
d-wo words tell the whole story, viz., neglect and violence. Tic oxplan- 
Jf°ry term, retained placenta, testifies to the one, and the certificate of 
Re coroner to the other. We all know how common fatal cases of metna 
are, in large hospitals, after delivery at full term. After abortions on the 
contrary, they are rare. Thus the uterine wards of the Bellevue Hospital 
Lave always contained a large complement of women who have entered 
Ro hospital in a very low state induced by some of the sequelae of abor- 
tion. Of these, in nine years, two only have died. • Dr. Oeorge K. Johnston 830 
LUSK, 
reports in seven years, in the Rotunda Hospital in Dublin, but one death 
in 234 cases of abortion, and that the result of mitral disease of the 
heart. I have, for the sake of convenience, exhibited the precise proper 
tion of deaths due to each of these several causes in tabular form. Codec 
tively they will be seen to have numbered 1395 cases, or about 42 per 
cent, of the entire number. 
Table I.—Deaths occurring during pregnancy, confinement, and the puerperal 
state, in New York, between the years 1867 and 1875, inclusive, excluding 
those from metria. 
H % 
1867. 1868. 1869. 1870. 1871. 1872. 1873. 1874. 1875. Total % o 
G 
Childbirth1 . . . . 18 13 20 20 37 38 22 19 16 203 
Convulsions . . . 55 36 47 46 54 62 30 51 27 408 
Uraemia2 4 8 3 5 5 7 29 22 83 
Flooding 16 35 13 25 20 24 20 25 26 204 
Placenta prmvia 4 10 5 11 9 14 11 18 82 
Protracted & instrumental labors 4 5 4 2 7 10 20 52 
Rupture of uterus . . . 44 3 4 5 5 6 511 47 
Extra-uterine pregnancy . . 1 1 5 3 1 4 ... 15 
Miscarriage3 . . . . 13 10 12 19 36 27 24 30 26 197 
Pregnancy4 . . . . 4 2 4 1 5 5 3 2 5 31 
Phthisis 321268845 39 
Smallpox 1 9 2 ... 7 19 
Scarlatina 2 4 1 4 2 13 
Erysipelas 1 ... 1 2 
Total . . . .118 116 122 132 185 196 146 194 186 1395 3342 
1 Under childbirth are included deaths from shock, from intercurrent non-puerperal diseases, from comply0®' 
tions, such as tumors, cancer, disease of the heart, and the like, and all oases reported under childbirth which 
proved fatal within twenty-four hours of delivery, not elsewhere mentioned. , 
2 A large number of deaths from urcemia are reported, in which it is not stated whether,convulsions existed 
or not. 
3 Under miscarriage are .reported all cases in which pregnancy was interrupted previous to the seventh 
month. 
4 Under 'pregnancy are given deaths, from non-puerperal causes, in which pregnancy existed and probably 
contributed to the fatal issue. The number of deaths from phthisis is specifically given in the report, as arc 
those from smallpox, scarlatina, and erysipelas, subsequent to 1870. 
(5) There thus remain 1947 cases which, variously reported as puerperal 
fever, puerperal peritonitis, metritis, metro-peritonitis, phlebitis, phleg- 
masia dolens, pyaemia, and septicaemia, furnish the subject for special 
inquiry ki this paper. All these varieties we will term briefly puerperal 
fever, attaching to the term, however, no special significance. The diag- 
nosis of anatomical lesions from clinical symptoms alone, unverified by 
post-mortem examination, is, in the most experienced hands, only approxi- 
mative. As usually reported by the practitioner, these lesions reflect f 
the most part his individual theory, or early training. As a matter ot 
convenience then we propose to employ the name puerperal fever as & 
general term to cover all the febrile conditions peculiar to the puerperal 
state. 
In the 1947 cases of puerperal fever, I have included cases of patients 
reported to have died of puerperal mania, the non-febrile form rarely 
proving speedily fatal. That this rule is not universal, I readily admit- 
Thus, I remember a case occurring in the Bellevue Hospital, in which the PUERPERAL FEVER. 
831 
fr'aniacal patient was confined in one of the cells of the hospital. During 
:.e night, she got out of bed and broke the windows. The night was 
utterly cold. The patient sat up in her night-dress with the cold air 
in upon her. On the next morning she was seized with pneu- 
lonia, and died. A few cases of death, too, reported from insane asylums 
Lot belong in this category. Giving to the term, puerperal fever, 
,en, this broad significance, we find that in nine years it was the cause 
Nearly one one-hundred-and-twenty-seventh of all the deaths occurring 
the city. It is to be regretted that the returns of births in the city are 
rendered. The actual number of births during the last nine 
ears may, however, be roughly set down at 284,000. This estimate is 
based upon the assumption that the natural birth-rate is thirty-three to 
jjhe thousand,1 an estimate which errs upon the side of liberality. The 
°tal number of deaths then to the entire number of confinements would 
at least in the proportion of one to eighty-five, or, from puerperal fever 
in the proportion of one to one hundred and forty-six. These 
figures proclaim more eloquently than any words can do, the necessity of 
ll’equently reviewing the state of our knowledge as to the nature of puer- 
Peral fever, and of inquiring as to how far it is due to causes which are 
to human control. 
At the outset, it is proper to recall that, as the various names applied 
to puerperal fever indicate, it is, with rare exceptions, associated at some 
Period of its progress with certain inflammatory processes which have 
starting-point in the generative apparatus, ihe lesions most corn- 
pionly found in post-mortem examinations consist of catarrhal inflamma- 
i°ns of the mucous membrane lining the vagina and uterus, with simple 
Iterations, or those presenting a diphtheritic character, inflammation 
111 the pelvic cellular tissue, metritis, local and general peritonitis, inflam- 
mation of the lymphatics and veins, thrombosis, pleuritis, pericarditis, 
tlvular affections of the heart, abscesses, and other destructive piocesses 
t the parenchymatous organs, and purulent collections in the joints. As 
rule, the occurrence of one or other of these inflammatory piocesses is 
A Uelironous with the first outbreak of fever. 
When we come to analyze our cases ,of puerperal fever, we find two 
general groups, the one infectious, the other non-infectious. 
The Non-infectious Group.—Every one who has seen much of hospital 
Practice, has of necessity observed instances of puerperal inflammations 
‘jpcl febrile conditions, often of a severe type, which have possessed this 
Instinctive peculiarity, that they have in no wise visibly affected the 
. ealtfi of puerperal patients in their vicinity. They possess this feature 
1)1 common, viz., that in them the symptoms of blood-poisoning are 
absent, or are present only to a subordinate extent, and as a late feature 
0l the disease. The nature of cases belonging to this group mn> be best 
by an examination of the known causes which cal them into 
mfistence. I give the following from a vast number of lecoided cases, 
Without pretending, however, that they exhaust the list. 
(P) Inflammations may arise from traumatic injuries, sue as lupture 
?. the cervix uteri during labor, those resulting from unskilfully per- 
Lrrued operations, and from the bruising or crushing of the soft parts of 
Jc mother in long labors, especially in cases of moderate pelvic deformity. 
The census for 1870 gives to New York a population of 942 202. The average of 
‘ nuual increase from 1860 ho 1870, was 15,000. I have taken 10,000 as the probable aver- 
=e increase since 1870. The inaccuracy in this calculation is not considerable enough to 
Serially affect the proportions. 832 
LUSK, 
(2) The imprudence of patients or their nurses. Thus I have frequently 
been able to trace, in hospital practice during the winter season, severe 
cases of cellulitis, pelvic peritonitis and general peritonitis, to the pa- 
tient’s getting out of bed, dripping with perspiration and clad only 1° 
a night-dress, and going thus bare-footed over a cold uncarpeted floor to 
the water-closet. Even in private practice, like instances of wilfulness 
are not unknown; nurses too, especially those who are reputed by the 
fair sex to know more than any doctor, are fertile sources of trouble. 
(3) Moral causes are frequently effective in producing serious disturb- 
ance, In studying the records of Bellevue Hospital for the year 1873,1 
was greatly impressed by the fact that in 240 deliveries in married women 
there were but two deaths from puerperal fever, while in 209 in non- 
married women there were thirteen deaths. From the Bureau of Vital 
Statistics I learn that one-eighth of the deaths from puerperal causes 
occur among unmarried mothers. Dr. Johnston dwells much upon 
similar state of affairs existing during his mastership at the Dublin 
Rotunda Hospital. In a paper on “ The Genesis of Puerperal Fever,” 
I reported an instance in which five women were confined in the same 
ward, by the same attendants, and under absolutely the same conditions, 
with the exception that one chanced to witness the sudden death of /1 
patient from rupture of the uterus. While the other four women did 
well, this one, after a period of great mental agitation, developed peri- 
tonitis and died. It has been suggested that such cases occur only in 
the records of hospital practice. This is not so. During the 
summer I saw in consultation, in a remote and very healthy rural dis- 
trict in which puerperal diseases were unknown, a case of severe fever, 
lasting eight days, which was traceable to the mother’s anxiety and fret 
over the illness of one of her children. Dr. Alfred Wiltshire, of London, 
after writing to me an account of a poor woman who died in less than 
twenty-four hours in collapse, brought on by a rough remark from her 
husband, adds, “I have seen many other similar though less severe 
cases, and I confess that my sympathies are deeply touched whenever I 
have to attend women who have cause for depression during labor.” 
(4) I have, in a number of cases, had occasion to notice the influence 
of old adhesions existing between the serous coverings of the pelvic 
organs, due to a by-gone peritonitis, upon the pregnant and puerperal 
states. The two following instances will serve as illustrations:— 
The first was that of a young wife, who, a few months after her marriage? 
had a miscarriage. Unfortunately a portion of the ovum remained in the 
uterus, where it became the source of protracted hemorrhage and some febrile 
disturbance. A couple of months later, however, the offending body yaS 
removed, after preliminary dilatation of the os, by a distinguished physician 
who was summoned in consultation. A sharp attack of pelvic peritonitis fob 
lowed, from which, however, the patient so far recovered as to enjoy a period 
of reasonable health. Then she became again pregnant. In the sixth month 
of gestation she began to lose flesh rapidly, and had repeated chills, with pi’0' 
fuse perspirations, and a continuously high temperature with evening exacei- 
bations. Living at the time, however, in a New Jersey rural district, her 
symptoms were attributed to malarial influences. I was consulted concerning 
the case in the eighth month, and on hearing the history predicted an inflam- 
mation of the kind under consideration ; and found, as I had anticipated, 011 
examination, a large and distinct tumor reaching from the left iliac fossa to 
the upper margin of the kidney, which was evidently the product of chronic 
1 American Journal of Obstetrics, vol. viii., Nov. 1875, p. 371. PUERPERAL FEVER. 
Cellulitis and peritonitis. Soon after, she gave birth to a premature but living 
child. In a few days subsequent to her confinement, the lady died. Every 
circumstance in the clinical history pointed to the connection between the 
slowly developing inflammation during pregnancy and the earlier acute attack 
°f peritonitis. 
In the second case I was called to see a patient suffering from puei’peral 
convulsions, in whom gestation was complicated by a large fibro-cystic tumor 
°1 the uterus. After administering chloroform, I dilated the os, and delivered 
the child by version. Hemorrhage followed, which was, however, promptly 
ari'esled. The three days following, my patient had no bad symptoms. On 
the fourth, she complained of pain on the left side, which gradually extended 
°ver the abdomen. Meantime the temperature rose, the pulse became rapid, 
and on the following day she died. The post-mortem examination showed no 
Astons of either the uterine cavity, the cervix, or the vagina, which were all 
n°rrnal in appearance. That portion of the uterus, however, which had under- 
g°ne fibro-cystic degeneration, and which was found to weigh between six and 
Beven pounds, was covered with fibrinous flakes. Everywhere the tumor was 
Slued to the adjacent serous surfaces by s? uesions of long standing, and 
strong, organized bands, many of them the size of a goose-quill, connected it 
'v'lth neighboring organs. There could be no doubt, on examining these ap- 
pearances, that the peritonitis had been caused by the dragging of the heavy 
Junior upon these adhesions, after the evacuation of the uterus and the loss of 
Ihe support of the abdominal walls. 
(5) It is proper to take into consideration the vulnerability of indi- 
vtduals. All puerperal women are said to tremble in the balance between 
d physiological and a pathological condition, and it is no unfounded as- 
sertion to say that trivial causes which would be inoperative in many 
eases will turn the scale in others. "We see this exemplified in first 
births, and in women who have borne children in excess. In this coll- 
ection, the question started by Dr. Nathan Allen, of Lowell, as to what 
is “ The Horaml. Standard of Woman for Propagation, 1 becomes of real 
lriterest. 
(6) It is to be borne in mind that the zymotic fevers, not peculiar to 
jddld-bed, may provoke in the puerperal woman the same mflammatory 
that are commonly associated with puerperal fever.2 I his is in 
c°nformity with the well-known surgical experience that a tebnle 
Paroxysm from any cause exerts an unfavorable influence upon a 
y°unded surface. Olshausen3 has, however, recently shown that pelvic 
lllflamrnations and peritonitis are somewhat rare in cases of scarlatina 
c°ttiplicating the puerperal state. He likewise adds affirmative evidence 
the view advanced by Braxton Hicks,4 that scarlatina, after a long, 
period of latency or incubation during pregnancy, can make its appear- 
dtlce two or three days after delivery, and, as a rule, with slight tin oat 
Symptoms. The discussion in the London Obstetrical Society has done 
riluch to draw attention anew to the effects of infective diseases upon the 
puerperal state. I should prefer, however, to exclude well-defined cases 
°4 typhus, typhoid, and scarlatina, complicating child-bed, from the 
' Amer. Journ. of Obstetrics, April, 1876, p. 1- i A , , 
Vide Hervieux, TraitS Clinique et Pratique des Maladies Puerperales; Art. Mala- 
le„s Wddentales, pp. 1073 et seq. . e , , , 
s 3 Untersuchungeu ueber die Complication des Puerpermm mit Scharlach und die 
s°genannte “Scarlatina PuerperalisArchiv fur Gynsekologie Bd. ix. Heft 2, 18/6. 
* Contribution to our Knowledge of Puerperal Diseases; Obstetrical transactions, vol. 
s P- 44. 
Obstetrical Transactions, London, vol. xvii. 
53 LUSK, 
category of puerperal fever, unless coexistent local lesions should involve 
the pathogeny in doubt.1 _ . 
How as regards the foregoing dangers to the puerperal woman, it 
rare that the physician is enabled to employ preventive measures; a no- 
th ese are necessarily not general, but those suggested by his tact, skxb? 
and wisdom, for independent application to each case. 
11. The Infectious Group.—The infectious form of puerperal fever lS 
characterized by blood-poisoning. The poison is of a septic nature- 
The usual points of introduction of the poison are the lesions of the pal' 
turient canal. This does not, however, exclude other points of entry? 
and clinical experience renders it highly probable that, under certain 
conditions, the poison may be primarily introduced into the blood 
through the respiratory and digestive organs. This form is contagioll,3’ 
but all cases of infection are not contagious in an equal degree. It 
customary for many to limit the term puerperal fever to the members ox 
this group; as, however, there is as yet no common understanding 0l 
authors among themselves, or among practitioners in general, as to the 
precise limitation of the term; as, indeed, hardly any two physicia 
mean precisely the same thing when they speak of puerperal fever, I sixth 
endeavor to avoid confusion by not using the term in a specific sense. . 
That the infectious diseases of child-birth are of septic origin, there xs 
now abundant evidence. The question of the identity of puerperal fevex 
and septicaemia is largely one of definition. It is a matter of ordinary 
experience that the retention of a small bit of the membranes within th 
uterus will produce fetid lochia; and, as the result of infection, a febrn 
condition, which, as a rule, subsides with the expulsion of the offending 
body and the use of disinfectant washes. A virulent form of fever is xlo 
unfrequently occasioned by retained coagula, or placental debris, whxc | 
have undergone decomposition. I was once sent to see a puerpcra 
patient, suffering from fever, on the fourth following her confix 
ment. On entering the room I found the stench intolerable; turnixx© 
down the sheets,! discovered that the patient was lying in a decomposb1# 
mass, and learned that her doctor had forbidden, after the birth of 
child, the removal of the soiled linen and blankets. The patient died 1,1 
the tim’d week from pyaemia multiplex. 
Haussmann2 reported a case of auto-infection in the rabbit, which fel' 
minated fatally. A portion of the membrane, retained in the left corxxxb 
led to diphtheritic losses of substance in the lower portion of thevag 
to hemorrhagic enteritis, and to peritonitis. The same author produce 
death from septicaemia by injecting into the gravid uterus of the rabD 
serum from the abdomen of a rabbit which had died from infectio11' 
The post-mortem examination showed the muscles filled with granul ’ 
and the peritoneum injected, but no fibrino-purulent exudation. I 1!)6 
tions into the uterus of pus from the abdomen of a woman dying fro 
infectious puerperal disease, produced no effect upon rabbits two wee 
gravid, while in the second half of pregnancy premature delivery all 
1 There does not appear to be any very good reason why a well-marked case of sc 
tina occurring in a puerperal patient should be termed puerperal fever, more than oi 
smallpox. Dr. George K. Johnston informs me that the cases of scarlatina oocnrvn^ong 
the Rotunda Hospital of Dublin have never started epidemics of puerperal fever an 
the lying-in patients. I remember but one case of the kind in the Bellevue Hospita , 
this did not affect unfavorably patients in the vicinity. ~ uurts 
2 Entstehung der iibertragbaren Krankheiten des Wochenbettes ; Beitrage zur De 
hlilfe und Gynsekologie, Bd. iii., Heft 3, S. 345. PUERPERAL FEVER. 
835 
death occurred, in one case in one and a half, in another in two and a 
half days. In the animal which died in thirty-six hours there was com- 
mencing perimetritis and peritonitis, while in the one dying after the 
lapse of sixty hours the abdomen was found to contain fibrin and pus,1 
B’Espine injected into the uterus of a rabbit, which had just produced her 
yeung, pus from the abdomen of a woman who had died from puerperal 
disease two days before. This was subsequently followed by other injec- 
tions of fetid fluids during the four days following. On the twelfth day 
the animal died. The autopsy revealed peritonitis, most marked in the 
pelvic cavity, inflammatory alterations in the vagina, uterus, and tubes, 
Sfnall abscesses in the body of the uterus, softened clots in the veins of 
the hroad ligaments, and infarctions of the liver.2 Schuller found that 
subcutaneous injections of septic material in female animals, during 
Pregnancy, produced a diphtheritic, ulcerative process on the uterine 
surface, which determined the separation of the placenta; diphtheritic 
patches, likewise, were found in the cornua ot the uterus.3 
Thus we find that in the human subject, and in experiments made 
upon animals, septic poisons introduced into the system following or near 
delivery produce lesions similar to those tound in puerperal fever. As a 
further coincidence, we notice that, as in puerperal fever, the lesions 
from direct, septic poisoning have nothing characteristic about them, 
producing in one case pyaemia, in another partial peritonitis, in another 
general peritonitis, in another diphtheritis, while in others the lesions 
are comparatively trivial—these differences being due to differences in 
renditions which are but imperfectly understood. 
My friend, Prof. Barker, in his magnificent work on “ The Puerperal 
■diseases,” which is, as every one knows, a masterpiece in the way ot 
clinical observation, mentions, as a distinction between septicaemia and 
puerperal fever, that, while puerperal fever is contagious, septicaemia is a 
Uon-contagious affection. I have the record of the following case which 
ufilitates against this theory. A physician in Hew York delivered a 
lonian of a putrid foetus. The woman died of septicaemia, iwo days 
uf'ter attendance upon the first case, he attended a second patient, who 
likewise died of septicaemia. Dr. Barker states that by inquiry among 
surgeons he cannot learn that septicaemia follows in their does 
puerperal fever in that of the obstetrician, and yet Sir James birnpson 
asserts it to have been the case in his younger days.4 Ihe vital statis- 
tics of Hew York, for the last nine years, show that a sequence of deaths 
following confinement in the practice of individuals has become veiy 
rai*e, and, let us hope, that if the enlightenment of these latei days has 
enabled the surgeon to avoid such a misfortune, in the end the same 
Profit may accrue to the practitioner of midwifery. 
But it is to be remembered that the conditions in a puerpeial patient, 
Und in one upon whom a surgical operation has been perfoimed, aie not 
I(fentical. Samuel, in speaking of immunities and dispositions to 
Septic poisoning, says;—“ The statistical frequency of septic, puerperal 
1 Ibid., p. 394. 
! Contribution k I’Etude de la Septic6mie Puerperale; Paris, 1873, p. 28. 
Experimented Beitrage zum Btudium der septischen Infection; Deustcne Zeitschrifl 
lir Ohirurgie, Bd. vi., B. 141. . „ ~ „ 
~ “I have repeatedly heard of instances of a rapid succession of surgical fever cases and 
, asters in the practice of the same surgeon, while the other surgeons in the same locality 
bad their patients recovering as usual.” On the analogy between Surgical and Puerperal 
ever; Simpson’s Obstetric works, edited by Priestley and Storer, vol. li. p. 19. LUSK, 
diseases is due to the length of the parturient canal, to the fact that 
through this long passage there must pass all the pathological and phy- 
siological excretions, and to the soiling of these parts with fingers, instru- 
ments, and secretions, which have become the bearers of sepsis.”1 Be 
found, on the other hand, that it was extremely difficult to produce a 
progressive ichorous condition by daily painting an open stump with u 
septic fluid,2 though the same was readily obtained when an infinitesimal 
quantity of septic fluid was injected underneath a fascia. Dr. Barker 
is, however, much too keen an observer to ever go far astray, and it ;s 
true, as will be mentioned hereafter, that there is a form of septicaemia 
which is not contagious. The only question to be raised is as to whether 
it is allowable to restrict the term to this form. As usual in all question9 
concerning puerperal fever, there is practical agreement as to facts, with 
divergence of opinions concerning definitions. 
Until very recently the whole subject of septicaemia has been in a state 
of wellnigh hopeless confusion. From Gaspard and Pannm, through u 
long list of experimenters, hardly any two have arrived at precisely 
similar results. Something like an approach to order has, however, hee,! 
produced since it has begun to be understood that the effects produced 
by septic fluids vary with the quality of the poison and the method 01 
experimentation, and that to obtain identity in the result, there must be 
identity in all the conditions. Thus Samuel has shown that the same 
organic substance produces different effects at different stages of decom- 
position ; again that the enteritis which is commonly quoted as character- 
istic of septic poisoning, occurs, as a rule, in animals, when the septic 
fluid is injected directly into the blood, and is rare when it finds it® 
way into the circulation through the lymphatics, as is the case usual!} 
in clinical experiences.3 There is one experimental point of extreme 
practical importance too in connection with puerperal septicaemia, vi2*> 
that if the injection of a septic fluid be made directly into a vessel, toxjc 
effects speedily follow, but are transitory, unless the amount of the fium 
be large, or its virulence exceptional, or the animal very young? 
whereas very small amounts injected subcutaneously, by developing 
rapidly spreading phlegmonous inflammation, resembling malignant erf' 
sipelas in man, are capable, after a period of incubation, of producing 
fatal results; or they may, if injected into a shut cavity or underneath 
a fascia, lead to the development of an inflammation of an ichorous char- 
acter. In other words, the eliminating organs suffice, under ordinal’} 
conditions, to remove from the blood the same amount of septic flLlf 
which would prove fatal if injected into the tissues,5 To produce sin}1' 
lar results the injections into the blood need to be repeated at intervals* 
This experience leads us to the conclusion that, in the tissues, septl(| 
poison possesses the capacity of self-multiplication, and that, in the loca 
inflammation set up, a reservoir is formed from which poison is con- 
tinuously poured into the circulation. 
This capacity of self-multiplication, which septic fluids possess, ha9 
* Ueber die Wirkung des Falilniss Process auf den lebenden Organismus ; Arch, 
exp. Pathologic, Bd. i. IS. 343. 
2 Loc. cit., p. 339. 3 Loc. cit., p. 349. 
4 Traube und Gscheidlen, Versliche ueber Faiilniss mid den Widerstand des lebende 
Organismus. Schles. Oes. f. valeriandische Guitar, Febr. 13, 1874. . 
sln some instances in which absorption from the tissues is very rapid, the effects of g 
cutaneous injections may be similar to those produced by injections made directly into t 
circulation, and the local lesion be insignificant. PUERPERAL FEVER. 
837 
Recently been found to be coincident with the presence of certain organic 
. ‘ies, termed variously micrococci, raicrospores, or sometimes, less spe- 
Clfically, bacteria. All carefully made experiments serve to show that, if 
a septic fluid be deprived of these organic bodies by boiling, or filtration, 
)vhile it continues capable of producing inflammation, the inflammation 
18 Usually of diminished intensity, and remains local in its character 
whereas the microspores, retained upon the Alter, possess all the virulent 
Properties of the original fluid.2 This does not alone necessarily prove 
,Jut the virus resides in the microspores, for it does not exclude the pos- 
sibility that both the virus and the microspores remain upon the filter. 
So far, attempts at isolating the microspores and cultivating them 
?eparately in vehicles, composed ot water holding in solution certain 
inorganic constituents necessary for their healthy nutrition, have been 
°. partially successful in proving them to be the sole source of infec- 
tlo». Some experiments of Tiegel and Klebs3 were attended with positive 
results, but Hiller arrived at different conclusions. He found that bac- 
|ei‘ia washed in pure water were innocuous.4 But pure water had long 
untore been proven by observers to be inimical to the well-being of the 
organisms in question. Schuller says that Hiller’s experiments prove 
apparently that while a putrid fluid may be in the highest degree poison- 
°Us, its component parts, viz., either the fluid or the bacteria singly, are 
Either deadly nor poisonous.5 The fact is that all isolation experiments 
are subject to what seems an unavoidable source of error. As Ha value 
lloted, early in his observations, the physiological action of bacteria is 
vnry dependent on the constitution of the medium in which they are 
eveloped, which is in entire harmony with what is known of organisms 
Juiich higher in the scale. u Many plants,” says Burdon Sanderson,6 
c°ntainino- active principles, become inert when transplanted tiom an 
aPpropriate&soil.” Bucholtz, in a series of experiments designed to test 
ff e influence of antiseptics upon the vitality of bacteria, found not only a 
cqflerence between those taken directly from the infusion and those col- 
lated in artificial fluids, but between bacteria derived from the same 
s°urce and cultivated in modifications of the nutrient medium.7 Under 
these circumstances, all evidence of a positive character is to be regarded 
a 8 of more value than that which is purely negative. . 
. ht is, however, from the constant presence ot the round bacteria in 
lnfected wounds, and their distribution through the tissues, that the argu- 
tfront in favor of connecting septic symptoms with the bactena has been 
Mainly deduced. Here the ground is sufficiently solid, and, judged by 
ol’dinary laws of scientific evidence, the pathological importance of the 
may be regarded as established. To be sure, we find them 
filtration through porous earthenware cylinders, the filtrate possesses no phlogo- 
fiegel, Correspondenzblatt fiir Schweizer Aertze, 1871, S. 12 o>. Klebs, Archiv flu 
P- Pathol, und Phannakol., Bd. i. Heft 1, S. 35. . . xr + ■ j 
n Klebs, Archiv fur exp. Pathologic und Pharmakologie; Beitrage zur Kenntmss der 
Patliogenen Schistomycetin ; Band iv.. Heft 3, S. 241 und ff. 1 iegel. oc. cut. 
■p . Kxp. Beitrage zur Lehre von der organisirte Natur der Contagion und von der 
s l"i8s; Archiv fur klinische Ohirurgie, Bd. xvu. Heft 4, fe. 659 u ft. 
rUr XP- Beitrage zum Studium der septischen Infection; Deutsche Zeitschnft far Ghi- 
Lectures on “ The relations of bacteria to disease British Med. Journal, March 27, 
f.8‘5 See, also, Klebs, Beitrage zur Kenntniss der pathogenen Schistomycetin; Arch. 
u' 1 athol. und Pharmakol., Bd. iii. S. 321. ,P1 . , 
UudAntiseptica und Bacterien; Arch. f. exp. Pathol, und Pharmakol., Bd. iv., Heft 1 838 
LUSK, 
in tongue-scrapings of healthy individuals, but tongue-scrapings are 
poisonous if injected into the tissues. That they do not ordinarily prove 
so in the mouth, is no more singular than that woorara can be swallowed 
with impunity. Tiegel has endeavored to show that the round bacteria 
are found normally in the internal organs of the body.1 If his experi- 
ments should in fact stand the test of criticism, they would only show 
that a few bacteria may be found in health in the liver and in the pan- 
creas, but never in anything like the same numbers or the same general 
distribution, nor with the same characteristic groupings, that have been 
proven for a number of infectious diseases.2 It is stated that they are 
sometimes absent from the blood taken during life in septic diseases. 
As, however, their constant presence has been confirmed in the vessels 
and glomeruli of the kidney, it is fair to assume that they are filtered 
out by those organs when the conditions favorable to their development 
do not exist in the blood. Again it is an open question, which awaits 
confirmation, whether it be not true, as Hueter claims, that the micro- 
spores do not disappear, but are taken up by the blood-globules, rendering 
the latter adhesive, and predisposing the blood to the stases character- 
istic of inflammation.3 Zahn has shown that the inflammation in the 
mesentery of the frog, in the Conheim experiment, does not take place it 
the air is first filtered through diluted carbolic acid.4 
As to the exact manner in which these minute bodies exercise their 
pernicious influence, whether they operate mechanically, or whether they 
produce a virus in the process of nutritive activity, or whether, as is 
probable, both suppositions are correct, we may safely leave as questions 
to be decided subsequent investigations. It is enough for us to note 
that the connection between sepsis and the round bacteria is intimate and 
vital. Panum,.who is often quoted as opposed to what is known as the 
Bacteria theory, admits as probable that the microsporon septicura is inocu- 
lable, appears in the blood during life, multiplies in the tissues, and, in part 
by production of a special poison, perhaps, and in part by mechanically 
irritating the tissues,excites inflammation, suppuration, and fever.5 Berg- 
mann, who once thought that he had found the secret of sepsis in a cry 3' 
tallizable substance derivable from putrid fluids, which he termed sepsin, 
now squarely accepts the modern doctrine. Virchow has so far given in 
his adhesion to the new school as to say; u Especially in this connection 
are to be mentioned the diphtheritic process and the erysipelatous, 
especially erysipelas malignum. The granular deposit in diphtherically 
affected tissues, of which I formerly spoke, has more and more proven to 
be of a parasitic character. What we formerly regarded as simple, organic 
granules, as infiltration, or exudation, has since proven to be a dense 
aggregation of micro-organisms which penetrate into the tissues and cell 3 
to compass their destruction.”7 Even Billroth, who contends that what 
he terms a zymoid ferment is the first thing developed in the line of cati- 
1 Virchow’s Archiv, Bd. lx. S. 453. 
2 Klebs., Arch, fur Path, und Pharmakol., Bd. iii, S. 319. 
3 Allgemeine Chirurgie, Cap. xvii.; Der fieberhafte Process. So, too, Schuller, loc. on- 
pp. 168, et seq. Birch-Hirschfeld likewise found bacteria in the white globules of pyBo' 
mia; Schmidt’s Jahrbiicher, Bd. 166, No. 5, S. 187. 
4 Arbeiten an der Berner pathol. Institut., 1871. 
5 Das putride Gift, die Bacterien, die putride Infection und Intoxication, und die Septl' 
casrnie ; Virchow’s Archiv, Bd. lx. S. 348. 
6 I have not been able to obtain access to Bergmann’s original paper, but make tin 
statement on the authority of Hueter, Allgemeine Chirurgie, S. 543. 
7 Die Fortschritte der Krieg’s Heilkunde; Berlin, 1874. PUERPERAL FEVER. 
839 
Ration, and that the bacteria are a sort of epipbenoraenon, concedes that 
;be organisms, by their migrations, may become the carriers of the virus 
the interstices of the tissues.1 I mention the less willing witnesses 
to the importance of bacteria in disease: I need not recapitulate the 
riarbes of a host of active advocates of the germ theory. 
. I have been thus explicit regarding the evidence concerning bacteria 
ln septic diseases, because it places the question of the infectious group 
puerperal fever-cases in the following position ;—Experiences occur- 
llng clinically, as well as those produced upon animals, teach us that 
Cei’tain lesions and symptoms, similar to those we are accustomed to re- 
Sai’d as characteristic of puerperal fever, result from septic poisoning. In 
a large class of cases, however, the connection between child-bed fever 
atld sepsis has been deduced rather from analogy than direct proof. For 
tjiose who chose to regard such as due to a specific poison peculiar to 
ti*e puerperal state, there was really no objection. If, however, round 
bacteria are characteristic of septic poisoning, the question presents itself 
lri a different light, and we have to inquire whether, in the less obvious 
°ases, bacteria are present in puerperal fever in the proportions and 
£>r°upings that we find them in other diseases due to putrid infection, 
it is precisely proof of this nature that has recently been abundantly 
tendered. 
. Waldeyer,2 Orth,3 Heiberg,4 and Yon Recklinghausen, found the 
tissues and lymphatics of the parametria filled vyith pus-like masses, 
Which consisted, in addition to pus-cells, chiefly ot bacteria. Bacteria 
farmed in the fluid of the peritoneal cavity. In one case examined by 
aldeyer, six hours after death, while the body was still warm, the 
Peritoneal exudation was like an emulsion, and furnished an abundant 
eposit which consisted almost entirely ot bacteria. Orth injected ten 
tainims of peritoneal fluid from a w'ornan dead of puerpeial lever into 
tile abdomen of a rabbit. As the animal was dying he broke up the 
Medulla oblongata, and found in the peritoneal fluid enormous quantities 
these orgamsms. In puerperal fever, round bacteria have been like- 
wise found, though in less quantities, in the lymphatics ot the dia- 
phragm, and in the fluids of the pleura, the pericardium, and the ventri- 
eies of the brain. In post-mortem examinations of fresh subjects, the 
serous fluids, withdrawn under proper precautions, do not contain round 
bacteria except in cases of septic infection.5 Orth found in the purulent 
cpntents of the vessels of the funis, in children who died, of sepsis, pie- 
eisely the same formations as existed in the exudations ot the mothei. 
The presence of these germs in puerperal fever serves not only to fix 
pases hitherto considered doubtful in the category of septic diseases, but 
afiords the best explanation of the protean phenomena of pueiperal 
jever itself. Steurer, formerly interne at the Bellevue Hospital, where 
witnessed the epidemic which prevailed in that institution in the 
} ear 1874, afterwards made, under the guidance of I rof. Yon Reckling- 
hausen, a special investigation of the pathological changes in a similar 
, 1 Untersuchungen über die vegetaliens Formen von Coccobacteria septica; Berlin, 
1874, S. 200. 
, 2 Ueber das Yerkommen von Bacterien bei der diphtberitischen Form des puerperal Fie- 
eis! Archiv fur Gynaskologie, Bd. iii. S. 293. _ 
i Untersuchungen ueber puerperal Fieber; Virchow s Archiv, Bd. Ivin. S. 437. 
pie puerperalen und pysemischen Processe ; Leipzig, 1873. ... 
~ Klebs, Beitrage zur Kenntniss der pathogGiiGn SchistoinycGtiu j Archivr fiir exp. Pa- 
°b und Pharmakol., Bd. iv. S. 441 u. if. 840 
LUSK, 
epidemic which occurred in Strasbourg. From a written communication 
received by me from Dr. Steurer, many of the following facts concerning 
the pathogeny of the disease have been derived. These facts, I may add, 
are fully supported by the investigations of others, and form a most 
valuable contribution to our knowledge of puerperal fever. 
Steurer’s cases all presented diphtheritic patches about the vulva, or 
upon the mucous membrane of the vagina and uterus. These patches 
were always associated with a loss of substance, and were composed of 
disintegrated fibrin, white and red blood-corpuscles, and colonies of round 
bacteria in great abundance. From the patches, the bacteria could be 
traced between the muscular fibres, and deep down into the canalicular 
spaces of the connective tissue, where their presence gave rise to cel In* 
litis. From the canalicular spaces they entered the lymphatics, with 
resulting lymphangitis. In many cases the lymphatics could be traced 
along the broad ligaments to the ovaries (puerperal ovaritis), and into 
the subperitoneal tissue of the lumbar region. Dy perforation of the 
walls of the lymphatics which directly underlie the peritoneum, they 
made their way into the peritoneal cavity and excited pyasmic peritonitis, 
an affection which differs from traumatic peritonitis, and for which the 
claim has been set up that it is peculiar to puerperal fever. The wide 
stomata upon the abdominal surface of the diaphragm allowed the facile 
entrance of the organisms into its lymphatics. Wald eye r found in dia- 
phragmitis the lymphatics of the diaphragm filled with bacteria. And 
thus following the lymphatic system, if we only admit that the round 
bacteria are the carriers of sepsis, a fact which hardly admits of dispute, 
the frequency, in severe types of puerperal fever, of inflammations of the 
serous membranes—of the peritoneum, the pleurae, the pericardium, and 
the joints—finds an easy explanation. We can understand, too, how it 
is not always altogether accident which determines in different cases 
the precise serous membranes which are affected. 
The ductus thoracicus is the principal channel through which the poi- 
son enters the blood. Bacteria are not usually found in the blood during 
life. A few hours after death they swarm in that fluid. Possibly the 
rapidity of the blood-currents during life does not favor the multiplica- 
tion of bacteria. That the bacteria do, however, enter the general cir- 
culation during life, is incontestable. Steurer writes, “As the kidneys 
are the great filters of the human system, I never neglected to examine 
them, and almost invariably found the glomeruli and arterioli filled with 
micrococci (round bacteria).” This is in correspondence with what oc- 
curs in other septic diseases, and accounts for the albuminuria and inter- 
stitial nephritis which often supervene in the advanced stages. We 
have seen already that, in consequence of septic poisoning, the white 
blood-globules have a tendency to adhere to the walls of the vessels. 
This leads to stases in the capillaries, to congestion of the deep-seated 
organs, and to an increase of blood in the large veins of the trunk. 
Finally death takes place from apnoea, partly from the inability of the 
blood-corpuscles to carry oxygen to the tissues, and partly from paralysis 
of the respiratory nerve centres.1 Sometimes the bacteria pass directly 
into the veins, where they give rise to phlebitis. Prof. Von Reckling- 
hausen recognizes three ways in which this may take place : (1) Through 
a thrombus ; and here let me call to mind that it is very common in 
1 Tide Schuller. Exp. Beitnige zur Studium der septischen Infection, Deutsche Zeit- 
schrift fur Chirurgie, Bd. vi. Heft. 1 und 2, S. 149 u. if. PUERPERAL FEVER. 
841 
Uterine phlebitis to find the uterus large, and the vessels at the placental 
Slte filled with soft thrombi ; (2) through direct perforation of the 
Veiious walls; (3) by being taken up by white corpuscles and by them 
conveyed into the vessels in the manner described by Cohnheim. 
. rhen the bacteria enter directly into the circulation, they sometimes, 
]u passing through the heart, adhere to the endocardium and the valves, 
causing exudation, ulceration, and decomposition, and thus give rise to 
so-called endocarditis ulcerosa puerperal is.l In the cases studied by 
Waldeyer and Steurer, there were diphtheritic patches, serving as the 
parting points of the puerperal processes. Whether these so-called 
. pbtheritic patches are identical with those which appear in the throat, 
ls .an open question. Morphologically, they are so, but, in hospitals, 
epidemics of puerperal diphtheritis are not associated with throat diph- 
To avoid misapprehension, let me distinctly state that diphtheritic 
Patches are not necessary to the infectious form of puerperal fever. They 
lndicate an unwholesome atmospheric condition, and are somewhat rare 
°lltside of public institutions. Orth and Heiberg noticed the same, 
general, post-mortem changes in those cases in which the patches were 
absent, as in those in which they were present. My own observations 
8lJ°w that they are rarely developed in the early stages of a hospital 
epidemic of puerperal fever, nor are they to be found in all cases when 
tach an epidemic is at its height. In some of the lying-in hospitals in 
lJ*'ope, puerperal diphtheritis appears, however, to be endemic. 
The question as to the extent to which erysipelas and puerperal fever 
e cognate diseases, is in a fair way to be solved by recent investigation. 
rth took the contents of a vesicle, from an erysipelatous patient, which 
Retained bacteria in great abundance, and employed the same for injec- 
under the skin of rabbits. In this way he succeeded in producing 
111 these animals a species of erysipelas malignum. In the subcutaneous 
and affected portions of the skin, he found enormous masses of 
a°teria, so far exceeding in quantity the amount introduced as to piove 
abundant new production.2 Samuel produced similar results by the 
pjection of ordinary putrid fluids containing round bacteria. An aff®c_ 
lQn resembling simple erysipelas he obtained most frequently by the 
application of "fluid to a wound torn open after the second or thud day. 
ykowski found that erysipelas could be produced by fluid containing 
lcrococci even when putrefaction did not exist. rihe contents of 
P.cPilous vesicles containing no micrococci, excited no morbid manifesta- 
"Where the erysipelatous process was fresh and progressing, micro- 
°Cci were found in great abundance in the lymphatics and canahculai 
Where the process was retrogressive, there were no micrococci 
0 he found, even in cases in which inflammation existed to an intense 
ekree.4 Virchow’s testimony we have already given. 
. Phus we find in surgical fever, in puerperal fever, in diphtheria, and 
11 ei'ysipelas, the presence of a common element which links them 
°gcther, and which establishes the relationship which has long been 
Cognized as existing between these various processes. Jtxpei intents 
itl(le by competent men, with care and intelligence, seive continually 
GivHeiberg, Die puerperalen und pyaemischen Processe; Leipzig, 1873, S. 22 und 34. 
a d ifferences to cases reported by Wirge and Eberth. , 
3 Gitersuchungen iiber Erysipel.; Arcb. fur exp. Pathol, und 1 harmakol., Bd. i. S. 81. 
4 A’ch. fur exp. Path, und Pharmak., Bd. i. S. 335 u. ff. 
b utersuchungen liber Erysipel.; Virchow’s Archiv, Bd. lx. o. 430. 842 
LUSK, 
to increase the probability that the bacteria are no chance products, but 
that they have a vital connection with the diseases designated. Whether 
these organisms are identical in the different infectious diseases in which 
they have been recognized, is another question. Billroth complains ox 
the monotonous appearance of always the same forms.1 When we bear 
in mind, however, that our best instruments fail to enable us to distin- 
guish the ovum which is to produce a mouse from one that will produce 
a tiger, though the ovum is at least one hundred times larger than the 
micrococcus, the argument loses something of its value. Whether iden- 
tical or not, they all possess the common property of penetrating the 
tissues, under favorable conditions, of multiplying, and of producing, by 
their migrations, local inflammations and general infection. 
I cannot refrain, in conclusion, from quoting entire the following state- 
ment of Panum, which appears to reconcile certain differences in the 
definitions of the term septicaemia by different authors:— 
“ The putrid poison may, during life, enter the blood with or without bacteria, 
especially from wounds, and occasion all the symptoms of septic poisoning, 
whereas, however, the bacterium termo does not appear to occur in the blood 
during life. This simple putrid infection does not appear to be inoculabb’- 
Another, as it appears, distinct, specific, pathogenic fungus, the microsporon 
septicum of Klebs, developed especially in pus (and blood?), perhaps undei 
the predisposing influence of the putrid poison, when the air (as in overcrowded 
hospitals) contains the latter, or when it is transferred by inoculation, seem® 
on the other hand during life to increase in the blood and tissues, and, in pal 
perhaps, by production of a special poison, in part, perhaps, in a xaofe 
mechanical way, by penetration, and, under circumstances by its irritative 
action on the tissues, excites inflammation, purulence, and fever.”2 
Causes of Puerperal Fever. 
The Atmosphere.—The effect of a poisoned state of the atmosphere 
is best observed in the so-called nosocomial malaria of hospitals. 
Bellevue I have had frequent occasion to witness febrile outbreaks among 
the patients in the lying-in service, which were instantaneously arrested 
by closing the tainted ward and transferring the inmates to a healthy 
locality. As at these times the nurses, the bedding, and the utensil9? 
remained unchanged, it is fair to assume that the previous, unhealthy 
condition was not due to the transfer of a poison from patient to patient 
by the attendants, but to something residing in the air of the vacated 
apartment. In the inquiry as to the production of this condition, it can 
be assumed that it is not caused by aggregation alone. The medica 
wards of Bellevue, always crowded, have been in time of.need safe recep- 
tacles for lying-in patients. It certainly is not due to the presence 111 
excess of what are generally regarded as the ordinary constituents of fh® 
atmosphere. We must, therefore, look for some additional elenien 
capable of unfavorably affecting the economy. When the disturbance 
produced by nosocomial malaria is not arrested by change of locality, 
the golden moment is allowed to slip by, the secretions of the patient 
affected become inocnlable. Tinder such circumstances the epidernxc 
spreads rapidly, and assumes continuously a more and more severe type- 
1 Untersuchmigen über die Coccobacteria septica, S. 3. ~ 
2 Das putride Gift., etc., Virchow’s Archiv, Band lx. S. 349. I have translated litera } 
The meaning of the sentences, in spite of the involved construction, is sufficiently clear- PUERPERAL FEVER. 
843 
ft du ring such an epidemic, the external genitals be carefully watched, 
ctlplitheritic patches may now and then be observed. At first these 
Patches may not be of any special clinical importance. It is possible that 
lbey may rapidly clear off, and thus come to be regarded as of little con- 
fluence. When, at length, the epidemic has assumed a pestilential 
ol'm, these patches, which may make their appearance in isolated cases 
any time in a hospital, are rarely absent. I have already dwelt upon 
uu composition of these patches, not because I believe that they are 
Essential to puerperal fever, but because their presence tells the tale of 
Pjdiat it is in the atmosphere which accomplishes the charnel-house work. 
Conditions have been present in the air to favor the multiplication of 
bacteria, and have fitted them to become the active producers of disease. 
Can we doubt this? First, the epidemic was mild. If a patient, how- 
?Ver, died, her tissues and secretions were filled with bacteria, as has 
feu described. Then the epidemic became virulent, and the lesions of 
me generative apparatus, especially of the external organs which were 
exposed to the air, became covered with patches which were found 
® swarm with micrococci. I cannot, under the conditions named, but 
Consider it more in accordance with ordinary scientific reasoning to con- 
c*ude that the micrococci played an important part in the production of 
£Uei'peral fever, than that the puerperal fever produced the micrococci. 
be sure, bacteria or their spores are always present in the atmosphere, 
aild it may be fairly asked how patients are ever spared from their per- 
Je»'se industry. The answer is that they are not always equally active 
*ol' evil. Bucholz found that the same bacteria, developed in Cohn’s 
*mid, offered more resistance to carbolic and salicylic acids than those 
°uitivated in an analogous fluid which he had adopted. Distilled water 
Anders the action of bacteria extremely feeble. In experiments upon 
Uuirnals, the results obtained with septic fluids depend in m) oidinaiy 
aegree upon the of the fluid, the material from which it is formed, 
fnd the conditions under which it is generated. Micrococci multiply in 
u°spitals when organic materials favorable to their growth are present in 
Bufiicient quantities. Robin and others have demonstrated the existence 
u* albuminoid matters in water condensed upon vessels containing leezmg 
futures, and placed in overcrowded wards of hospitals. When le 
Faults of crowding become manifest, these albuminoid matters not on y 
JmPart a peculiar fetid odor and putrefy with great rapidity, but rapidly 
fhart putrefaction to normal blood and healthy muscle with which they 
re brought in contact.1 Micrococci both cause putrefaction, and serve 
toe carriers of septic virus. Hueter found putrid blood a most favor- 
flye fluid for septic experiments. It was noticeable in Bellevue Hospital 
/yat febrile outbreaks always arose in, and were usually confined to the 
Jard in the hospital which, by a bad arrangement, was assigned to 
Indents for the first four or five days following confinement, i. e., during 
I.I'®1'® Period of the lochia cruenta. As puerperal fever is rare after the 
Jtb day, this at first sight would seem natural. But if a patient was 
transferred directly after confinement, during one of these unheal thy 
flei’iods, to the ward containing the patients who had passed the first five 
rfys, but had not completed the ten days, she would escape the fever. 
'vas always the same ward that required to be disinfected. In a com- 
apartment all the confinements took place ; and at all times, 
Ujerefbre, the conditions were present for loading the atmosphere with 
1 Legons sur les Humeurs ; Paris, 1867, p. 195. 844 
LUSK, 
the products of decomposing blood. In the summer months, as long a3 
the windows were open all the time, the patients enjoyed immunity troiu 
nosocomial malaria. In the early fall, as soon as it became necessary 
close the windows partially on account of the cool nights, it was not 
uncommon for the more trivial disturbances, such as so-called milk-lever, 
the hospital pulse, and catarrhal affections of the genitalia, to manifest 
themselves. Through the months of February, March, and April, the 
mortality was usually greatest. During the winter months there was, 
as a rule, crowding of patients, insufficient ventilation, the saturation o 
the air with albuminoid materials chiefly derived from blood, which* 
under the furthering influence of the heat requisite to make the wards 
comfortable, entered readily into decomposition. That the latter wiffiel 
months should prove the most perilous, is in accordance not only witn 
the theory of continuous accumulation, but with the experimental iaC 
that weeks sometimes elapse before a decomposing substance acquires the 
highest degree of virulence. 
Apart from the nosocomial malaria of hospitals, there is reason to be- 
lieve in the influence at times of certain general wide-spread atmospheric 
states which affect the entire community. In the year. 1871, the mor- 
tality from child-bed in New York was 399 ; in 1872, 503 ; in 1873, 431’ 
in 1874, 439, and in 1875, 420. Now the excess in the deaths for 187 
was due wholly to an increase in the cases of metria, those from orq 
nary accidents remaining nearly the same as in the preceding years. 111 
disease certainly did not extend into the city from the hospitals servUA 
as foci, for the mortality that year at Bellevue Hospital was hardly moi 
than half the usual average. There was no especial Mortality that yeal 
from either diphtheria, erysipelas, or scarlatina, but the aggregate mol' 
tality was the largest known in the history of the city. There are 
positive data connecting the civil deaths from puerperal fever in 
with parasiticism, but the prevalence of epizootics, of epidemic catarrh*1 
affections, of peculiarly fatal forms of pneumonia, and other disease 
which are now attributed to the presence of minute organisms in fb 
atmosphere, renders such a source highly probable. 
It is proper to say here that, though the argument is very strong *n 
favor of regarding the genitalia of puerperal women as the exclusive 
point of entry into the system of infectious materials, it seems impossible 
at the present time to make all the facts coincide with such a them’}’ 
I have the records of a number of cases occurring during an epidemic o 
puerperal fever, in which patients were either attacked With fever plu- 
vious to parturition, or in whose cases the unusual length of labor, tn 
frequency of post-partum hemorrhage, and the imperfect contraction ° 
the uterus, immediately after confinement, were signs of some abnorma 
influence exercised upon the economy at an early period of labor, p,e 
vious to the existence of traumatism. That deleterious materials may 
find other channels for entering the system than a wounded surface, 
evidenced by the cachectic condition not unfrequently produced in pb} 
sicians by too assiduous attendance in dissecting-rooms and places i 
which post-mortem examinations are conducted. One severe and rapm } 
fatal case of puerperal fever, which occurred in Bellevue Hospital, I ml' 
it impossible to attribute to any other cause than that the woman, n 
five months previous to her confinement, served as a helper in a lyffiA 
ward. The post-mortem examination disclosed no special local lesion-1 
but her symptoms were those of intense septicaemia. It does not } 
seem quite time to give up the idea that, under exceptional circun PUERPERAL FEVER. 
845 
stances, the respiratory, and probably the digestive, tracts, may allow 
Ule passage of materials of a septic character. 
Inoculation.—Another and frequent source of puerperal fever is by 
,/reet inoculation. Any material of a septic character, introduced into 
Vl6 genital passages of a woman during or after confinement, may pro- 
auce a general infection of the system. But the point upon which I 
wish especially to dwell is that it is possible to trace epidemics of puer- 
peral fever directly to carrying puerperal poison from patient to patient, 
trough the medium of attendants. In such cases, changes in wards 
aTd the most rigid sanitary precautions avail but little, as long as the 
auected personnel is continued in charge. Unless this fact is fully 
recognized, all the cleverest devices in hospital construction will fail to 
Prevent the occurrence of disasters. In epidemics this source of danger is 
especially to be guarded against, as septic poison is increased in intensity 
successive inoculations. Bavaine1 showed that when a number of 
animals were poisoned, the one from the other, while from ten to fifteen 
drops of putrid blood were required to produce death in the first animal 
°ne ten-trillionth part of a drop was sufficient in the twenty-fifth animal 
°f the series, and in puerperal fever epidemics a similar augmentation in 
rhe deadliness of the poisons generated by patients is observed. 
The nurses in hospitals and in private practice are usually the carriers 
°f contagion. In studying the records of New York City for nine 
s’ears, I find, however, that the occurrence of two deaths from puerperal 
disease, following one another so closely as to lead to the suspicion of 
inoculation, occurred to thirty physicians; a sequence of three cases oc- 
curred in the practice of three physicians; one physician lost three cases, 
and afterwards two, in succession ; one physician had once two deaths, 
°nce three deaths, and twice four deaths following one another; finally, 
a physician reported once a loss of two cases near together, then of six 
Patients in six months, and then of six patients in six weeks. Thus in 
|Te practice of more than 1200 physicians, in nine years, I find, exclud- 
}ng cases occurring in hospitals, that the experience of thirty-six only 
|®uds color to the idea that puerperal fever is due to criminal neglect on 
yJe part of the medical profession. Undoubtedly in many of these cases, 
to°, the responsibility is only apparent, as when a practitioner has, for 
example, had the misfortune to lose in one week a woman from puerpe- 
lal convulsions, and another in the following week from placental hem- 
orrhage. Singularly enough, not one of the sequences mentioned oc- 
curred in the practice of a physician connected with a lying-in hospital. 
11 face of the charge that the physicians holding obstetrical appoint- 
ments in public institutions are active disseminators of puerperal fever 
trough populous communities, I find that the total loss from all puer- 
peral causes occurring in the private practice of ten physicians intimately 
Associated with such institutions, numbered, during the nine years, but 
r 'vonty-one cases. Of these, thirteen were the result of ordinary accidents, 
onPf eight cases of metria proper, of which one was developed before 
physician was called in attendance; whereas a single physician, hold- 
no hospital appointment, lost during the same time twenty-seven 
*a®ess of which twenty-one were cases of metria. 
-t have been interested in endeavoring to ascertain how far experience 
Corresponds with Seraelweiss’s theory that puerperal fever owes its origin 
0 poisonous materials obtained from dissecting-rooms, and introduced into 
1 Report before the Academic de Medecine, Sept. 17, 1872. 846 
LUSK, 
the genital canal by the hands of physicians attending cases of labor* 
With this view I have made personal application to a number of gentl6' 
men who have engaged in midwifery practice while performing 
functions of demonstrators of anatomy in our medical schools. Dr. D* 
B. Sands, of the College of Physicians and Surgeons, reports that in the 
five years during which he held the office of demonstrator, he attended 
about sixty cases of labor. All did well. He lost his first patient, from 
child-bed, a short time after he had resigned his position in the dissect' 
ing-room. Dr. J. W. Wright, the present Professor of Obstetrics in the 
Medical Department of the New York University, who held for oneye&r 
the position of Demonstrator in the Woman’s College, writes me that “ dot' 
ing the year, I attended one hundred and four cases, including twenty-two 
forceps cases, two of craniotomy, two of podalic version, and four 
breech presentation. Of this number I lost two cases, one from phi eg' 
masia dolens complicating uraemia, from both of which troubles the 
patient had suffered during her previous labor, and one from double pneu- 
monia, the result of unusual exposure following confinement. Out ot 
these one hundred and four cases, I can recall but three or four cases ol 
metritis, and those of a mild character; I have never thought they ha01 
anjr special connection \yith my duties in the dissecting-room. I may 
add that for ten years I have attended a pretty large number of confine- 
ments each year, and that during the whole of this time I have been 111 
the habit of making autopsies as occasion has offered, and of handling 
and examining pathological specimens both in and out of the dissecting- 
room, notwithstanding which, my death record among this class of case9 
has been unusually low.” Dr. Samuel B. Ward, formerly Demonstrate1 
at the Woman’s College, at present Professor of Surgery in the Medicm 
School at Albany, writes: “While I was daily in the dissecting-roonu 
during the winter sessions of the school from 1868 to 1872,1 attendee 
thirty-two confinements of which I have notes. All of the patients 
recovered, nor did any of them suffer from any complication that coum 
be traced to infection.” It is familiarly known that after Semelweiss bad 
introduced the practice, among the physicians attending patients at the 
large lying-in hospital in Vienna, of washing the hands in a solutio11 
of chloride of lime, there was a great diminution in the mortality 
which prevailed, notwithstanding which, G. Braun reports, however, tb*J 
in 1857, in the month of July, in two hundred and forty-five deliver^9 
there were seventeen deaths. The following month, Prof. Klein gave 
orders to suspend the use of disinfectants. By chance, in August tbefe 
were only six deaths out of two hundred and fifty confinements, and 111 
September, of two hundred and seventy-five patients, none died. Fro1*1 
1857 to 1860, the mortality was slight, though disinfectants were »9 
used, while during the three following years, in spite of the systeraaW 
and persistent employment of these agents, the death-rate once rn°re 
assumed formidable proportions.1 _ , 
Of course I do not wish to underrate the importance of Semelweiss & 
labors. There is no question but that it is a perilous experiment to pa9i3 
from the dissecting-room to a patient in labor, without employing rig(ll' 
ous measures to disinfect the hands and all parts of the person brougj1 
into contact with the dead body. But it is well to call attention to fbe 
fact that puerperal fever is not due to any single, simple cause, nor is 
Q 32 
1 Ruckblicke auf die Gesnndkeits Yerkaltnisse unter den Wbcknerinnen, u.s. w., o* 0 ’ 
33. PUERPERAL FEVER. 
847 
effectually guarded against by a single precaution ; and again that 
poison does not of necessity exist in every cadaver examined. 
■*daussmann found that injections into the vagina of gravid rabbits, in 
latter half of pregnancy, of serum from the corpse of a person not 
of septicaemia, produced no fatal results, while rapid death resulted 
b'°m injections, under the same conditions, of pus from the abdomen 
a woman dying from puerperal infectious disease.1 
ll,.—Deaths occurring in New York, between the years 1861 and 1815, 
inclusive, from metria, excluding other causes, which proved fatal during 
the puerperal period. 
Year. 
Jan. 
Feb. 
Mar. 
April 
May. 
June. 
July. 
-Aug. 
Sept. 
Oct. 
Nov. 
Dec. 
Total 
deaths 
from 
metria. 
Total 
from 
all 
causes. 
1867 
16 
10“ 
14 
16 
12 
5 
6 
8 
5 
5 
9 
14 
120 
238 
1868 
17 
14 
27 
16 
18 
9 
12 
8 
7 
3 
8 
12 
151 
267 
1869 
25 
26 
18 
10 
15 
14 
12 
15 
8 
12 
16 
19 
190 
312 
1870 . 
12 
17 
37 
27 
20 
10 
12 
16 
10 
12 
11 
17 
201 
333 
l87l 
21 
30 
22 
25 
26 
17 
11 
13 
.7 
7 
12 
23 
214 
399 
1872 ' 
26 
37 
41 
40 
27 
21 
14 
24 
13 
14 
18 
32 
307 
503 
1878 
33 
40 
32 
39 
29 
22 
16 
15 
13 
11 
23 
12 
285 
431 
1874 
19 
32 
24 
33 
34 
21 
18 
15 
10 
7 
7 
25 
245 
439 
*875 
28 
28 
40 
30 
22 
17 
10 
10 
5 
11 
14 
19 
234 
420 
Total . . 
197 
244 
255 
236 
203 
136 
111 
124 
78 
72 
118 
173 
1947 
3342 
Season of Year. X have in a special table (Table II.) classified all the 
deaths from metria in New York, during nine years, according to the 
Months in which they occurred, and from this it appeals that moie than 
twice as many deaths took place between the six months from December 
May inclusive, as between the six months from June to November 
delusive. The greatest mortality occurred in February and March, 
Counting to 499 cases, or rather more than one-fourth ot the entire 
The smallest death-rate occurred in September and October, in 
which months but 150 deaths, or one-thirteenth of the entire number, 
to°k place. 
i 1 bntersuchungen und versuche liber die Entstehung der übertragbaren Krtmkbeiten 
JesffWochenbettes; Beitrilge zur Geburtshulfe und Gynakologie, Bd. m, Hett 3, b. 3i4, 848 
LUSK, 
Table III.— 
-Deaths from puerperal 
of New 
causes in 
York. 
the different city wards 
i. 
II. 
III. 
IV. 
V. 
VI. 
VII. 
VIII. 
IX. 
X. 
XI. 
XII. 
XU1- 
1867 
4 
0 
0 
10 
6 
3 
7 
17 
4 
15 
2 
13 
2 
1868 
4 
1 
1 
12 
3 
4 
9 
11 
9 
8 
8 
28 
7 
1869 
7 
0 
0 
5 
2 
5 
20 
24 
8 
19 
13 
20 
16 
1870 
4 
0 
1 
5 
6 
5 
6 
20 
4 
19 
13 
21 
16 
1871 
6 
2 
4 
4 
8 
3 
17 
17 
11 
21 
21 
27 
10 
1872 
6 
1 
4 
5 
4 
11 
13 
19 
10 
26 
14 
47 
11 
1873 
8 
0 
2 
5 
4 
12 
12 
19 
8 
20 
14 
40 
14 
1874 
7 
0 
1 
7 
7 
14 
14 
26 
8 
23 
11 
24 
13 
1875 
9 
2 
2 
3 
4 
7 
17 
14 
13 
17 
20 
25 
18 
Total 
65 
6 
15 
66 
44 
64 
115 
167 
75 
168 
116 
2451 
107 
Estimated number of 
births4 
4284 
387 
1089 
7053 
5049 
6237 
12,855 
10,395 
14,137 
12,325 
18,975 
14,107 
9898 
Eatio of deaths to 
births 
1 : 78 
1:64.5 
1 : 72 
1 ; 126 
1 : 115 
1 
: 97.5 
1 
: 112 
: 62 
: 188 
1 
73 
1:163.5 
1 : 57 
1 : 93 
xiy. 
XV. 
XVI. 
XVII. 
XVIII. 
XIX. 
XX. 
XXI. 
XXII. 
XXIII. 
XXIV- 
Total- 
1867 
9 
9 
8 
38 
15 
22 
18 
24 
12 
238 
1868 
7 
5 
6 
32 
18 
17 
21 
35 
21 
26? 
1869 
10 
4 
9 
33 
21 
37 
22 
27 
10 
313 
1870 
2 
5 
9 
41 
28 
34 
19 
53 
22 
333 
1871 
8 
6 
18 
41 
21 
38 
37 
54 
25 
399 
1872 
14 
11 
23 
45 
24 
85 
45 
43 
42 
503 
1873 
6 
7 
14 
40 
24 
51 
40 
54 
38 
431 
1874 
7 
6 
20 
36 
8 
56 
39 
66 
34 
12 
439 
1875 
14 
12 
18 
51 
27 
53 
19 
30 
39 
6 
1 
420 
Total 
76 
65 
125 
357 
186 
3932 
260 
3863 
243 
17 
1 
3313 
Estimated number of 
births4 
7850 
8197 
14,363 
28,323 
17,701 
25,542 
22,394 
16,840 
21,191 
Eatio of deaths to 
births 
1 ; 103 
1 : 126 
1 ; 113 
1 : 79 
1 ; 95 
1 : 65 
1 ; 86 
1:45.6 
1: 
37 
i o2 
1 The twelfth ward includes Ward’s Island Hospital and the Colored Home, which furnished together 4 
deaths ; deducting these the ratio would be 1 ; 99. . he(j 
2 The nineteenth ward contains the Nursery and Child’s Hospital and the Charity Hospital, which furnxs 
together 83 deaths ; deducting these the ratio would become 1; 82. 
3 Includes 189 cases from Bellevue Hospital, deducting which the ratio would become 1 ; 85. 
4 The number of births in each ward is roughly estimated by assuming the population of 1870 to be 
average of the nine years, and then allowing 33 births to the thousand. This method makes no pretenc 
accuracy, but it is not likely that exact returns would materially alter the relative proportions given- 
furnishes a total of 279,000, or 5000 less than that obtained by assuming an annual increase of 16,000 to 
entire population of the city. 
Influence of Locality.—l have likewise prepared a table showing the 
number of deaths from puerperal causes occurring in each year in tn 
several wards into which the city is divided, and the ratio of deaths PUERPERAL FEVER. 
849 
|Te estimated number of births in each ward. The average ratio is, as 
has been already stated, about 1 to 85. In the 9th Ward, however, it 
1 to 188; in the 11th Ward, 1 to 163.5 ; and in the 15th Ward, 1 to 
126. These wards make the most favorable showing in the city. By 
Reference to the map, they are all found to occupy the same territorial zone. 
I’l the 17th Ward, situated between the 11th and 15th Wards, the ratio 
deaths to births, it is true, was 1 to 79; but the 17th Ward is the 
]ost densely populated section of the city. As neither the 9th nor the 
llth Wards are otherwise especially favored, both containing a large and 
crowded tenement-house population, it is hard to understand their rela- 
te immunity from deaths due to puerperal diseases, unless upon the as- 
Sllmption that local causes, probably superior drainage, render them 
Exceptionally free from endemic sources ot disease. 
IY.—Deaths from puerperal causes in the 18th, 19th, and 21s£ wards, 
with the relative proportion of deaths, not occurring in Hospitals, among the 
population east and west of Third Avenue. 
Died in 
Deaths upon 
the west side 
Deaths upon 
the east side 
Relative proportion of 
deaths ou west and east 
Year. 
Total. 
hospital. 
of Third 
Avenue. 
of Third 
Avenue. 
side, expressed in 
percentages. 
1867 
61 
20 
8 
33 
24 per cent. 
1868 
70 
28 
8 
34 
23.5 
1869 
85 
23 
12 
50 
24 
1870 
115 
34 
9 
72 
12.5 
1871 
113 
32 
15 
66 
22.7 
1872 
173 
43 
10 
120 
8.3 
1873 
129 
37 
15 
77 
19.5 
1874 
130 
45 
14 
71 
19.7 
i87s ; ; ; 
110 
15 
8 
87 
9.2 
■Aggregate . 
986 
277 
99 
610 
16.2 
Social State.—l have, too, sought to ascertain whether the wealthy and 
classes enjoy special immunities from puerperal disease. The 
district bounded by Fourth and Sixth Avenues, and Twelfth and fifty- 
-111 nth Streets, contains the great proportion ot those who make up the 
privileged classes. In this portion of the city, the proportion ot deaths 
°m puerperal causes to the deaths from the same sources th lough out 
, cify, is as Ito 48. The precise population ot the district I cannot 
°6tain, but it is safe to say that it contains at least one-thirtieth ot the 
en£re population of the city. . 
Phe eighteenth, nineteenth-, and twenty-first wards, included between 
-i.xth Avenue and the East Elver, and extending from Fourteenth to 
Streets, contain in a marked degree the two extremes of 
ealth and poverty. Third Avenue separates the temtory into two 
fd’ial parts, and forms a fair dividing line between the upper and the 
J°Wer social strata. The population upon the west side ot Ihird Ave- 
lle is, it is true, less than that upon the east side, possibly not more 
jan half as great, but the mortality of nine yeais trom pueiperal causes 
"as io this favored region less than one-sixth, even aftei deducting 
j 1 I am informed by politicians that the vote in the ward mentioned is about 50 per cent, 
rger 0n the east side of Third Avenue. 
54 850 
LUSK, 
deaths occurring in hospitals, which for the most part lie upon the east 
side. In 1872, the fatal year, the proportion was one to twelve. 
Table 
V— 
Deaths from scarlatina, diphtheria, omcZ erysipelas, 
and, from aU 
causes, by quarters, 
compared with deaths from metria, for the nine years 
ending December 31, 1875. 
1867. 
1868. 
1869. 
Ih* 
jj 
Causes of 
Xt 
X 
death. 
£ 
O4 
c3 
o 
c3 
2 
c4 
d 
o 
d 
a4 
3 
3 
"* 
"3 
o 
rH 
(M 
eo 
* 
cq 
CO 
Eh 
cq 
CO 
Scarlatina 
264 
194 
89 
103 
650 
318 
351 
102 
90 
861 
299 
285 
159 
223 
966 
Diphtheria 
79 
66 
63 
63 
251 
92 
87 
43 
55 
277 
87 
89 
66 
86 
323 
Erysipelas 
40 
32 
20 
22 
114 
31 
45 
13 
13 
102 
54 
55 
14 
29 
152 
All causes 
5197 
5121 
7516 
5325 
23,159 
5953 
5523 
8658 
4755 
24,889 
5919 
6065 
7390 
5793 
25,1^7 
Hetria 
120 
151 
ISO 
1870. 
1871. 
1872. 
U 
Causes of 
X 
U 
death. 
c3 
0 
C4 
*3 
o 
d 
S4 
"* 
d 
o 
d 
2 
G4 
3 
O 
<M 
CO 
H 
cq 
CO 
tH 
Eh 
rH 
CM 
CO 
Scarlatina 
418 
258 
106 
193 
975 
274 
196 
137 
184 
791 
301 
367 
132 
190 
9f0 
Diphtheria 
94 
69 
67 
78 
308 
89 
49 
46 
54 
238 
93 
86 
87 
180 
446 
Erysipelas 
50 
42 
4 
25 
121 
54 
50 
18 
23 
145 
64 
73 
23 
25 
18-5 
All causes 
6517 
6293 
8416 
5949 
27,175 
6622 
6621 
7833 
6900 
26,976 
7406 
8737 
10,025 
6479 
33,647 
Metria 
201 
214 
307 
1873. 
1874. 
1875. 
Causes of 
■§ 
x 
X 
death. 
c3 
O4 
1 
'ce 
o 
d 
d 
a4 
'd 
O 
d 
0 
O4 
** 
& 
o 
rH 
Cq 
CO 
Eh 
cq 
CO 
Eh 
cq 
eo 
Scarlatina 
242 
275 
202 
326 
1045 
322 
239 
166 
152 
879 
186 
161 
63 
104 
514 
Diphtheria 
169 
184 
316 
482 
1151 
334 
314 
320 
697 
1665 
608 
549 
489 
683 
2329 
Erysipelas 
83 
60 
30 
31 
204 
49 
62 
25 
33 
169 
66 
51 
21 
29 
167 
All causes 
6815 
6583 
8983 
6703 
29,084 
6328 
6548 
8509 
.7342 
28,727 
7840 
7065 
9257 
6547 
30,709 
Metria 
286 
245 
334 
Relations to Zymotic Diseases.—l prepared, some time ago, tables _to 
answer the inquiry as to whether there was any relation between the t1’6' 
quency of cases of scarlatina, diphtheria, and erysipelas, and those iron 
metria proper. Previous to their publication,however,l was anticipate 
in my deductions by a paper upon the same subject by Dr. Matthews 
Duncan.1 I therefore simply submit the tables with the comment tba 
1 On the alleged Occasional Epidemic Prevalence of Puerperal Pyminia, or Puerpe 
Pever, and Erysipelas ; Edinburgh Medical Journal, March, 1876, p. 774. PUERPERAL FEVER. 
851 
no ielation to exist between the statistical frequency of puer- 
ev! fever.^ud tbe zymotic diseases mentioned. The tables do not, how- 
vi/’ invalidate any direct testimony which goes to show that, in indi- 
-2v Ua . lrJ®^ances5 a real connection between puerperal fever and the 
J'motic diseases may exist. 
Prevention of Puerperal Fever. 
eiPiH?,342 deaths fr?m P™T?ral causes> 420 died in hospital, or one- 
-olf ™of the entire number. Of the 1947 eases of metria, about 300, or not 
time one-sixth, were contributed by the hospitals. Upon such a showing 
>e tirst impulse would be to cry out loudly for the suppression of materni- 
inT Bnt ,11 y™ei- policy suggests the inquiry whether the large mortality 
1 hospitals is an evil necessity. To this the answer is “ No.” It is pos- 
-I,Jle, in the present state of our scientific knowledge, to so control the 
onditions that favor the generation of puerperal diseases in lanm hos- 
mmls, as to make them safe asylums for the needy. 
Thus in the Charity Hospital, Hr. Hitching reports the number of con- 
Pements between July 1,1874, and May 1, 1876, at 1149; of which 
u ended in death, or 1 in 57. But only six were cases of metria, or 1 
a 191 deliveries, a better record than that afforded by the average of the 
at large. In the Nursery and Child’s Hospital, there one 
eath from metria in 1874, and one in 1875. In 1872, the number of 
c°afinements was 205. I regret that a request for the number of confine- 
?Pents in the succeeding years has been refused me. The Marion Street 
Pying-in Asylum, an excellent institution for married women, reports 
-pV° deaths from metria in nine years. Hr. G-oodell reports that, at the 
rcston Petreat, in 756 cases of labor there have been but two deaths from 
?eptic disease; Winckel,1 of the Lying-in Institution in Hresden, reported, 
n 1873, eighteen deaths from metria, or 1.8 per cent., but from the 10th 
*y January to the 7th of July, in 570 deliveries there was but one case of 
eptic disease; in the year 1872 the death-rate exceeded 5 per cent. The 
Eduction in the mortality was no fortuitous circumstance, but was due to 
measures for the prevention of disease.2 Stadfeldt reduced the mor- 
ality from puerperal fever, in the Maternity Hospital of Copenhagen, from 
111 37, the proportion between theyears 1865 and 1869, to lin 87, between 
years 1870 and 1874.3 Hr. Johnston reports in the Eotunda Hospital 
Hublin, during seven years, 7860 deliveries (I have excluded the cases 
I abortion) with 169 deaths, of which 85, or 1 in 91, were from metria.4 
1 rot. J. J. Bischoff reports that in the Maternity of Basel, between the 
Mars 1862 and 1867 inclusive, in 514 confinements there were 33 deaths, 
r m about the proportion of one to sixteen. In 1868, of 75 patients 
°afined, there died three, or one in twenty-five. In 1869, of 86 patients 
_°rifined, seven died, or one in twelve. In 1870 effective measures of 
H’evention were introduced, and, that year, in 80 confinements there were 
j° deaths.s In 1871, two out of 124 patients died, or one in sixty-two. 
II 1872, in 153 confinements there were four deaths, a proportion of one 
■Pn the Means employed at the Preston Retreat for the Prevention and Treatment of 
U2?fPeral Diseases, p. 13. 
a richte un(j gfudien, u.s. w., Leipzig, 1874, S. 183. 
4 £es. Maternites, leur Organisation et Administration; Copenhague, 1876. 
s er)es of Clinical Reports, from 1870 to 1876 inclusive. 
• J Bischoff, Zur Prophylaxis des puerperal Fiebers; Basel, 1876, S. 12,13. 852 
LUSK, 
to nearly forty. The next year, 1878, strict measures were again put 
in force, and in 184 labors there were two deaths, or one in ninety-two. 
In 1874, in 214 labors there were three deaths, one to seventy-one, but 
one of the patients entered the hospital with endocarditis, of which 
affection she died. In 1875, in 204 confinements.there were two deaths 
one from hemorrhage, and one from pyelitis which existed at the time 
the patient entered the hospital. 
Surely these figures do not support the idea that it is better for a 
woman to be confined in a street gutter than to enter the portals of a 
lying-in asylum. Dr. Goodell’s experience shows that a hospital for re- 
spectable married women may be so conducted that its inmates may 
enjoy absolutely a greater degree of safety than do women in their homes, 
surrounded by all the aids that wealth can command. Equally good 
results are not to be obtained in hospitals which are open to unfortunates 
of every class. But there is much misapprehension and confusion of 
ideas respecting the fate of these women, when no charitable provision 
is made for them. In Copenhagen, the Maternity Hospital is closed for 
from six to eight weeks in the summer time. During this period, un- 
married, parturient women receive pecuniary assistance from the hospital 
to enable them to obtain a place in which to be confined. How Stadfeldt 
reports a larger mortality among this class than among those delivered 
in the hospital. Yet they are confined at a favorable season of the year, 
without any communication with the furniture, the sage-femmes, or the 
physicians of the hospital. As they fortunately receive nothing but 
money, that can hardly be suspected of communicating contagion- 
What their fate would be in Hew York City, perhaps, may be judged 
from the following facts : Excluding cases confined in hospitals, nearly, 
one-thirtieth of all the deaths and one-twenty-fourth of the cases ot 
metria are reported by four practitioners. Ten practitioners out of 1200 
signed the death certificates of one-fifteenth of the women dying from 
puerperal causes, and one-tenth of the cases of metria. But it is not to 
be supposed that these deaths were all the result of malpractice and in- 
competence. The true history of most of them probably wTas that the 
doctor was engaged to attend the case of confinement for a small fee, 
with the understanding that he should make no calls subsequently, unless 
specially summoned by the friends of the patient. The latter, left to 
ignorant care, or perhaps without any assistance whatever, and exposed 
to all the pernicious influences bred by poverty, when illness supervened 
probably did not call the physician to her aid until the time for help had 
passed, so that in the end his professional functions were confined to pro- 
curing the requisite permit for burial. 
Humanity demands that charity should furnish places of refuge m 
which poor outcasts can receive assistance during the perils of child' 
bearing. If we must then have maternities, we should make them sale, 
and this can be in great measure accomplished by remembering the two- 
fold source of danger arising from a poisoned atmosphere and direct inocu- 
lation. A hospital must be clean, spacious, and well ventilated, or its 
atmosphere will become charged with decomposing albuminoid sub- 
stances, and produce nosocomial malaria. But the experience of the 
Hopital Cochin,1 a costly, palace-like structure, with every appliance ot 
art, proves that fresh air alone does not protect patients from the conse- 
quences of inoculation. On the other hand, the most rigid sanitary pre' 
1 Billet, E6forme des MaternitG, p. 75. PUERPERAL FEVER. 
853 
Cautions observed by the attendants will not prevent a badly ventilated 
'Ward from becoming unhealthy, unless unoccupied wards are kept to 
'jhich patients can be transferred upon the first admonition of danger. 
At the Charity Hospital, the service consists of two large wards, occu- 
pied for three weeks at a time alternately. Dr. Groodell states that at 
11 e Preston Retreat the wards are used invariably in rotation. In coll- 
ection with the Maternity at Copenhagen, there are a number of small 
BuPplementary hospitals scattered through the city, which serve assafety- 
valves for the central institution. Artificial methods of ventilation 
the task of keeping the wards healthy, comparatively easy. They 
not need, however, to be complicated and expensive. The good re- 
pute of the Rotunda Hospital, it seems to me, is in large measure due to 
natural ventilation afforded by open fireplaces. 
The testimony is very general to the advantages of frequently washing 
wards with carbolic acid. At the Charity Hospital, in addition, the 
'vards are fumigated three times a week by burning a mixture of carbolic 
a°id, chloride of lime, and sulphur. During parturition, Stadfeldt ex- 
poses the woman to a fine spray of carbolic acid. If, after confinement, 
Paginal washes of carbolic acid should be used, every woman should be 
applied with her own nozzle, which can be made of glass tubing, and 
attached in turn to the irrigator. When not in use, these should be 
ept in solutions of carbolic acid. 
A liberal supply of metallic catheters should be always kept on hand 
ar>d, when not in use, placed in a disinfectant fluid. Sponges, in a hospi- 
tal, are an abomination. Oakum, lint, or old cloths should be employed 
to receive the discharges, and, when removed, should be placed at once 
0 a vessel containing disinfectants, and then, instead of going into the 
should be burned. As regards all prophylactic measures, cheap- 
ens is not to be consulted. 1 . 
As puerperal patients require much attention, lying-m wards should 
Possess a sufficiency of attendants, best, perhaps, by making them training 
BeWls for nurses. Nurses should be intelligent enough not only to com- 
prehend their duties, but their responsibility. Physicians should wash 
their hands with disinfectants before and after making examinations, 
aild nurses should do the same whenever their hands are brought into 
with vaginal secretions. D’Espine has shown that the lochia of 
.le third day of a healthy patient will poison a rabbit.1 A nurse employed 
-ln the puerperal wards ought not to have access to cases of laboi. A 
Patient attacked with fever should be immediately removed to another 
Pai't of the building, and the nurse in attendance should go wi i er. 
special wards for the recently confined should never be established. As 
of details is essential to success, a lying-m hospital should 
a resident medical head with plenary power to enforce the most 
porous discipline. The adoption of Lister’s principles in maternity 
has, when carried out with the requisite discipline, served to 
Pupate the well-founded objections to their existence. It makes no 
dAference whether they are old hospitals or new, cottages or pavilions. 
All that is required is space, light, air, intelligent nursing an active 
.head, and generosity in needed supplies, to keep them as free from mfec- 
diseases as are the homes of the better classes. _ I have already 
J°wn, in another paper, how, through limited room, ignorant nurses, 
1 Contributions it I’Etnde de la Septic6raie Puerperale, p. 18. 854 
LUSK, 
lax discipline, and niggardly management, an epidemic, costly in life’ 
could be generated. 
So far from tearing down the maternity hospitals now in existence, 
new maternities of small size, for married women, modelled after the 
Preston Retreat, are urgently called for to meet the present waste of life 
among the very poor. I cannot but hope that such institutions, intelli- 
gently constructed, ordered, and maintained, may yet be the outcome 
of private charity, A small maternity has the advantage over a large 
one that, when a dangerous element is introduced, repressive measures 
can be more rapidly and effectively carried into execution. I have already 
taken up so much time that I will not dwell upon the duties of the phy- 
sician toward his private patients; how he should avoid conveying to 
them zymotic diseases, or septic poisons; how he should understand 
that the proper management of labor involves a normal puerperal state; 
how he should guard lest the antecedents of his patients should unfavor- 
ably affect the period of parturition and child-bed. I have only to add 
that, among the wealthy and refined, there is an annual sacrifice of lovely 
women, due, not to want of skill or care, not to infection, but to the 
fact that the enervating influences of civilization and the pressure of 
social life, have apparently unfitted them for offering effective resistance 
to any form of traumatism. Dr. E. H. Clarke’s little work entitled “ SeX 
in Education,” strikes the key note of a subject requiring on the part of 
obstetricians the profoundest consideration. 
In closing this paper, I beg to offer the following conclusions:— 
I. There is no specific, puerperal fever, and, as long as, when the term 
is limited, each physician uses it in some sense personal to himself, it i 9 
best to employ it as a general term for all the febrile affections peculiar 
to the puerperal state. 
11. Puerperal fever, the term being used as above, may be either a 
non-infectious or an infectious disease. 
111. The non-infectious form is due to traumatic inflammations of a 
simple character, to old peritoneal adhesions, to moral causes, and to the 
vulnerability of the patient. 
IV. The infectious form, on the other hand, is a septic disease, inti- 
mately associated with the existence in the tissues of minute 
which form the connecting link between puerperal fever and erysipelas 
and diphtheria. 
Y. Its causes are certain atmospheric conditions (nosocomial malaria 
of hospitals), and infection from septic materials. It prevails most ill 
certain winter months, and finds its victims chiefly among the very poor* 
yi. Prevention is best accomplished in hospitals by the adoption of 
Lister’s principles.1 Maternity hospitals are no longer necessarily f°cl 
1 The following regulations, enforced by Bischoff, in Basel, will serve as an example J-y 
Removal from the genitalia, after confinement, of debris capable of undergoing putrefac- 
tion. Protection of the wounded surfaces from all air not impregnated with carbolic acid- 
Hands of attendants, and all instruments used in labor, to be disinfected with carbolic acid- 
A full bath to be given upon the advent of labor, and the vagina to be washed out with » 
two per cent, solution of carbolic acid. In cases of premature rupture of membranes, 0 
protracted labor, artificially induced premature labor, and of dead foetus, a repetition 0 
the injection every two hours. Hands and instruments to be lubricated when necessary 
with a ten per cent, preparation of carbolized glycerine. In cases of version, of artificia 
removal of the placenta, of putrid foetus, of post-partura hemorrhage with relaxation of tne 
uterus, employment of intra-uterine injections of two to three per cent, solutions of carbofic 
acid. After the end of labor, the external genitalia to be inspected, and a ten per cen PUERPERAL FEVER. 
855 
°f disease. Small maternities, if well managed, meet a need among the 
very poor, and their establishment by the charitable should be encour- 
aged. In private practice the physician should never, and need never, 
be the carrier of contagion. The antecedents of nurses should be investi- 
gated. Auto-infection should be very rare in cases properly managed 
during the period of labor. 
VIL The question of personal responsibility cannot be too strongly 
upon the medical profession. 
Discussion on Dr. Lusk’s Paper. 
After the reading of the preceding paper, Dr, 11. P. Yeomans, of Mount 
forest, Ontario, Canada, said With regard to Dr. Lusk’s statement that 
bacteria in puerperal fever cause endocarditis, I would say that the presence 
°f lactic acid in the blood may produce precisely the same cardiac conditions, 
and that when injected into the veins of animals, it has developed endocarditis, 
and caused deposits of fibrin on the valves. Now it is a significant fact that, 
in cases of puerperal fever, lactic acid is one of the morbid constituents of the 
blood. In such cases it is not necessary, therefore, to invoke the presence of 
bacteria as the cause of the endocarditis. 
Dr. William Goodell, of Philadelphia, said:—l have listened with much 
Pleasure to the admirable paper just read. Iheie aie points in it on which I 
sbouM like to dwell: but, as the time for discussion is very limited, I shall 
confine my remarks to the prevention of puerperal disorders. I contend that 
?o statistics are trustworthy, excepting those of hospitals and of other public 
lnstitutions, for physicians very naturally shrink from reporting their fatal 
cases of puerperal fever as such. In evidence of this, I may adduce the tact 
that at one time I was cognizant of fourteen deaths in two weeks from puer- 
peral fever. Yet the weekly mortuary returns of the Boaid ot Health gave 
for that time but twelve deaths in the whole city from that disease. With re- 
gard to the prevention of fever in the inmates of the lying-in institution of 
fbich lam in charge, lam governed by four golden rules: tfteanhne**, Venti- 
latton, Rotation, and Isolation. And lam the more satisfied with then since, 
among 1021 hospital patients who have passed under my caie, I haj e ad 
a single case of phlegmasia dolens, and but one of pelvic a scef®’ , ‘ 
}°st only three from fever. Each one of these rules is a, _ , ~ 
lng many specifications, but since the first three exp am ’ • 
cWll on the last only. By isolation I mean the imitation of the home-e v on- 
ment—in other words, the putting a hospital patient m a con i i 
Possible to that which she would have at home. While tins be 
7>lly reached in a hospital, yet it should be approache as c L , ' 
the same sponge, the same chamber-pot, or the same sy „ ? woman 
several patients, this law of home-environment is violated; for e e y o an 
Hen?1’6'1 at, home has her OWII 'L^nel^P with which every 
»omaenA„Tneot°thePOnm-seiwashe9 her own person Hence every bed is 
Provided with its own vessel, and hence every woman’s person is sweetened, 
carbolized oil to be applied to all lesions. Eupture of the perineum to be closed with 
carbolized silk or catgutsutures. The parts to be washed clean, and picked lint soaked in 
Obelized oil Gen percent) to be laid upon the vulva. Vaginal injections of a two per 
Cent. solution of carbolic acid to be used twice a day—or, m cases of difficult labor, putrid 
foetus, or retainedB,portions of ovum, to be repeated every two hours. In cases of retained 
Ponions of hindering the contraction of the uterus, nitm-uterme injections of a 
Bvo or three1 per cent, solution of carbolic acid m water twice a day Ihe nurse to wash 
at each visit the genitalia and inner surface of the th'ghs, wi i a ukewarm solution ol 
earbolic acid. I have already given the results of this treatment. 856 
LUSK, 
not by detergent vaginal or intra-uterine injections, but by the upright position, 
by making her get out of bed and slip into a chair several times a day. Since 
the same ward holds, and the same nurse attends, a number of women at the 
same time, this is a flagrant violation of the law of home-environment, but 
one which cannot be avoided in hospital practice. As a make-weight, however, 
I put but few women in the same ward, and make the nurse use a nail-brush, 
take frequent baths, and wear such clothing as can be washed. As soon as 
the women are out of bed for good, the nurse is relieved from duty; she takes 
a carbolized soap-bath, and goes into a clean ward, which has lain fallow for 
some two weeks or more, and usually gets a week of rest before a new batch 
of patients falls to her care. I myself always wash my hands with carbolized 
soap, before making an examination, and, to make assurance doubly sure, I 
keep an obstetric and a gynaecological hand. With my left hand I make all my 
office and dispensary vaginal examinations ; my right hand I reserve as much 
as possible for obstetric work. Since moist heat forms the condition under 
which poison-germs best germinate, after a ward is once occupied, the floor 
should not be washed. An accidental stain may be wiped up, but nothing 
more. I have been led to this practice from observing that the cleariest ward- 
floor, when drying, emits a bad smell, and from finding, some hours after such 
a floor-washing, that the body temperature of my patients often shows a sharp 
curve-peak. From the cloud of epidermic scales, and of other human and 
consequently septic debris, raised by the broom, I am also opposed to sweep- 
ing a ward, and especially while any patient is in it who has not yet got her 
milk—that is to say, whose labor-lesions have not yet become protected by a 
covering of granulations. But, since such a mode of enforcing cleanliness, 
although a wide departure from our ideal of the home-environment, cannot be 
well dispensed with, I would suggest the plan devised by my friend, Dr. Addi- 
nell Hewson, viz., to strew the sawdust of some terebinthinate wood, such as 
cedar or pitch-pine, over the floor of the ward before it is swept. The saw- 
dust of any ordinary wood would do, if sprinkled with turpentine, which, 
while being antiseptic, would give the needful amount of dampness without 
moistening the floors. Since fatty degeneration of the heart as well as of the 
other viscera is one of the most common lesions of child-bed fever, to avert 
this tendency large doses should be given of such antiseptics and antipyretics 
as quinia and alcohol, combined with opium enough to allay all pain. And 
such a heart-tonic as digitalis should be given instead of a pure depressant 
like veratrum viride. 
Dr. W. H. Bypord, of Chicago, said :—I believe with Dr. Lusk that puer- 
peral fever is produced by many different causes, and assumes many different 
forms. Sometimes it originates under isolated conditions, and is autogenetic, 
resulting then from various intrinsic causes, such as decomposition of blood 
clots, or of retained membranes, etc. In others it has a zymotic origin from 
various extrinsic causes, which prove at times morbific, owing to the peculiar 
state of the patient. Frequently cases of puerperal fever result from over- 
crowding in hospitals ; at least they are always more prevalent in close build- 
ings where there is no good ventilation. The disease ought not to be called 
epidemic ; it is rather endemic. But there is another class of cases which 
differs from these, especially in miasmatic sections. Some years since I wit- 
nessed an epidemic of “ black tongue” which occurred in Indiana. During 
the height of the disease, which lasted two months, every case perished and 
every lying-in woman in that neighborhood died of puerperal fever ; but as the 
epidemic subsided, the virulence of the fever grew less, and some cases began 
to recover. When, finally, the “ black tongue” disappeared, puerperal fever 
vanished witli it, and the younger doctors then thought that they had dis- 
covered the cause of the latter disease. I believe puerperal fever to be conta- 
gious under certain circumstances, but think that it cannot be carried by the 
physician after he has washed himself with carbolic acid. 
Dr. John L. Atlee, of Lancaster, said:—l had attended a thousand cases PUERPERAL FEVER. 
857 
labor without seeing puerperal fever, and from this good luck had argued 
aat there was no necessity for more than ordinary cleanliness on the part of 
,16 physician. But once 1 had a case of phlegmonous erysipelas, which I 
c I'essed, and then, during the succeeding afternoon and night, attended three 
Cases of easy delivery. The next morning I left them in charge of a friend, 
aild "Went to Baltimore as a delegate to the American Medical Association. On 
return I found my friend waiting for me at the station, to take me to see 
r*ese women, all of whom had puerperal fever. I found one already dead, and 
ae other two hopelessly ill. Under the teachings of Hodge and Meigs, it 
W°uld then have been considered heresy to say that puerperal fever was com- 
municable, and yet I carried the disease, having used no special disinfectant, 
ail(l 1 believe that I was the innocent cause of the death of those three ladies. 
therefore urge that the profession should use extraordinary measures against 
Personal infection and the carrying of this disease. 
Dr. J, p. White, of Buffalo, said :—Puerperal fever was said years ago not 
he communicable, but most of us have changed our minds upon this point. 
’ c may call it infectious or contagious as we will, but it has spread about 
jmigbborhoods. I know of cases in which it has been carried, and I know that 
m*s communicable. The opposing opinions of Dr. Hodge, Dr. Meigs, and 
pthers, have been overturned, and there is now no doubt that puerperal fever 
ls eminently contagious. No man has a right to go directly from a case of 
Puerperal fever, and attend another patient in labor. I know of no disin- 
ectant that will make it safe to attend a case of labor after one of puerperal 
mver. Jn the treatment of this disease, I place much reliance upon opium, for 
'vhich there is great tolerance in puerperal fever. I have given as much as one 
Spain of morphia every hour for forty-eight consecutive hours, and have been 
for my boldness by the recovery of my patient. 
Dr. E. H. Trenholme, of Montreal, said:—l have given from a grain to a 
S'rain and a third of morphia, every hour, with positive benefit; and I have 
auver lost a patient from puerperal fever, although I have met with five cases. 
Dr. J. (j' Hubbard, of Ashtabula, Ohio, said :—I should like to test the 
fen§e of the Section as to whether, in cases of puerperal fever, the child should 
>e allowed to remain in bed with the mother or not. Most physicians allow 
m child to remain as long as it can get a drop of milk. 
Dr. George W. Mears, of Indianapolis, said :—I consider puerperal fever 
|n°re infectious than contagious, in the strict sense of those terms. I knew a 
P D’sician once to lose seven cases of labor from this cause within two weeks 
;®.Very case of the kind which he attended), notwithstanding that he had used 
Uecessary precautions, such as the free application of disinfectants, change 
clothes, etc. They were obviously all instances of personal transmission, 
0 other physician in the city having had a case of the kind to tieat. A ew 
ceks’ absence from home served to free him from the infecting influence, no 
iHr instance of the disease having subsequently occurred in his piactice. I 
Jelieve it also possible that the fever arising from other causes than that of 
*ysipelas may be conveyed, but not as readily, by the attendant on la 101. 
ccording to my observation, when the infection arises from eiysipelas the 
*DI develops erysipelas and the mother peritonitis, 
i Dr. Alexander R, Simpson, of Edinburgh, said: Hie cbapteis in our 
eM-books, instead of being headed “Puerperal Fever,” as they aie, should be 
entitled, “On the Fevers of the Puerperal State,” not specially referring to 
Pcerperal fever as an entity. The puerperal woman is liable to ordinary dis- 
but in her they assume peculiar features, and are so marked as to give 
,?e to the idea of a special disease, called puerpeial level. 1 believe that 
~ 611 these fevers are merely typhoid fevers in the pueipetal woman. In 
cine cases the development is due to the poison of scailatina; but both ty- 
* Hid and scarlet fever are diseases which are as natural to the puerperal 
l °nian as to the non-puerperal. Ido not know whethei such tables have 
een drawn up, but I should like to see statistics of the results of wounds re- 858 
LUSK,PUERPERAL FEVER. 
ceived in battle, as to the difference in the ratio of recovery of those wounded 
early in the day, when they are fresh, and those wounded later. Such data 
would apply to cases of puerperal women ; whether the women are fresh from 
a short labor, or exhausted by a long and tedious one. With our present 
knowledge of the subject, it matters little, as far as treatment is 
whether the poison be chemical or animal. To meet the difficulty of personal 
infection, we should be careful not to carry the poison about in our daily 
rounds. Most of the germ desti’oyers are acids, as carbolic, sulphurous, and 
salicylic acids, but, as a disinfectant, I would call attention to one which can 
be found in every household, and that is common vinegar; I have, on many 
occasions, found it extremely efficacious. After extraordinary exposure, the 
clothing should be fumigated with sulphurous acid. 
Dr. Lusk, in reply, said :—I beg to thank the Section for the attention 
which has been given to my paper, and for the discussion which has followed- 
In reply to Dr. Yeomans, I would say that it is true that the presence ot 
lactic acid in the blood causes endocarditis, but that I confined my remarks to 
a single form of endocarditis, of which the great characteristic is the presence 
of masses of bacteria upon the cardiac valves. But the great question lb 
whether the poison can be destroyed after its inoculation has taken place. 1 
think that it can. I think that the mother ought to be separated, in these 
cases, from the child, as it is better for both. 1 use Labarraque’s solution to 
disinfect my hands, and have never carried the disease from hospital to p1’1' 
vate patients. 859 
ELECTROLYSIS, WITH SPECIAL REFERENCE TO THE 
TREATMENT OP OVARIAN CYSTS. 
BY 
FREDERICK SEMELEDER, M.D., 
OP VIENNA. 
Electricity, the essential nature of which we are unable to explain, 
reveals itself to us under all the different known forms of motion, both 
as mechanical power and as molecular movement, whether as light, heat, 
°r chemical action. The phenomena of these are essentially identical; 
ley are correlative, and are constantly being transformed one into 
Mother. We can command, to a certain extent, by choosing among the 
ai’ious sources of electricity, and by different arrangements of apparatus, 
particular manifestation which we wish to produce; but no form of 
e'ectricity can be generated which does not display, more or less, all its 
various qualities. "Especially is it impossible to conceive of any electric 
°Ul’rent acting on a living body without causing chemical action, and 
Perhaps the only way in which electricity can act in the living tissues 
18 through its chemical effects. 
-Electrolysis is the name given to that application of electricity in which 
chemical action is principally sought for, and, especially in medicine, 
by the use of either the galvanic or the faradaic_ current, an 
attenapt is made to dissolve or destroy organic productions, infiltrations, 
or distinct tumors. Electrolysis is extensively used for 
Industrial purposes (electrotyping, electroplating, etc.), but its applica- 
|°ns to medicine and surgery are as yet very limited ; this branch of 
®*ectro-therapeutics is still in its infancy, its philosophy is very imper- 
ectly understood, the number of cases in which it has been employed is 
and the data for judging of its value are widely scattered ; the time 
0l: writing a treatise on medical electro-chemistry has not yet arrived, 
phe effects of electricaf currents on simple, inorganic solutions are 
easdy understood ; but it is different when we have to deal with organic 
and highly complex substances, such as are met with in the living body. 
electric current passing through common water decomposes it, setting 
J6e oxygen at the positive and hydrogen at the negative pole; with a 
Bolution of common salt a similar process goes on, the oxygen formed at 
i. Positive pole acting on the salt and decomposing it. In the case of 
I(faids like those found in the living body, containing albumen and 
az°tic combinations, we know, as a general rule, that, at the positive 
VOxygen) po]e5 albumen, fibrin, fat-acids, etc., are separated, while at the 
egative (hydrogen) pole there appear the alkaline and earthy bases, iron, 
aild coloring matters. 
• D an electric current is passed through a watery solution of albumen, 
a short time (say five minutes) a clot will be found at each pole ; that 
a the positive pole is the larger and denser, the wire (copper) becomes 
reen by oxidation, and the whole clot has a slight, greenish tinge; the 
• fd at the negative pole is more cloudy, soft, and diffuse, and of a gray- 
sh tinge? while the wire becomes blackened from the development of 860 
SEMELEDER, 
sulphuretted hydrogen. The same thing is observed (except that tbe 
clots are smaller) when the wires are applied, after the shell is removed* 
to the soft membrane which covers the white of an egg. The above 
remarks apply to the constant, galvanic current; although the faradai0 
current also decomposes water and coagulated albumen, yet the electi’0' 
lytic properties of any faradaic current, which a living subject can endui’6* 
are so insignificant, that its value in this respect may be disregarded. 
What has been described as taking place in an albuminous solution, 
is precisely analogous to that which occurs in the living body, the efteet9 
varying somewhat, however, according as both poles are introduced °r 
applied on the surface, or as one or the other is introduced while the 
other is applied externally; and from a knowledge of these differences 
may be derived varied indications for the therapeutic use of electricity* 
With these introductory remarks, I beg to call the attention of the Sep' 
tion to a new application of electricity in surgery ; I mean the electrolyte 
treatment of ovarian cysts. When, a year ago, I published my fi 
successful cases, a claim of priority was made by two gentlemen, one cl 
whom had indeed reported cures of ovarian cysts, by electricity, as long 
ago as 1859. But these cases excited no attention at the time, and wero 
so entirely forgotten that in Prof. Schrceder’s Essay on Gynaecology, in 
Ziemssen’s Cyclopaedia, no earlier cases were referred to than those ot 
Dr. Fieber, published in 1874. All that I claim is the credit of having 
again brought the method before the profession, and I sincerely hopo 
that it will not require fifty years to elapse before the value of this mod0 
of treatment is acknowledged, as was the case with ovariotomy, tho 
great invention of Dr. McDowell, from whose deserved reputation d 
would certainly he the last to detract. 
But science is constantly progressive, and what was yesterday con- 
sidered a great triumph, may to-morrow be superseded, and just a 9 
legitimately abandoned as it was praised the day before. Hence Ido 
not hesitate to repeat, before this assembly, my assertion, that I hopo 
within a short time to see ovariotomy abandoned, or at least restricted 
to a very few exceptional cases. My grounds for entertaining this opinion 
I have recently published at length, and shall not therefore repeat pt 
this time what I have already written; but I will merely say that six 
cases of ovarian dropsy, which I have treated in this way, have been 
completely cured in from four weeks’ to five months’ time, according to 
the size of the tumor; and that in a case of fibro-cystoma of the womb, 
under electrical treatment, the liquid contents of the Cysts have been 
absorbed, the fibrous, solid masses remaining nearly unaltered. Tho 
ovarian cases were not selected but were taken indiscriminately; tho 
cysts varied in size from that of a cocoanut to that of a pregnant uterus 
at full term. In one case the tumor was undoubtedly monocystic, with 
thickish contents; and in another pxdycystic ; in two cases the cyst con- 
tents were quite thin;, while one was probably a case of dermoid cyst* 
The ages of the patients varied from eighteen to forty-five years ; one was 
a virgin; one married, but sterile; and four had borne children. 
The constant current was employed in all the cases ; in one, no needlo9 
were introduced, but both electrodes applied to the surface, and yet tho 
contents of the tumor were absorbed. The currents employed were mim 
ones; no imflammation of importance occurred, and consequently n° 
adhesions were formed ; the pain was insignificant, anaesthetics never 
having been required, and no patient having been confined to bed. 
Thus far, no relapse has occurred. The method is equally applicable to ELECTROLYSIS FOR OVARIAN CYSTS. 
861 
and to multiple cysts ; to those with albuminous, with saline, and 
fatty contents; to those with and those without adhesions; to 
hose which have and those which have not been previously tapped. 
In one of my cases, after the liquid contents had been absorbed, hard, 
Cartilaginous bodies in the cyst remained, apparently unaltered; the 
c:m wails, in all, underwent contraction, and a solid lump, of the size of 
a Brnall apple, remained when all the liquid had disappeared. One obvi- 
advantage of this method of treatment over ovariotomy, is that it 
,°es not deprive the patient of one of her most important organs. The 
tings, in my cases, usually lasted only a few minutes, and were repeated 
haily.—in one case, even during the menstrual period. 
The modus operandi of this method of treatment is not thoroughly 
Understood. In addition to the decomposition and absorption of the 
lcLaid, some change must take place even in those parts of the cyst walls 
do not come into direct contact with the electrodes, for the further 
Induction of liquid is prevented. Dr. Althaus’s theory as to the effect 
on tumors containing saline liquids, is that, the salt being 
aecorhposed, a caustic alkali is formed, and by setting up a mild inflam- 
matory process increases the vitality of the tissues, and thus leads to the 
aWrption of the fluid. 
> Defore resorting to ovariotomy in any case, the surgeon should at least 
§i\'e electricity a trial; for, even if it fail, the patient will be in no worse 
Condition for the operation, while the risks of the latter more than 
c°anter-balance the evil of a little delay. 862 
PARACENTESIS, ASPIRATION, AND TRANSFUSION. 
BY 
SIMON' FITCH, A.M., M.D. Edin., 
Fifty years ago, paracentesis was seldom employed, except in cases of 
fluid distension of the abdomen, bladder, or scrotum, after other mean9 
of relief had failed, and then it was a clumsy and unvalued procedure- 
The old trocar, having a triangular point and a big head, with a sph*' 
canula behind it, went in with a jerk, endangering intestine and testicle 
in tapping for ascites and hydrocele; then the canula, pushed onward9 
over the big head expanding the segments of its split end, would often 
catch some bit of the three-cornered aperture, and fail to enter perfectly? 
or in entering would tear or split up the edges of the aperture, and all°)v 
the fluids to leak injuriously into or upon the neighboring tissues, as 
the operation for hydrocele, or in puncturing the bladder; and finally* 
the instrument would leave a jagged, punctured wound, indisposed t° 
heal. 
But at the present time paracentesis is called upon both to detect aud 
treat a marvellous variety of diseases, and some of them of great impo1’' 
tance, such as hydrothorax, empyema, hydro-pericardium, ascites and 
purulent deposits in the abdomen, cysts of the broad ligament and of the 
ovary, intra-pelvic and lumbar abscesses, retention of urine with ml' 
permeable urethra, distressing tympanitis, strangulated hernia, hydatid9 
and abscesses of the liver and kidneys, hurtful effusions within or aboid 
the hips and other joints, hydrocephalus, and spina-bifida ; and the pre' 
sent duties of paracentesis are more critical, in consequence of the sensiti^6 
and vital character of the textures and parts in and upon which man/ 
of these diseases are situated, such as the lungs, the heart, the abdomi' 
viscera, the pelvic organs, the great joints, the spinal cord, and the brais- 
in dealing with such diseases, in such parts, none of the trocars 
in use are equal to what is required of them, either for exploration or 
treatment. 
OF ST JOHN, NEW BRUNSWICK, CANADA. 
Paracentesis now, with or without aspiration, with or without injection? 
is commonly done either with a single tubular trocar having an tiU' 
guarded point (which is most dangerous to the interior), or the guard 19 
an open canula, to be pushed over the point after it has entered, and 01 
itself only somewhat less dangerous if it gets in, while it is uncertain t° 
enter ; and we will do wrong to employ these uncertain and dangerou9 
instruments if an efficient and safe instrument can be had. 
The perfect trocar should be; (1) Easy of insertion, the puncturing 
tube entering by a clean incision, and the protecting canula following 
without the least stretching of the aperture, or possibility of failure ; 
Harmless when inserted, so that it shall not injure the interior ot th 
cavity, or adjacent parts; (3) Safe as a probe or sound, or artificial fing 
for internal exploration; (4) Adapted to the aspirator and every form 0 
exhausting apparatus, both attachment and detachment being instanta- 
neous; (5) Competent to give the freest exit or entrance to fluids to be di 9' PARACENTESIS, ASPIRATION, AND TRANSFUSION. 
charged or injected; and (6) Certain to leave an incised wound, ready to 
heal. Let us now glance at the growth 'and present character of the 
fiaodern trocar, and try to ascertain what should be done towards per- 
fecting it. 
.In 1850 the improvements seem to have commenced, when Sir James 
I • Simpson reduced the large head of the old trocar to the same size as 
*ne shaft, so that it should stretch the orifice less, and, as the canula 
c°nld then be advanced without spreading, he omitted the split in the 
®hd, and published his employment of a long and slender trocar of this 
hind, with an exhausting syringe attached, as a means of diagnosis in 
Various internal enlargements, especially in pelvic tumors, and so initi- 
afed the idea which Dieulafoy afterwards developed into his admirable 
aspirator. The plan of having the canula itself pointed, so as to penetrate 
lndependently of the stylet, was first conceived by Fergusson, of London, 
in 1858 devised a pen-like tubular needle, for injection of perchloride 
iron in the treatment of mevi and aneurisms. In 1858, Dr. Alexander 
Wood, of Edinburgh, adapted this instrument to the subcutaneous in- 
jection of morphia, and a modification of the same instrument is now in 
Universal use. Shortly afterwards, Mr. Spencer Wells enlarged this 
Httle tubular trocar, for ovarian tapping, and had the edges of the 
Pointed end made sharp and cutting for one half the circumference of 
tube, whereby a semilunar incision is made ; and he added, or restored, 
a shorter sliding canula on the outside, which, upon the puncture being 
effected by the point of the inner tube, is pushed forward as a guard 
against its further cutting action. 
This instrument, superior in many respects to the old trocar and 
canula, especially in that the wound made is incised, rather than punc- 
tured, has still this grave fault of the old instrument, that the protecting 
canula is on the outside. If the distal orifice of this outer canula be made 
thin to pass with less resistance through the aperture by the 
P°inted smaller tube, the open thin end will itself present a cutting edge 
dangerous to the interior of the cavity and to the contained or adjacent 
viscera. To lessen the difficulty of getting the outer canula through the 
aperture, over the inner tube, the distal end is sometimes made obtusely 
Pointed, but this makes it only the more dangerous to the interior, 
specially in the smaller or aspirator sizes of the instrument. It on the 
other hand the terminal margin of the outer canula be blunted or made 
thicker, it will present a ridge or shoulder outside of and behind the 
entering point of the inner tube, liable to catch and carry before it the 
Sa°, or the immediate investment of the cavity, and so fail to properly 
enter. 
, Aow, this accident may occasion considerable inconvenience, or even 
. e productive of great harm, in cases of simple tapping ; as foi instance 
111 hydrocele and in retention of urine, where, if the tunica vaginalis 
01 bladder be not very tense, it is oftentimes difficult to get the outer 
Par)ula in without pushing so hard as to endanger its going in with a 
ffinip, and hurting something, so tightly does the punctured membrane 
• ng to the inner tube in advance of the edge of the outer canula ; and 
tn empyema, with a thick and tough pleura, so much force is sometimes 
Repaired to urge the entrance of the outer canula, as to endanger a 
Separation of the pleura from the ribs. And in tapping for the tempo- 
fiiry relief of ovarian dropsy, if the outer canula do not follow the trocar, 
0r inner tube, quite into the sac, or if in entering it catch and tear or 
split up a fragile sac, more or less of the cystic fluid escapes into the 864 
FITCH, 
abdominal cavity, and forms one if not the chief cause of the fatality 
which sometimes follows this Simple operation. 
But should injection be attempted with an imperfect introduction ot 
the protecting tube, whether that tube be the canula of the old trocar, 
or the outer tube of Mr. Wells’s trocar, the result may be most disastrous- 
I have seen intense peritonitis occasioned by tincture of iodine thrown 
upon the peritoneum in such an attempt to inject an ovarian cyst, and 
Syme, in his “Principles of Surgery,” noticing a like faulty injection tor 
cure of hydrocele, remarks: “If the liquid is allowed to remain in tho 
cellular substance, it gives rise to violent inflammation, and soon term*' 
nates in sloughing of the scrotum.” 
I have encountered on many occasions embarrassments similar to the 
above, and in common with others had tried to obviate the uncertainty 
of entrance of the outer canula, by cutting down to the bladder or tunica 
vaginalis, or pleura, or peritoneum, or whatever might be the immediate 
investment of the fluid to be evacuated ; until it occurred to me to reverse 
the relation of the tubes to each other, and have the protecting tube on 
the inside. And while in Edinburgh, in 1871,1 had a double, tubular 
trocar made by Gardner upon the following plan : The outer tube, 
smooth and of uniform size, has the distal end pointed and cutting like 
a lancet, so that it penetrates easily, and to any depth, without any need 
of previous incision of superimposed tissues ; and the protecting tube, 
being now inside, may be advanced into the interior of the cavity, with 
absolute certainty of entrance, and without a possibility of even touch- 
ing the margin of the aperture, or any of the tissues through which the 
outer tube has passed. The cutting edges must rise from the point ot 
the trocar by a very acute angle, not more then 30° for the largest sizo 
and only 15° for the aspirator sizes; and the cutting-edges must be very 
thin and sharp, but of course sharp for only one-half the circumference ot 
the tube, the half next the point, as if sharp all around a circular pieco 
would be cut out, and a round hole left. 
Instruments similar to the above were made under my direction by 
Krohne and Sesemann, in May of that same year, and were exhibited at 
the next rneeting of the British Medical Association, in London, August, 
1873. The largest size is noticed in Spencer Wells’s recent work o’1 
“ Diseases of the Ovaries,” p. 336. But the smaller sized instruments 
seem to have been overlooked, for Mr. Alfred Goodrich, in a letter to the 
British Medical Journal, August 8, 1874, says: “In emptying a cavity 
wflth the aspirator the operator is often alarmed by finding the instrument 
filled with blood, arising from the walls of the collapsing cavity being 
forcibly sucked against the sharp point of the needle and he proposes, 
as if it were his own idea, that the trocar consist of two tubes, the outer ono 
pointed, the inner one not so. But in the same journal for August 2A 
Mr. George Brown, of the Northeastern Hospital for Children, referring 
to Mr. Goodrich’s suggestion of a trocar guarded an inner tube, 
remarks : “ The idea is not original; we have had one in constant use 
for more than twelve months, which was supplied by Messrs. Krohne 
and Sesemann.” Now these excellent instrument-makers, in 1871, three 
years before this correspondence, constructed my instrument, which, 111 
the catalogue of the museum at the forty-first annual meeting of the 
British Medical Association, was designated “Wells’s Trocar improved 
by Fitch.” 
This instrument is not perfect; for, although the entrance of the pr°' 
tecting tube is rendered free from the possibility of failure, yet the opt'll PARACENTESIS, ASPIRATION, AND TRANSFUSION. 
865 
end of this same tube is hazardous, especially in the aspirator-trocar, 
where it must be thin and sharp, to avoid bulk; thus in tapping the 
bladder, we dare not draw off the last of the urine, lest we injure the 
fluiiig of the contracting viscus, and this danger is pretty generally felt 
by surgeons. In the August numbers of the journal just quoted, a corre- 
spondence appeared in reference to a successful paracentesis for hydrops 
Pericardii, in which Mr. Singleton Smith, upon whose patient the operation 
lad been performed, admitted the risk which accrued, not only from the 
boguarded point of the aspirator-trocar in the cavity of the pericardium, 
as the fluid was drained off, but also from the sharp edge of a canula 
fobbing against the pericardium, or corning into contact with the beat- 
iPg heart. About the same date, the Lancet, under the head of “ Medical 
observed that in “ tapping of the chest, when the fluid has been 
evacuated by the exhausting apparatus, the lung in expanding may 
strike against the sharp and hard canula. To prevent this, M. Behier, 
bf Laris, uses a canula of soft metal to be introduced into the ordinary 
which, when the pleura is emptied, bends down against the parietes 
the chest, and the lung does not suffer.” Now a tube of soft metal 
ban not be drawn very thin, and, were it made large enough for the bore 
be permeable to fluids, it would be too bulky to enter a small canula, 
bnd then coughing or other movement of the patient would be liable to 
throw the lung against the soft tube, and bending it down, stop the flow 
Prematurely. Perhaps enough has been said and quoted upon this point, 
and upon the disadvantages of the open canula ; I think we all feel the 
of a safer trocar than any hitherto used. 
I now announce a most important modification of the double tubular 
ffocar, which avoids the danger of the open canula, and by which the 
while performing its highest achievements of discovery and 
bnre, may be used as a trustworthy exploring probe and sound , and 
bicii will, I believe, in time supersede every other form of the instru- 
Retaining my first improvement of making the outei canula the 
Puncturing, or rather the incising, trocar, I have had the distal oiifice, 
b* open top, of the inner canula closed over by a rounded oi dome- 
laped roof, so that, when it is projected beyond the cutting point of 
tbe outer canula, the two tubes fit closely together, and the end of the 
c°uibined instrument feels perfectly smooth like the end of a rectal 
s°und, or catheter, or probe, and may be freely moved within the cavity 
Penetrated, whether this be an ovarian cyst, a uterine fibro-cyst, the 
ab.domen, the thorax, the bladder, a joint, or even the pericardium, 
Wlthout danger of wounding any viscus or organ, puncturing any vessel, 
b*" even scratching or abrading the lining of the cavity, 01 of any paits 
therein. 
■ ahe base of this dome being of the same external circumfeience as the 
Illrier tube, of which it is the continuation, and fitting the outer tube 
aeeUrately, there can be no escape of fluid till the dome is advanced 01 
Pushed out so as to occlude and shut out the cutting point of the outer 
7be; then there is disclosed by this movement a fenestra, or oval 
Pertnre on the under side of the inner tube, just below the roof, or dome, 
°ut of the lower wall and one-third of each side-wall, of the full size 
• .Lie bore of the tube, and by which fluids may be fieely evacuated or 
‘fleeted ; the distal end of this segment is sloped off towards the dome, 
b that no obstruction can lie there, while at the pioximal boundary a 
Urvyd lip projects over one-third of the whole fenestra to prevent the 
ossibility of obstruction; and the fenestia thus guaidcd, and being, 
55 866 
FITCH, 
moreover, on tlie under side, cannot be stopped by the wall of the 
cavity coming into contact with it, nor by the falling upon it of 
natural textures, or layers of false membrane, or flakes of plasma, aS 
often happens with the open end of the old canula. If, while dis' 
Figures 1,2, 3, represent the ovarian trocar; 4, 5, the aspirator trocars; the in[er' 
mediate sizes for paracentesis abdominis, paracentesis thoracis, etc., and the transfusjo 
trocar, are sufficiently represented by one or all of these figures. Fig. 1 shows the cutting 
point [a b) of the outer canula advanced, ready for puncture, with the dome of the io,lG 
canula retracted, shutting the instrument just behind the point [b] against ingress or egrps 
of fluid; cis the thumb-rest for projection and retraction of the dome by the thumb ot t 
hand holding the instrument; dis a slot with a knob regulating and fixing the dome a'l 
point in any desired position; turning the knob one-half revolution into the proximal tran ' 
verse slot allows the tubes to be separated for cleansing and oiling; / is a continuation 
the inner canula, forming a tubular handle, which directs the current downwards—one en 
of an India-rubber tube is drawn over the lower orifice of this handle ; k is a bit of gla®s 
tubing by which the character of the fluid may be observed, or its absence noticed; tat 
bulb is a simple expansion of the India-rubber tube (without valves or joints to interrnp 
the easy flow of fluid or to whip the blood in transfusion). Fig. 2 has the thumb-r 
pushed forwards and turned into the distal branch slot, projecting the inner tube and doifl 
(m), sheathing the cutting edge and point {a b) of the outer canula, and disclosing f1 
fenestra (n) cut out of the under and side walls of the inner canula ; n, in Fig. 2, and o, * 
Fig. 3, show the curved process of the lower wall of the inner canula, underlying ‘'A 
proximal third of the fenestra, to prevent occlusion from contact of cyst-wall, or vein-"'11 J 
or any floating substance. Fig. 4is the aspirator trocar, with the dome retracted ; Fig- 
has the dome projected; eh is the nozzle; e the proximal end, over which the end of 
India-rubber bulbous tube or the tube of the aspirator may be drawn ; / the conical dista 
end to be inserted into {g) the funnel-shaped end of the inner canula, and fixed by 
turn of the hose-coupling nut (7t). Fig. 6. The clamp forceps for holding the sac upon * 
trocar during evacuation of the contents; also, for closing the orifice in the sac upon 
drawal of the trocar, and preventing leakage of cystic fluid into the peritoneal cavity. 
charging the fluid for which it was introduced, there be found 
aggregation of cysts, or a multilocular sac, this instrument may be u®e 
as a long artificial finger to examine the interior of the original cavity’ 
and to Veel for a proper place to enter, where it may be held till tU 
cutting point is advanced to make an aperture for its introduction. 
Thus, in ovariotomy, it will be found extremely convenient, the le 
hand supporting the tumor and the right holding the instrumen > PARACENTESIS, ASPIRATION, AND TRANSFUSION. 
867 
can be instantly changed, by an easy movement of tbe same hand, 
*r°ni a trocar to a sound, and vice versa, to define and puncture cyst after 
Y>’st, until tbe bulk of the whole is sufficiently reduced to admit of with- 
drawal through the abdominal incision, with only one aperture in the 
cyst-wall first punctured, and this always occupied by the instrument 
thus prevents leakage; and the dome-trocar may here be used, 
"Where the end of the open canula could not be with safety, to stir up 
aild liquefy the loculose contents, and to break down such obstructions to 
floW as imperfect septa and membranous intersections, while it still 
Plugs the original aperture, thus preventing escape of cystic fluid into 
the cavity of the abdomen; and it oftentimes obviates the necessity of 
eularging the aperture in the cyst for the introduction of the hand, 
"'hich procedure should be avoided, as involving overflow of cyst-fluid 
dpon the peritoneum. 
In operating for hydatids of the liver or kidney, the dome-trocar, of 
aspirator size, may be used to loosen and dissever these little bodies 
the aspirator is extracting them through the same instrument. 
■A-nd we may, with one of these smooth-ended instruments, of suitable 
length, search for and drain off the last drops of urine, during aspirato- 
PUneture of the bladder, which we dare not do with the end of the open 
uaiiula, much less with the sharp point of the ordinary single-tube aspi- 
rator needle; or, while the dome instrument is the bladder, we 
Ipay use it to explore the interior both before and after emptying it. 
In cases of intractably enlarged prostate, I believe that we may properly 
1 each the bladder by perforating this gland with a dome-tiocar having 
a less curve than an ordinary sound, and thus not only ielie\e the bladder 
up the time, but cuve permanent release from the olt-iecuinng retentions. 
■1- Pave forced a common strong catheter through the pi estate in such a 
and the patient, who was previously nearly worn to death with 
Pis disability, is now enjoying a new prostatic bit oi uietlna, and is inde- 
pendent of instruments. . 
For explorations of bone, we may insert a probe-sized instrument, with 
tPe point projecting, till we reach the proper depth; then, advancing 
IP® dome, we have a harmless probe with which to search foi canes or 
exfoliation, leaving only a capillary wound, without entrance o an oi 
exit of blood. . The dome, in all the sizes, should be solid or accurately 
n°ored over, to prevent lodgment of anything there which mig it im- 
pede its easy withdrawal from the cavity. ... 
The life-giving operation of transfusion may, I think, be quickly and 
done with this instrument. A short dome-trocar, of suitable size, 
having been attached to each end of an India-rubber tube a oot ong, 
the middle expanded into a bulb, one of the trocars is nisei ted into 
IJe vein which is to furnish the blood, and, when the apparatus is filled, 
J!ie other trocar is introduced into the receiving vein, when the opera- 
fl0n is completed. The tubes are closed and opened at their distal ends 
y retraction and projection of their domes, which prevents the possible 
of air; and no valve or stopcock is needed. The receiving 
Veio should be exposed by a short incision, but the supplying vein will 
generally be sufficient!v prominent to be entered without previous bis- 
ection. As soon as the lancet-end of the outer tube is inserted, the 
Jf°me is projected, and the tubes thus guarded may be safely pushed as 
*ar as required, downward into the furnishing vein, and upward into the 
1 Reiving vein, and no ligature will be needed. Thus tune, so valuable 868 
FITCH, 
in this operation, is saved, disturbance of the vein is avoided, and injury 
to the interior of the vein need not be feared. 
If the mediate method he preferred, a common glass, or hard India- 
rubber, or metal, syringe, with the piston removed, and the nozzle ul' 
serted into a flexible tube, armed with one trocar, will be a suitable 
reservoir into which the blood may be caught, as in ordinary venesection? 
or the blood may be defibrinated by whipping, and strained into tbe 
syringe; the dome with the open fenestra is left projected till the trocar 
fills, then it is retracted, closing the fenestra, and leaving the point of tho 
outer tube ready for puncture. Upon inserting the trocar, we need not 
replace the piston, for sufficient and more steady propulsion may be ob- 
tained by merely raising the syringe. 
The hole in the side of the nozzle, used by Mr. Wagstaffe, is liable to 
occlusion from the contiguous wall of the vein; in the dome-trocar 
is obviated by a curved projection of the tube-wall over the proximal end 
of the fenestra, open at the sides, as previously described. In this opera- 
tion it is very important that the dome be solid to prevent lodgment ol 
clot. 
The aspirator attachment deserves attention, for it can be applied to any 
syringe or exhausting apparatus; the adjustment is effected instantane- 
ously and without moving either trocar or exhausting apparatus, or twin- 
ing the flexible, connecting tube, by merely pushing the end of the aspi- 
rator nozzle into the funnel-shaped end of the inner canula, and fixing 
it by one turn of a loose ring-nut, like a hose-coupling. The India-rubber 
tube connecting the nozzle with the aspirator has the usual bit of glass- 
tubing, so that the current may be observed or its absence noticed. 
Some peculiarities of the different sized instruments should be men- 
tioned. The ovarian trocar has a thumb-nut (for which I have to 
Dr. Thomas Keith), by which either the cutting point or the dome may 
be advanced or retracted, and fixed in either position by the thumb o* 
the hand holding the instrument. The proximal end of the inner canula 
is prolonged into a hollow, curved handle, very convenient to hold by? 
while it also directs the current of the flowing liquid downwards; and 
one end of an India-rubber tube, three feet long (with a bit of glass tub- 
ing in it), may be drawn over the lower orifice of this hollow handle, t0 
conduct the fluid into a receiving vessel; the middle of this tube is e2C' 
panded into an elastic bulb, by which the flow through the tube may b0 
promoted until the siphon current is established; and we may use it f°r 
washing out or for injecting the cavity. Mr. Wells’s grapples may b0 
slipped upon this trocar, or long, light clamp-forceps, with ring ends, may 
be used to seize the sac, upon or even before puncturing, and, held in th0 
hand with the trocar, will accommodate themselves to the varying dis- 
tances to which the trocar enters. 
The trocar for paracentesis abdominis has a curved, hollow handle con- 
tinuous with the inner tube like the ovarian trocar. . 
All the sizes below that for paracentesis abdominis, have their proximo 
ends adapted to the aspirator nozzle, and therefore a separate, curved? 
hollow handle is provided to fit all of them, and may be instantly fi^eL 
to either by a ring-nut, similar to that of the aspirator nozzle; and Wit11 
this handle an India-rubber tube and bulb may be used, as with tb 
ovarian trocar, when we wish to simply empty a cavity without tbe 
aspirator. , 
The instruments may be of any size. Of those which I have ha 
made, the ovarian trocar is ten inches long, including the handle which i 3 PARACENTESIS, ASPIRATION, AND TRANSFUSION. 
869 
-Tllr inches, with the internal diameter of the inner tube half an inch. 
W • Washington L. Atlee tells me that he has used one of these in his 
Ust forty-one ovariotomies, and expresses unqualified approval of it. 
The abdominal trocar is six inches long, including two inches for the 
handle, the calibre equalling that of a ]STo. 11 catheter of the American 
Seale, 17 of the French. The smallest sizes correspond with Dieulafoy’s 
pi rat or needles ; of these, two are each seven inches long, and tine, for 
le bladder and deep tapping; two are four inches eacli in length, and 
pouter, for hydrothoi ■ax, transfusion, etc.; one is short and very tine, for 
Tfdro-pericardium, spina bifida, etc. 870 
UTERINE HEMORRHAGE DURING GESTATION. 
BY 
E. H. TRENHOLME, M.D., 8.C.L., 
PROFESSOR OF MIDWIFERY AND DISEASES OF WOMEN AND CHILDREN IN BISHOP’S COLLEGE? 
MONTREAL; ATTENDING PHYSICIAN TO THE WOMAN’S HOSPITAL; FELLOW OF THE 
OBSTETRICAL SOCIETY OP LONDON, ETC. 
The object of the present paper is simply and briefly to point out a 
form of hemorrhage met with during pregnancy, heretofore unrecognized 
by writers upon midwifery. It is foreign to my purpose to speak of tho 
subject in general, or even to recall to your minds some excellent papo1’® 
that have lately appeared from the pens of the well-known and honored 
Dr. Fordyce Barker, and others. 
I will first offer the history of the following case, as illustrating the 
subject:— 
Mrs. N., aet. 39 years, and of English parentage, was a feeble, anaemic woroam 
of dark complexion, spare in flesh, and of a lymphatic temperament. She had 
been married some sixteen years, and was the mother of five children, the 
youngest of whom was eight years of age. She had been deserted by her ha5' 
band after the birth of her last child, but he had returned to live with h®1 
during November and part of December, 1874, after which time he had take11 
his final departure for parts unknown. The menstrual flow had appeared a® 
usual in January, 1875, but for the first time had been rather profuse, auc 
had never entirely ceased; although the hemorrhage had moderated between 
the terras, it had been increasingly severe at each period up to the removal 0 
a dead foetus, of about the size of a third or fourth months’ child, on AugllS 
' • ' f* 
7,1875. For some months the patient had had constant pains in the uterus, oi 
sharp cutting character, and, as she remarked, “not at all like labor-painB. 
The condition of the patient, and the persistence of the pains, with the bleecl' 
ing, led me to suspect malignant disease of the organ. 
To make a diagnosis, the os was dilated sufficiently to allow the introdn0' 
tion of the index finger, when I felt a globular body, well up in the cavity 0 
the uterus, and barely accessible to the touch. Dilatation of the os was con- 
tinued until the greater part of the hand could be introduced. From the on 
set there were no indications of the presence of the decidua ; the mucous mein 
brane around the lower segment of the uterus was smooth and glossy to tn 
touch ; the cavity of the womb was found to be occupied by a projecting b°( y 
somewhat like a large sessile tumor, with its base toward the right side, an 
occupying about one-quarter of the superficial surface. This body was felt 
be a foetus in its amniotic and epichorial decidual envelopes ; the point of cofl 
lescence between the epichorial and parietal deciduae was easily recognized. 
The condition of matters having been determined, the membranes were i’u 
tured, and the foetus with its placenta removed. This, however, was n 
effected without difficulty, as the epichorial membrane had to be forcibly sePag 
rated at the point of its uterine attachment; the sensation felt in so doing vV‘ 
very perceptible and characteristic. The parietal decidua was in no way mt 
fered with by the delivery thus accomplished. The uterus contracted well, all 
the patient made a good recovery without any subsequent return of hem 
rhage. UTERINE HEMORRHAGE. 
871 
. The uterine decidua has been the centre of attraction to many able 
during the past few years. Much has been done toward 
emcidating its anatomy and physiological functions. The changes, truly 
Ciarvellous, that occur during ordinary menstruation are somewhat defi- 
nitely known. From this basis, so well established, we may reasonably 
cope for rapid advancement in the successful treatment of uterine dis- 
use, and from the same source we may expect to obtain hints for the 
inore correct appreciation of some of the pathological conditions met 
'Vlth in pregnancy. 
To understand the irregular development and behavior of the mucous 
ftiernbrane, we must bear in mind its regular and normal course in gesta- 
li°n. This course may be briefly stated as follows : (1) Hypertrophy and 
hiding of the mucous membrane preparatory to the reception of the im- 
bregnated ovum ; (2) The imbedding of the ovum in the decidua, and 
*Te consequent dividing of that membrane into three, viz., the utero-epi- 
chorial, the epichorial, and the parietal deciduae; (3) The subsequent 
anion of the epichorial and parietal deciduae, forming one homogeneous 
Membrane. As soon as this is accomplished, the uterine cavity is per- 
fectly occluded, and any discharge from the interior is impossible. 
A normal conception and gestation must proceed in the above order ; 
any serious deviation occurs, difficulties must follow; deficient 
vital action, and excessive vital action, alike work mischief. In the lat- 
for ease, a fold of the mucous membrane may protrude into the canal of 
file cervix, or even pass outside the external os ; a case of this nature 
°ame under my notice a short time ago, in which the protruding mass 
Appeared to be a plug of tenacious mucus; and it was only when this 
'vas forcibly removed that the nature of the case became known. I need 
hardly say that abortion followed. On the other hand, deficient vital 
action is followed by imperfect development of the membiane, and an 
absence of that perfect union of the epichorial and parietal decidure which 
fakes place in normal pregnancy. This form of abnoimal development 
met with, as might be expected, in anaemic and exhausted women, it 
also occurs in those of apparently good, general health, but whose vital 
powers have been exhausted by too frequent and rapid gestations. Aa- 
bure tries to meet the requirements of the case, but her powers aie too 
focble to do so efficiently. 
The epichorial decidua, being deficient in vitality, fails to enlarge and 
allow the embryo fair scope for development, ihe envelope acts as a 
compressor, forcing the foetus toward the placental surface, and at the 
saine time interfering with its nutrient supply and growth, ihe ovum 
its envelopes, in fact, form a sort of sessile tumor, such as was 
n°ticed in the case referred to. 
The muscular structure of the uterus is apt to be excessive in giowth, 
and not deficient, as at first thought we might be inclined to suspect; 
know7, however, that hyperplasia or subinvolution aie not indications 
fo excessive vital activity, but rather the reverse; most probably it will 
be found that subinvolution is markedly present. Clinical facts indicate 
view as probably correct. In the case mentioned, the uterus was 
ffauch larger than was necessary for the accommodation of the foetus, 
bnere was no impediment to the escape of any fluid tioin the left Fallo- 
foan tube to the vagina, a condition which would permit of free meli- 
oration if that function could really be performed during gestation, 
wbich I very much doubt. That hemorrhage can really occur from the 
cavity of the uterus, and that, too, from a decidua of pregnancy without 872 
TRENHOLME, UTERINE HEMORRHAGE. 
causing; abortion, is quite possible, and need not be doubted; per bap 9 
we have in this condition the clue to the mystery of super-foetation. 
The purport of these remarks is to explain the cause of the uterine 
hemorrhage met with during gestation. The form of gestation and the 
condition of the uterus itself give an easy solution to what has heretofore 
been inexplicable; the exact point or points of hemorrhagic escape wid 
undoubtedly be ascertained hereafter. The condition of the enlarged 
uterus, the character of the mucous membrane, and the unnatural and 
irregular strain upon the organ, are sufficient factors to account for the 
monthly and continuous flow of blood referred to. We know that ses- 
sile and submucous tumors are frequent causes of uterine hemorrhage, and 
as this form of pregnancy resembles these cases in their chief outlines, V 
is naturally followed by similar results. 
As to treatment, I have but little to say. When we meet with such 
pregnancies, whether complicated with metrorrhagia or not, it seems to 
me that the proper treatment is to induce abortion. Apart from the ex- 
hausting hemorrhages, cases are met with in which the uterine distress 
and constitutional disturbance are so great as to urgently demand our 
interference; there is little ground for hesitancy in the matter, as we 
cannot reasonably expect a normal termination to an abnormal ges- 
tation. 
The following conclusions seem to be justified by what has gone 
before:— 
I. That an abnormal development of the uterine decidua is not apt to 
occur. 
11. That hemorrhages other than those of placenta praavia can take 
place from the cavity of the gravid uterus, only in cases where there i 9 
an abnormal condition of this membrane. 
111. That menstrual hemorrhages can take place from the cavity of the 
uterus without accompanying abortion. 
IV. That this condition might permit of superfcetation. 
Y. That the treatment indicated in such cases of gestation, when the 
uterine and general distress are great, is to remove the products of con- 
ception, whether such distress is or is not accompanied by metrorrhagia- CHRONIC INVERSION OF THE UTERUS. 
BY 
JAMES P. WHITE, M.D., 
Professor of obstetrics in the medical department of the university of buffalo. 
In introducing the subject of Chronic Inversion of the Uterus to the 
Section on Obstetrics, I propose simply to bring prominently forward 
facts and conclusions already in a great measure laid before the profession, 
and to urge the claims of the operation described to the confidence of 
Ris representative body. 
Never having witnessed the occurrence of the accident in question, I 
Jfrill not attempt to describe its causes or the manner of its occurrence, 
but shall consider chiefly the question of treatment or restoration. The 
gravity of the accident and the sad condition of its victims will be con- 
ceded by all who have observed the miserable state of those suffering from 
its effects. Without discussing the possibility of spontaneous reduction, 
has been asserted by one or two recent writers to sometimes take 
Place, it certainly does not occur with sufficient frequency to warrant 
delay in our efforts for artificial reposition, in the expectation that a cure 
be effected by the unaided efforts of nature. . 
, Until quite recently, inversion of the uterus unless restored within a 
?hort time after its occurrence, was regarded by all writers as entirely 
and the unfortunate female was left without hope of restora- 
U°n, to drag out a loathsome existence. So miserable has the sufferer 
fr°m this terrible accident been made by it, that relief by extirpation of 
Ue organ, with all its attendant dangers, and consequent defoimity if 
Succeeded by recovery, has been acceded to as preferable to living on in 
big deplorable state. Meigs, I suspect, at the time he wio e very 
bi’iefly the sentiments of the profession in relation to the practica ty 
°f restoration, in his “ Letters to his Class,” on the diseases of females 
peaking of a case of six months’ duration, after descri mg -> 
«ud exsanguine condition of the woman, he says : a ?aieN , 
fer the patient? Will you reposit or reinstate this womb . ion can t. 
might as well try to invert one of the non-gravid uteri on my 
jucture-room table as to reposit this one. The time is gone by. You 
W no art or skill, nor any power equal to the performance of such a 
Oracle of surgery as that.” All the authorities of the_ same date 
I’d the reposition of the uterus, after involution, as highly impi obable, 
do not direct any efforts to be made for its res ora 1 ; . ’ 
Velpeau, and Bedford content themselves with diiectin 
®Ucb measures as will contribute to the comfort of the woman and with 
Suggesting that removal of the organ may, m extreme cases, be resorted 
I0* Notwithstanding the success which has attended the opeiation for 
Ruction of the inverted uterus during the last few years especially in 
merica, the more recent writers still seem incredulous They continue 
to §Ne the same directions for the alleviation and treatment of this con- 
Letters to his Class, by Charles D. Meigs, M.D., page 232. 874 
J. P. WHITE, 
dition that are to be found in the older authors. I have myself treated 
by reduction, since March, 1856, twelve cases of uterine inversion, varying 
in duration from immediately after the occurrence of the accident to no 
less than twenty-two years. Reduction in all was effected at the flrst 
effort, and, as far as could be ascertained, without laceration of tissue. 
similar measures other gynaecologists in this country and in Europe have 
repeatedly succeeded in accomplishing reduction in cases of chronic in- 
version, and yet the feasibility of the method is by no means uniformly 
admitted by writers and practitioners at the present day. 
Thus, Leishman, whose recent work on Midwifery is justly regarded 
as high authority, at first hesitatingly admits that “ elastic pressiH’0 
alone, or aided by incisions in the neck, will overcome every case of i°' 
version except when fixed by inflammatory adhesions,” but subsequently 
goes on to describe the method of removing the uterus “when the doom 
of the patient seems fixed;” and adds, under such circumstances, “'ve 
can have no hesitation in resorting to a measure so extreme as tbo 
removal of the organ.”1 Schroeder, a German authority whose work ha 9 
been translated and published in this country, dismisses the whole sub' 
ject of chronic inversion by saying, “ Reposition is easy as long as tbo 
os is not yet firmly contracted ; otherwise great difficulties may be met 
with, and repeated trials under chloroform may become necessary- 
Meadows, in England, in his Manual of Midwifery, says : “When the case 
has remained unrelieved for many weeks, though attempts should alvvay9 
be made to secure reduction, etc., yet the chances are very greatly again 
success.” Courty says that, if reduction be impossible, it will be necessary 
to resort to palliative treatment or to extirpation of the uterus for its rad1' 
cal cure. Dillinger, in a work republished in London in 1871, say 9, 
“ Chronic inversion is held to require palliation ; if that is vain, remova 
by ligature or excision.” Barnes, of London, thinks it necessary t° 
invent some new operative procedure, in order to avoid “the varion9 
methods of amputating the uterus, or of effecting forcible reduction, a 9 
by Professor White’s method,” etc., and accordingly recommends fll' 
cisions in the neck, and gives a plate of an elastic pessary, to aid 111 
effecting gradual pressure. He very justly admits the failure of elast10 
bags in the vagina, as they, when distended, stretch the vagina exce9' 
sively, require a firm point d’appui in the perineum, which cannot aLvay9 
be had, and also fail to exert pressure upon the fundus with suflicioll 
force and directness. Tie might also have added, in relation to th0 
elastic bags, that they produce painful pressure upon the rectum yn< 
neck of the bladder, and cannot be borne by the patient for any consid0' 
rable time. , 
In the abstract of Society proceedings, given in the Obstetrical Journa 
of Great Britain and Ireland, republished in Philadelphia, in the Augo9 
number, 1873, will be found a very full report of a discussion in tn 
Obstetrical Society of Dublin, on the subject of chronic inversion of tb0 
uterus. Two cases, of six and seven months respectively, were report0 
by Drs. Kidd and Johnston, giving rise to a debate on the subject 111 
which several members present participated. Dr. MeClintock, in tn 
course of his remarks, said that he was satisfied that cases would arj90 
where all manipulations would entirely fail to replace the organ. tn 
President, Dr. Evory Kennedy, said that, in dealing with these cases o 
1 Leishman’s System of Midwifery, American edition, p. 417. 
2 Manual of Midwifery, American edition, page 315. CHRONIC INVERSION OF THE UTERUS. 
875 
they could not classify them merely as acute and chronic. He 
nought there was an intermediate stage, in which it was just possible to 
reduce by compression the uterus back into its place, but when that stage 
JVas passed, the thing became impossible. He looked upon it that up to 
l°ur or five months after the accident the case was not a chronic one, 
that facilities still existed for reduction which did not exist at a 
inter period. Again, that he was not aware of reduction having been 
effected after fifteen years. He thought that the condition of the tissue 
be so altered in the course of ten or fifteen years that it would 
be totally impossible to effect reduction at the end of that time. 
. In the January number of the Obstetrical Journal, for 1876, a descrip- 
tion of the amputation of an inverted uterus is published without one 
H'ord of editorial comment. It was of only three months’ standing, and 
Utis excised with the ecraseur by Professor Martini Barta, as the only 
Affans of arresting the hemorrhage incident to this condition. During 
present year also, I find published, in the American Journal of 
Obstetrics, an article “On Ablation of the Body of the Womb in irre- 
ducible Uterine inversion, by External Hysterotomy,” by M. Do niff, of 
Oar is. This paper, which was read before the French Academy of 
Medicine, arrives at the conclusion that external hysterotomy is an 
extreme surgical resource, but precious in cases of irreducible inversion.l 
But it is useless to multiply citations illustrative of the hesitation and 
Prejudice which still prevail on this subject, recommending, as several 
Authors do, for the relief of uterine inversion, an operation of much greater 
danger to the patient than reduction, and one which leaves her, when 
sbe escapes with her life, in a sadly mutilated condition. 
Whence this almost universal want of confidence? The cases of reduc- 
tion are now so numerous, and the operation, in ray opinion, so demon- 
strably practicable, as not to admit of doubt. I am utterly unable to 
Account for this unbelief, and feel, therefore, justified in detaining }ou 
iDth a brief history of the steps by which I arrived at a different conclu- 
sion. Some remarks upon the method of operating, and a reference to 
three illustrative cases, will also be added. 
There ma}7 be found in the Buffalo Medical Journal for March, 1856, 
Au account of a case of inversion of eight days’ standing which had been 
sported, with a description of the successful operation for its ieduction 
W the Buffalo Medical Society in the preceding February. I concluded 
that article with the following remarks: “This case is regardedl as inte- 
resting in many respects. It will encourage the growing belief among 
Accoucheurs that reduction may be undertaken with reasonable hope of 
Recess, at a period much later than most writers have heretofore advised. 
the same article, alluding to a case of fourteen days stair mg w uch 
ffd fallen under ray observation long before (in 1842), and in which, in 
Accordance with the teachings of that day, no attempt at restoration had 
been made I added : “With my present views upon this subject, 1 should 
Abandon such a case as hopeless only after a long effort at leposition. 
.Ally convinced, from the result of the efforts made in this instance, 
eight days after inversion, of the feasibility of restoring the uterus in 
hiany cases heretofore considered irreducible, I did not meet with an 
°Pportunity of putting my convictions to the test until March 12, 1858, 
when I visited Mrs. M., near Hornellsville, H. Y., who had been confined 
°n the 22d of September previously, almost six months before, and, after 
1 American Journal of Obstetrics, June, 18(6, page 348. 876 
J. P. WHITE, 
about one hour’s continuous effort, succeeded in repositing the uterus, 
which had been completely inverted. A full account of this case, with 
illustrative plates and a description of the manner in which reduction 
was accomplished, was published in the July number of the American 
Journal of the Medical Sciences for 1858. Permit me to crave indulgence 
for one word in relation to priority in this operation. Tyler Smith, i*l 
London, on April 24, 1858, published in the London Medical Times and 
Gazette an account of a successful operation for inversion. But I submit 
that this was forty-two days after my operation in Hornellsville, and 
more than two years after I had taken the initiative and had published 
my views and “hopes,” in connection with the report of a case of eight 
days’ duration. 
Upon this point, I trust that I shall be pardoned for gratefully quoting 
the following passage from an able article on this subject by the late Hr* 
Henry Miller, the impartial and distinguished Professor of Obstetrics id 
the University of Louisville:1 “Before I proceed to do this [give an 
account of the method of manipulation pursued by Hr. White], it is meet 
that I should pay a tribute of honor to our countryman, Professor James 
P. White, who has not received the credit he so well deserves for hiß 
leadership in the revolution of gynaecological practice which he inaugu- 
rated.” The writer then proceeds to a careful analysis of the facts which 
led him to the above conclusion, which it is unnecessary here to detail- 
On August 24,1858, in the presence of Professors Austin Flint, Austin 
Flint, Jr., Thos. F, Rochester, W. 11. Mason, and others, I reduced an 
inverted uterus of over fifteen years’ standing. A full account of tin 9 
case, as reported to the Buffalo Medical Association, with the remark8 
of the above-named distinguished gentlemen, will be found in the Butfal° 
Medical Journal for October, 1858. The difficulty encountered in the 
operation bears no proportion to the duration of the inversion. I believe 
it to be as difficult to restore the uterus immediately after complete invo- 
lution has taken place, as at any subsequent period. In Yo. 9of mf 
series, a case of only six months’ duration (at Port Hover, Canada, reported 
to the Medical Society of the State of Hew York, and published in the 
Transactions of that body for 1872), reduction was far more difficult than 
in the case of fifteen or in that of twenty-two years. In the case of BIX 
months, two protracted efforts, under chloroform, had been made before 
I saw the patient; each attempt had been succeeded by some peritoneal 
inflammation, and it was the opinion of all present at the final operation 
that reduction was protracted in consequence of firm adhesions of the 
uterus to the surrounding tissues. The same difficulty was encountered 
in my tenth case, one of nearly seven years’ duration, in Yew Bedford? 
Mass. At an early period in the history of this case, as will be seen by 
the excellent report of Prof. Bixby, the ecraseur had been applied, and 
such pressure made as resulted in breaking the chain of the instrument? 
the operation being succeeded by inflammation, which produced adhesions- 
The remark of Evory Kennedy, that “ the organ undergoes such chang6 
in process of time as to render reposition impossible,” is not well founded- 
The uterus becomes as small and inflexible immediately upon the conclu- 
sion of involution, which, according to the bes.t authorities, occurs withlll 
twelve or at most sixteen weeks after delivery, as at any subsequent period 
1 Thoughts on Chronic Inversion of the Uterus, specially with reference to Gastrotorny 
as a substitute for Amputation of the Uterus. By Henry Miller, M.D, Richmond anl 
Louisville Medical Journal, April, 1870, p. 14. CHRONIC INVERSION" OF THE UTERUS. 
877 
before the menopause. Reduction, therefore, at the expiration of twenty 
years, is not more difficult than after the same number of weeks, as far 
as the manipulation of the organ itself is concerned. 
There is, however, an intervening period between the commencement 
aud the conclusion of the process of involution, when the organ must, 
Tli my opinion, be handled with more care. Whilst undergoing this 
change, the uterus does not possess the firmness and elasticity of the 
organ, nor the muscular flexibility and toughness of 
that at full period of gestation. Whilst in this transition state, under- 
going the process of fatty degeneration, it is, I apprehend, far more 
brittle and liable to rupture than after this change is fully accomplished. 
In the cases in which the operation was resorted to at eight days, at 
three weeks, and even at five weeks after delivery, as in my eighth case,1 
the organ did not possess the firmness of normal uterine tissue in the 
state. In the report of the last case (eighth) will be 
I°und the following remarks: “ Indeed, lam induced to suspect that at 
this period after delivery the uterus cannot be subjected, without danger 
°f laceration, to manipulations which would be perfectly safe at a later 
Period after complete involution has taken place. The sensations occa- 
sioned by pressure were such as to excite apprehensions lest the tissues 
should yield under the fingers.” It may be added also that this was the 
first case in which the repositor was used, and the safety ot the structures 
be attributed, in part, to its aid during the operation. 
It will probably be found safer, in view of this friable condition of the 
issues after the commencement of involution, to wait loi the comple- 
tion of this process, notwithstanding the increased difficulties of the 
operation occasioned by such delay. Priestly, in his lectuies on the 
subject of the involution of the uterine parietes, assures us that “ with 
the advance of the fatty transformations, the uterus becomes in a corre- 
spondino- de°ree friable, and continues so until it has completely letumed 
to its normal condition,” and that “it is occasionally so soft and Liable 
Whilst affected by this fatty degeneration, that a sound passed into the 
uterine cavity might be readily pushed through the uterine walls. Ihe 
given whilst manipulating the uterus in the couise of involu- 
tion confirms these remarks of Dr. Priestly, and leads me to suspect 
danger in all operative procedures upon the organ during this 
Physiological process. . , . , 
. In relation to the modus operandi of the operation of reduction, there 
18 little to be added to the description given in 1858, ot the manner in 
reposition is accomplished. There seems great and unnecessary 
Uuibiguity and confusion on this subject. In all recent cases, the fundus 
uten can be pressed into the body and neck, or “dimpled, as it is 
teruied, by pressure upon the most depending part. In this manner I 
certain that the two cases which were reduced immediately after 
delivery and to some extent that of eight days duration, were earned 
UP- In the case of Dr. Lockwood’s patient, in 1861, the womb had been 
diverted for about forty minutes when I arrived. Administering some 
paregoric and brandy to relieve the patient’s semi-collapsed condition, I 
Beized the uterus, pulled off the partly adherent placenta, and passed 
hand, with the fundus before it, up through the neck and into the 
r>l Report of two cases of Chronic Inversion of the Uterus, with a description of the Uterine 
J*ePositor. By James P. White, M.D., Transactions of the New York State Medical 
fe°ciety for 1872, page 200. 878 
J. P. WHITE, 
cavity of the replaced womb, with scarcely more difficulty than would 
he encountered in inverting a wet bladder. Retaining my hand there 
for a short time, contraction soon came on under the influence of the 
ergot and stimulants which had been freely given. The patient made a 
good recovery, and has since borne children. So with the case of eight 
days, it is stated in the report that, “ having succeeded in ‘dimpling’ the 
fundus, pressure was maintained with the thumb at that point until the 
hand had become nearly powerless. To preserve this depression whilst 
the muscles of the hand were permitted to rest, a rectal bougie about 
twelve inches in length and one inch and a fourth in diameter, was carried 
along in its place, flxed in the dimple, and pressure uninterraittingly con- 
tinued through it, by the left hand outside the vulva. Gradually, the 
concavity of the fundus was found to be deeper, until it finally became 
completely restored.” 
This is doubtless the manner in which reduction takes place in ah 
recent cases, whilst the organ is large and the walls flexible, and I was 
at first led into the error of supposing that this same method obtained 
in all cases. This delusion was, however, completely dispelled by mY 
first case of chronic inversion, of six months’ standing, in the account oi 
which the following description of the method of reduction is given. 
“There can be no doubt that the os first commenced to yield, and pressed 
down upon the intra-vaginal hand, which, it will be recollected, inclosed the 
entire body and fundus of the uterus, and the upper extremity of the bougi6? 
and kept them in contact. This part [the os] gradually dilated, and passed 
down upon and over the neck, which in turn dilated and doubled down up°° 
itself. The fundus did not perceptibly dimple in its centre or at either Fall0' 
pian orifice, and was not reflected upon itself during the operation. Tbe 
organ was too firm, and the cavity too small, for any depression to be made 
upon the walls of the fundus. In recent cases, on the contrary, reduction may 
doubtless be effected by doubling-in, or dimpling, the fundus, and using it aS 
a wedge to dilate the neck and os.' That reduction takes place in all cases 
after complete involution by thus dilating the os and reflecting it down over 
the neck and body consecutively, has been several times verified by exami°a* 
tions made by competent observers, as well as by myself, during the progress 
of these operations. The uterus and vagina in complete inversions represent 
a continuous bag or sac doubled or reflected upon itself, with the open e*' 
tremity of the sac securely fixed. Pressure upon the closed end of the bag 
(the fundus) will, it is plainly perceived, under such circumstances, result m 
straightening the bag by completely turning it the other side out. So with 
the parts concerned in inversion. Pressure upon the fundus, if gentle am 
well directed, pulls open first the mouth of the womb, then its neck, and finally? 
if persevered in, doubles the body upon itself also, and carries the fundus 
through the os, and neck, and body, to its normal position.” 
I have nothing to change in this description, given twenty years ag°? 
of the modus operandi of reposition in chronic inversion. In the cases oi 
fifteen years’ and of twenty two years’ standing, the attention of t*lG 
distinguished gentlemen who were present was called to this fact (t‘ie 
reflection of the os upon the neck and body), and they were requested to 
pass a finger up beside the hand of the operator and verify the observa- 
tion. Similar careful examinations were made by those present at th 
two most difficult of all my reductions, that at Port Dover, Canada, auc 
that at Hew Bedford, in both of which peritoneal inflammation bm 
been excited by previous surgical interference, resulting in adhesion3? 
and in both also the same relation of parts was ascertained to ex)s 
during the progress of the operation. In my opinion it would be unWige CHRONIC INVERSION OF THE UTERUS. 
879 
double in the fundus upon the body, after complete involution, even 
B U were practicable to do so. The size of the tumor to be carried up 
through the cavity of the neck and os, would be increased by this intro- 
flexion, and would, by just so much, augment the difficulty of reduction. 
■Any one who may make the effort to dimple the fundus of the unim- 
pßpgnated uterus into the cavity, will perceive that it is impossible to 
efiect reduction or inversion in this manner even upon the dead subject. 
By this explanation all the apparent discrepancies, as to the manner of 
eduction, can be reconciled. One practitioner has operated on a recent 
case, and restored the womb by dimpling in the fundus, whilst his no 
less observing and truthful fellow has restored the involuted organ by 
Reflecting: the os over the neck and body, without at all being- able to 
aepress the fundus. 
It is incorrect for Dr. Barnes to call the procedure just described, “ a 
forcible reduction.” I submit that there is no conceivable method of 
dilating the os and neck of the uterus less forcible than that of making 
gentle, elastic pressure upon the fundus, producing thereby equable and 
Moderate traction by the vagina which is attached within the os in com- 
plete inversion. The vagina pulls open the os with less liability to 
laceration than the pressure of the tent, the India-rubber bag, or any 
other mechanical means can do. Does any gynaecologist of the present 
day hesitate to dilate this canal for the removal of intra-uterine growths? 
Boes any uterine pathologist believe that it would be impossible safely 
fo dilate the os and bring down the fundus of the uterus completely 
inverting the organ—if carefully and perseveringly undertaken? If 
these questions are affirmatively answered, why may we not pull open 
the neck by means of the vagina in the same gentle mannei as we could 
it open when in a normal position, and thus cany the fundus up 
through it by means of pressure upon that part when it is in a dovvn- 
P'V'ard direction? Perhaps I may be too sanguine, but my piesent belief 
is that well-directed pressure upon the fundus,if continued long enough, 
t'dll, in all cases, unless prevented by firm adhesions, result in restoration 
°R reposition, no matter how much time may have elapsed since inver- 
sion has occurred. Observation and careful reflection upon the 
puses which have been committed to my charge, now numbering twelve 
ill all, and varying in duration, as already stated, through neat a 
Quarter of a century, confirm me in the opinion first expressed in Icoo. 
Indeed my convictions are very decided, and lam incredulous to 
the necessity of ever resorting to amputation, or to the still mote o )jcc- 
tionable operation of gastrotomy. True, the womb may not always be 
Reduced at a single sitting, as in all the cases which I have encoun eted , 
hut, by means of the “ repositor,” uniform and gentle pressme can be 
Maintained until the os is fully dilated and the fundus pushed up t iiough 
M The insurmountable difficulty heretofore has been supposed to con- 
Slßt in our inability to maintain uniform and persistent piessuie fora 
sufficient length of time. The hand would soon become fatigued, and 
uuother hand, even of the same individual, could not be substituted with- 
°ut losing a part of what had been gained. This loss is increased when 
the hand of a fellow practitioner is introduced to continue the operation. 
■y° doubt great physical endurance, being able to maintain one position 
I°r a great length of time, has been an essential element of success. The 
various substitutes which have heretofore been resorted to for continuing 
Pressure when the operator has become exhausted, have utterly failed, 
elastic ba°-s so often called in requisition, pi ess moie upon the viscera 880 
J. P. WHITE, 
resting upon the large surfaces anteriorly and posteriorly situated, than 
upon the fundus, which has no firm ossific base of support as have the 
rectum and bladder. The uterus ascends very soon, owing to the yielding 
nature of the vagina and perineum, and escapes from the reach of the dis- 
tended vaginal bags. The repositor (which will soon be described), when 
it is deemed better to proceed in a more gradual manner, or when it may 
be found impossible to effect reduction by a single effort, can be received 
with the uterus into a large cylindrical speculum, and, by means of n 
“T” bandage, can be made to press directly upon the fundus until the os 
is gradually dilated and all resistance overcome. By means of the large 
spring at the outer extremity, the amount of pressure can be graduated 
to an ounce. The disk of this instrument will follow up the fundus, 
without compressing painfully the urethra or rectum, by means of this 
continuous elastic pressure in the upward direction, until the fundus 
disappears in the os and neck. Any intelligent assistant can be trusted 
to increase or diminish the pressure, during the absence of the operator, 
as the exigencies of the case may demand. 
The construction and action of the “ uterine repositor” will be readily 
understood by reference to the accompanying wood-cut, Figs. 1 and 2. 
Fig. 1. a. Uterus in process of reduction, b. Anterior lip or wall of the uterus with 
the fingers of the left hand pressing upon it and assisting in pulling open the uterine cavity- 
c. Posterior uterine wall semi-reflected, d. Anterior vaginal wall. e. Wooden or hare 
rubber stem of Repositor, its enlarged extremity held in contact with the fundus by t“e 
intra-vaginal hand of the operator, f. Distal extremity of stem made into a screw, so as to 
be fastened into g, a coil of No. II steel spring wire, requiring eight or ten pounds pressure 
by the breast of the operator, against which it is placed, to bring it down. 
Pig. 2. h. Uterine extremity of stem e, which is terminated with a soft India rubber disk 
If inch diameter, the concavity into which the fundus is received being about one-half inc» 
deep, with its terminal margin thin and soft. 
The instrument is composed of a stem of wood or hard rubber, curved 
to conform to the vaginal curvature, with a coil of steel wire attached to 
the outer extremity, whilst the other end is expanded and hollowed so 
as to receive the fundus of the uterus in its concavity or disk. The edge 
of this disk is tipped with soft rubber, being an inch and three-eighths 
in diameter, and about half an inch deep. The concave extremity ot CHRONIC INVERSION OF THE UTERUS. 
881 
*bis instrument is carried up into the vagina and placed in contact with 
*be fundus, and then firmly held by the hand in the vagina. The outer 
e,ld of the instrument, or coil of wire, is placed against the breast of the 
°perator on the same level with the uterus. By means of this large cir- 
Cldar spring, the instrument readily keeps its place on the clothing of 
me operator, and leaves the other hand free to be used above the pubes 
to assist in fixing the uterus and assist also in forcing open the dilating 
°S5 which can ordinarily be plainly felt through the abdominal walls. 
The spring at the outer end of the instrument enables the operator 
Without danger of lacerating the tissues to keep up a constant gentle 
Pressure upon the fundus, and by leaning forward to increase this pres- 
Slll'e intermittingly. The force thus exerted is applied more directly 
Ton the fundus by means of the repositor than would be possible if the 
mtunb and fingers were used, or the round end of the large bougie. I have 
°ften been delighted, since I have used the repositor, to find that it gave 
rrie a third hand which did not become fatigued, and which permitted me 
*■? use the left hand in manipulating over the hypogastrium, while the 
J'lght easily held the instrument in contact with the fundus, and firmly 
grasped that part of the uterus which was not yet reflected, and which 
jpuiained in the vagina. The disk, in which the fundus rests, is less 
ikely to bruise or lacerate the organ than any other mechanical appli- 
ance. The intra-vaginal hand compresses the body and fundus, and 
essens its vascularity, whilst something is gained by intermitting the 
Pressure, also lessening by its use the exhaustion incident to unintermit- 
muscular effort on the part of the operator. 
It may be well to state that the patient is_always placed at the side 
the bed with the feet resting in the laps of intelligent assistants, each 
pf whom is also charged with the care of the knee and hand of that side. 
Ihe hips of the patient are brought quite to the edge of the bed, which 
18 raised so as to bring the parts on a level with the breast and aims of 
m® operator. He should occupy the space between the extremities of the 
Patient, resting upon his knees. This position gives him greatei mobility 
ban the sitting posture, and is much less fatiguing than standing. It is 
est t0 manipulate the uterus freely, thus rendering it more flexible and 
,?sseningits vascular congestion, before commencing the effort of lestoia- 
,lon- The back of the hand should rest in the concavity of the sacrum, 
should be completely introduced into the vagina, the body am tun- 
• 118 of the uterus with the upper end of the repositor being hi inly giaspect 
fhe palm. The amesthetic should be entrusted to a competent piacti- 
loner, and should be carried not only to insensibility, but as far as it can 
3e without danger. It is unnecessary to add that the operation should 
fVer be undertaken without having had the patients bowels com- 
P etely evacuated a few hours previously. It is also unnecessary to say 
~Jaf it should not be undertaken during the menstrual flow. Some- 
.'hies, however, the hemorrhage is so continuous that the menstrual epoch 
8 not well marked, when the operation may be proceeded with without 
e&i’ of dangerous hemorrhage. It is remarkable, in view o _ie slight 
fauses which usually give rise to hemorrhage in most cases of inversion, 
Pttle blood is lost during the manipulations incident to restoration. 
bis is doubtless in a great measure due to the fact that the bleeding is 
„°ntrolled by the compression exerted by the hand around the body and 
Tidus. Kor, if the manipulations are gently and carefully practised, is 
® banger of metritis by any means as great as might be expected. 
I shall now give the histories of three typical cases, one of six months’, 
56 882 
J. P. WHITE, 
one of seven years’, and one of twenty-two years’ duration. In order 
to secure confidence in the feasibility of the operation, and avoid the 
bias which inevitably attaches to the observation of an enthusiast, -*• 
have selected two which were kindly reported by distinguished gently 
men who witnessed the operations. The first case is one of six month9 
duration, and the first in which I effected reduction after complete dj' 
volution, although I had already successfully treated two cases of rauCl 
shorter duration. 
Case I.I—On the third of March, 1858, Dr. C. D. Robinson, of Hornellsvih®’ 
wrote to me that he “ had been called in consultation with a neighboring 
sician, and found a patient with an inverted uterus of more than five month9 
standing.” My opinion was desired as to “ the possibility of returning th 
inverted organ and the propriety of extirpation.” In my reply, the implo 
priety of removal, unless as a last resort, was insisted on, and the hope 
pressed that a prolonged and well-directed effort might succeed in reduction ? 
and it was said that, in my belief, it was due to the poor woman that th 
attempt should be made before she was abandoned to the evils of chron 
inversion. A few days subsequent to this date, I was requested to visit her 
my earliest convenience. Engagements in the city prevented my comply1®19 
with this request until the twelfth of March. On accompanying Dr. Robin 9?11 
to the residence of the patient, Mrs. A. M., I found her extremely ausem1 ’ 
confined to her bed, and suffering greatly from the loss of blood. 
The history of the case, as furnished by herself, her husband, and the me‘ 
cal gentlemen who had been in attendance, was as follows: At the age of " . 
she was taken in labor at the maturity of her second pregnancy, on the ** 
day of September last, Dr. Batten in attendance. This labor was natural 
the conclusion of the second stage, when she gave birth to a large male chmr 
Placenta adherent, but removed at the expiration of about thirty minute9’ 
and its delivery followed by copious flowing, severe pain, and faintings. D 
prostration was so great as to require the constant use of stimulants dun 
the succeeding forty-eight hours, and for three weeks she continued extreme ) 
weak and faint. At about this time she took an aloetic cathartic, which 
sioned violent efforts at stool, accompanied by pains resembling those 
labour. Profuse hemorrhage followed these straining efforts, and a lar=V 
pear-shaped tumor made its appearance through the os externum. The ne 
or smaller extremity of this body was at the vulva, and the larger extrem1 j 
down between her thighs. By the assistance of her husband, she was enam 
to return this tumor within the vulva, when a messenger was dispatched * 
Dr. Batten. Dr. 8., upon his arrival, introduced his hand into the vaglJ1‘ 
and carried the uterus high up into the pelvis, and resorted to astring6 
and cold for the purpose of arresting the flow of blood, which continued P1 
fuse and difficult to control. The prostration being at this time very gre®' ' 
the horizontal posture was enjoined, stimulants and tonics were given, and t 
bowels were moved by enemata. .A 
During the succeeding three months she had occasional hemorrhages, wlll01, 
were severe, with constant discharge of muco-sanguinolent matter. Tw° 
three times, during this period, she so far improved as to walk about her r°° 
and partially supervise her domestic affairs, though looking very pale 
being very feeble. About the middle of January she had another sc' 
attack of hemorrhage, the tumor again presented itself externally, ana 
again returned as before; that is, pushed back within the vulva. Dr. B. ag‘l 
visited her, and prescribed such remedies as seemed necessary to control 
flowing. Since about the first of February she has been compelled, from 
debility consequent upon the exhausting, sanguinolent and leucorrhoeal , 
charges, to preserve the recumbent posture. Lactation, doubtless, has ad 
1 Yide Amer. Journ. of Med. Sciences, July, 1858. CHRONIC INVERSION OF THE UTERUS. 
883 
the exhaustion, and being confined to her bed she has little appetite, the 
®t°naach is irritable, and the bowels are costive. Ever since the patient took 
aloetic cathartic and the tumor made its first appearance between the 
ugbs, she has been aware of the existence of something unnatural in the 
'agina. This body has occasionally made its appearance externally, requir- 
the assistance of her husband to x*eplace it, and she has had frequent 
aUacks of a “ straining sensation” described as accompanying its first com- 
plete descent. She has suffered greatly from all the symptoms arising from 
and from sympathy with the uterine irritation necessarily developed 
lY the malposition of the womb. The pulse now numbers 130; she is 
Ranched or wax-colored, and grows dizzy and faint when raised to the semi- 
ecutubent posture, and cannot be moved without experiencing a sense of pros- 
ration. It should have been stated that, on February 25, Dr. Robinson, of 
Uornellsville, and Dr. Reynale, of Dansville, visited the patient in consulta- 
l°n with Dr. Batten, when inversion of the uterus w'as diagnosed, and measures 
°alculated to ameliorate her condition were resorted to. 
Upon making a careful examination (nearly twenty-five weeks having now 
lapsed since confinement), the fundus of the uterus is found just within the 
0s externum, and about one inch and three-fourths in its transverse diameter, 
abd scarcely exceeding an inch in its antero-posterior diameter (Fig. 3). The 
'3°dy and neck of the organ occupy the vagina, and the neck is not more than 
°be inch in diameter, and feels like the pedicle ot a polypus. The inversion is 
Rcognized as complete, and the organ is no larger than when in its natural 
Position six months after delivery. Introducing a large cylindrical speculum 
lnto the vagina, the fundus of the uterus passes readily into its cavity, thus 
Remonstrating the complete involution of the uterus, and Ringing distinctly 
into view the rou°h mucous membrane of its now outer covexing, which bleeds 
uPon the slightest touch with the finger or sound. It is seen to be covered 
muco-purulent matter also, and is not susceptible of indentation by 
Pressure with the point of the sound. 
Fig. 3.—Position of the uterus in chronic inversion. 
Fig. 4.—Vagina put upon the stretch by pressure upon the Hindus 
1 he bowels having been freely moved by an enema, I proceeded to the ope- 
aUon of reduction in the presence of Drs. Robinson, Reynale, Batten, Dimick, 
and Mr. J. W Robinson, medical student. The patient was placed, for the 
°Peration, upon an elevated, firm bed, with the hips brought quite to its edge, 
!e knees separated, the feet resting in the laps of Drs. Reynale and Robinson, 
Dth directions to each to support a knee and hand of the patient, and prevent 884 
J. P. WHITE, 
her from moving about. Dr. Batten brought the patient moderately under tbv 
influence of chloroform, which was continued throughout the operation, 
I placed myself upon my knees, between the patient’s legs, her pelvis being 
a convenient elevation for manipulation. I introduced my right hand cot*1 
pletely into the vagina, and firmly grasped the entire body and neck ot t" 
uterus. It may here be remarked that the parts were so firmly contracted a 9 
to render the introduction of the hand difficult. At the same time that t" 
entire uterine tumor was grasped by the right hand, a large rectal bougie 
carried up, and also received into its palm and held firmly in contact with t" 
fundus of the uterus, the hand being sufficiently large to receive both, a" 
keep them in apposition. Continuous, gentle pressure was now made upoll 
the external extremity of the bougie with the left hand, whilst the right co"3' 
pressed the uterine tumor, and kept the upper extremity of the instrum 
directly upon the fundus, and, with the dorsum of the hand in the concavity 0 
the sacrum, directed the force in the axis of the pelvic cavity, putting t" 
vagina completely upon the stretch (Fig, 4). This pressure was exerted, a" 
this position unintermittingly maintained, although the force was not to s«c 
a degree as to endanger laceration of the utero-vaginal connection, until #•' 
strength wras nearly exhausted from continuity of effort. At length, and wh®*1 
about to relinquish the task, the uterine tumor began to shorten at its ne<>i 
and the mouth of the organ to push upon the upper surface of the hand, f 
depression or dimpling of the fundus was at any time perceptible. AscenduV 
more and more rapidly as the neck diminished in length (Fig. 5), the fund"9 
finally passed out of the hand, aud was easily pushed by the bougie throng 
the mouth and neck of the organ up to its proper position (Fig. 6). 
Fig. 5. Manner in which the os and neck double upon the body 
Fig. 6.—After complete restoration. 
In order to verify the restoration, Simpson’s sound was introduced alongs" 
of the bougie, and was found to enter a little more than two and one-ha 
inches above the os, which could now be distinctly felt. The large specnl""b 
already referred to, was now slipped up around the bougie, when the os 
brought distinctly into view, surrounding also the bougie. The sound 
again carried through the os to the fundus, through the speculum, and all t3 
medical gentlemen present saw' that it passed easily beyond the mouth, tot 
shoulder of the sound, and could not, without force, be carried further. 
was demonstrated not only the reduction of the uterus, but that the orga 
was accurately measured, and found scarcely, if at all, enlarged. The sPeC>1 
him and sound were now withdrawn, the patient carefully removed to the et CHRONIC INVERSION OF THE UTERUS. 
885 
1G bougie retained in place by the hand, to prevent reinversion. Mean- 
me, stimulants were given to sustain the patient, and ergot in such doses as 
Gl'e deemed likely to excite the tonic contraction of the uterus. The patient 
'Qou recovered from the effects of the chloroform, and expressed herself as 
idling quite as comfortable as before the operation from which she had suffered 
little. The discharge of blood was slight, and, when the effects of the 
0 doroform had passed off, and she had taken a little brandy and water, she 
expi‘essed herself as feeling comfortable. Pulse not sensibly changed in 
Oddity, and numbering the same as before the operation. 
Urs. Robinson and Batten remained with the patient during the succeeding 
dght, maintaining the bougie in the uterus, supporting it gently, 
jhid rendering such other attention as the patient required. Continuing the 
Pressure upon the fundus of the uterus was perhaps unnecessary, but it was 
d°ught safe not to withdraw the bougie until the next day.1 
March 13, Dr. Robinson wrote; “The patient is quite comfortable; pulse 
Free from pain. Withdrew the bougie this morning, and found the os 
llteri embracing it pretty firmly.” Tonics with nutritious diet were continued, 
a’M quietude in the horizontal position enjoined. On the Isth, he wrote: 
* The 
patient is quite comfortable this morning. Made a digital examination, 
ail(l found the uterus perfectly in situ, and mouth well contracted. Has some 
Pulse 100.” March 23, he again wrote: “She is improving; has 
*“®u much annoyed by neuralgia and sickness of stomach, but both are giving 
rVay, as is the lencorrhoeal discharge. Ihe treatment has been sustaining 
Porter, wine, quinine, iron, etc.), with nutritious diet.1 In conclusion, Dr. R. 
adtls" u She will get well, and 1 feel gratified in the success of the eftort of 
esforation, not only on account of the patient being relieved of a loathsome 
• ady, but also that I have been instrumental in contributing to the profes- 
a!°hal reputation of one for whom I feel a deep friendship, as your success in 
hls case will relieve obstetrical surgery from the opprobrium which has hith- 
!lto been attached to it in cases of chronic inversion of the uterus.” _ln reply 
0 a letter of inquiry from me, Dr. Robinson wrote, April 22: 1 visited her 
Jasteiday, and found her verv cheerful and able to sit at the table and take 
,ea *ith us. Her final recovery is now beyond all doubt. In short, the ope- 
fatl°n has been as successful as its most sanguine friends could desire Her 
has been protracted; slow, perhaps; but when we take into 
HCo«ntthe great prostration from the long continuance of the malady and 
* ® exhausting hemorrhages and lencorrhoeal discharges to which she had been 
Ejected, the only wonder is that she has recovered at all.” Ihw patient, I 
nearly twenty years after reduction (September, 7), is qm e 
and able to attend to her household duties. 
Case lL2_ln July, 1872, Dr. George T. Hough, a very intelligent prac- 
,tloner hi New Bedford, Mass., wrote me to know “if I could be induced to 
1 r?e there and operate upon a case of chronic inversion ol tte u enib wuc 
ia< lately come into his hands.” After long efforts to persuat .e mcie u- 
j Us sufferer and her friends of the feasibility of making an effort for her relief, 
, 'v’as at length invited by him to visit heron the 15th of May, 7- . n 
ffsTsiug through Boston on my way to New Bedford, I called upon Dr. George 
u * uxby, the celebrated gynaecologist of that city, and inv itec inn o accom 
me. Dr. Bixby was present at the operation, rendered valuable assist- 
j!Ce’ and furnished the following report to the American Journal of Obstetiies, 
X take the liberty of transcribing with many thanks, not only oi this 
hmt of the case, but for his many courtesies. ~, . 
t. All*s. H., aged 35, native of New Bedford, first menstruated during her thir- 
Geilth year. She married at fourteen, and has given birth as follows: the 
as’t> all subsequent cases the bougie has been withdrawn immediatelj after restoration 
and Mre is little or 110 danger of spontaneous remversiou while the patient is kept quiet 
2 Ihe horizontal position. , 0 ~ in-,/ 
' ‘de Transactions of the New York State Medical Society, 16-4. 886 
J. P. WHITE, 
first, fourteen years after marriage; the second, eighteen months after tl]® 
first. She was attended in her last confinement, more than six years ago, W 
an irregular practitioner. After the delivery of the child, the medical attend' 
ant left the patient for two hours, and on his return proceeded to remove t*1® 
placenta in a very rough and hurried manner. For three weeks convalesce^0® 
proceeded as usual. She was then taken with profuse hemorrhage. The latt01 
continued in varying quantities and intervals for several weeks, when f*l 
family physician was called. Upon examination, he diagnosticated uteri0® 
polypus, and a surgeon was summoned to remove it. Accepting and confi1’01' 
ing the opinion of the attending physician, the operation was immediate 
undertaken. The wire of the ecraseur was with some difficulty applied abo 
the pedicle, hut upon making traction it parted. Upon close inspection, aft®1 
the accident, it was ascertained that the case was one of uterine inversion* 
originally partial, but rendered complete by the previous manipulation 
Nothing further was done at this time. , 
June, 1812, I)r. George T. Hough, of New Bedford, was called. He foun 
the patient confined to "her sofa, where she had been almost continuously si°c® 
her last confinement. She was thin and chlorotic; menstruation had be°n 
regular as to time, but profuse. She suffered, in the intervals, from freqnfn 
attacks of hemorrhage, which were provoked by exertions as slight as walking 
across the room. Frequently slight hemorrhages through the entire interva 
of menstruation ; at other times there was a complete absence of the same. . 
vaginal examination revealed the following: External genitals normal; with11* 
the vagina, a round, regular, conical body, more or less immovable, and ° 
stricted at its superior extremity. Upon the application of the usual dia» 
nostic signs, Ur. Hough pronounced the case one of chronic inversion of 
uterus. Not feeling quite sure of his diagnosis, Dr. Johnson, of New Bedfob » 
was called in consultation. Dr. Hough’s opinion was confirmed by Dr. J. \ 
June, 1812, Dr. Hough consulted Prof, James P. White, of Buffalo, by left01’ 
and subsequently Dr. White was called to see the case. 
On the sixteenth of May, 1813, an examination was undertaken by ' 
White, in the presence and with the assistance of the following gentlemen- 
Dr. Mason, of Norwich, Ct., Professor of Physiology in the Buffalo Medi°a 
College, Drs. Hough, Johnson, Hooper, Yermeyne, and Hayes, of New Bedftn ’ 
and Dr. Bixby, of Boston. Artificial teeth removed and urine drawn; ethei’i2* 
tion commenced by Prof. Mason. When completely anaesthetized, the pat‘ 
was placed upon her back across the bed with her pelvis near one side, in 
favorable position to allow the lower extremities to be flexed and rest in 
laps of two seated assistants. By palpation the uterine tumor in the sup1*- 
pubic region was found wanting. The excessive emaciation of the patien 
rendered this point easily demonstrable. By the vagina, the finger came 1 
contact with a smooth, round, cone-shaped body, more or less movable, a° 
constricted at its upper extremity. By the sound, a complete cul-de-sac 'f 
found encircling the entire constricted portion. By recto-vesical exploration* 
no interposing tumor was found, and the finger in the rectum was separat® 
merely by the rectal and vesical walls from the sound in the bladder. d 
case having been clearly recognized as one of chronic inversion of the uter° ’ 
the operation of reduction was undertaken as follows: Prof. White a, 
sumed the kneeling posture before the patient, and between the two seat0 
assistants. The left hand, well-lubricated, was carefully introduced 0 
vagina, and the fingers slowly insinuated under and about the mass. M'h1 
the latter was sustained by the palm of the hand, the constricted port1 
was embraced by the thumb and finger from opposing sides. With 1 . 
right hand, Dr. White’s “egg-beater, uterine repositor,” was introduce 
into the vagina, its concave extremity placed against the fundus or 
of the tumor, and its spring-end against the chest of the operator, *io 
done, the right hand, now free, was employed for making conn ter-press0 
above the pubes, or for any other desired purpose. Gentle but unyield1 => CHRONIC INVERSION OF THE UTERUS. 
887 
| Assure, rendered equable and manageable by the action of the spring, was 
eol'tinued without an}r variation for thirty minutes, little more force being 
Verted than that required to compress the spring. Thirty minutes after 
commencement of the operation, patient in good condition; hemorrhage 
; tumor in vagina still firm; constriction unyielding. One hour 
I(lrn commencement of the operation, hemorrhage insignificant; tumor more 
a tendency to collapse, manifested by retarded respiration and pulse, 
as combated by the injection of an ounce of clear brandy into the rectum, 
r° the heart’s action promptly responded. The use of the “ egg-beater 
upositor” was now continued, its action varied by a slow to-and-fro motion 
? t'he body upon the spring. At one and a half hours, the patient continued 
0 llear the operation well; hemorrhage insignificant; pulse somewhat accele- 
ated ; tumor more soft and compressible ; a large-sized, gum-elastic, rectal 
o,igie was substituted for the “ egg-beater.” At two hours and ten minutes, 
bider the pressure of the bougie and manipulation with the fingers, the con- 
-8 fiction relaxed, and the organ assumed its normal position. The 
Patient rallied from the anaesthesia in less than a quarter of an hour. Re- 
gion took place slowly. Notwithstanding this prolonged manipulation, 
Either the vagina nor the perineum was in any way injured. 
t>r. Hough thus writes in regard to the subsequent condition of the patient: 
e day after the operation there were symptoms of metritis, which rapidly 
!ISappearcd under appropriate treatment. There were no bad symptoms fol- 
ding the operation, but two weeks after she suffered from a slight attack of 
Pneumonia from exposure to a draft of cold air at night. One month after the 
aily j vaginal examination reveals the uterus in a normal position. Some 
Souths afterwards, desiring to know the condition of the patient, X addressed 
a I;iote of inquiry to Dr. Hough, to which the following reply was received 
New Bedford, Jan. 16, 1814. 
Bear Dr. White At your request I visited Mrs. H. yesterday. She says, “ Tell 
Doctor that lam perfectly well in every respect,” and she seems so. Upon inquiry, I 
1111(1 all the functions normal; menstruation perfectly regular, lasting two days; scanty, if 
She has lost her chloro-amemic look, and has a good color. Bats and sleeps 
ell> and in fact is well. Very respectfully yours. REO- L OUGH- 
Case lII.—In the winter of 1811-2,1 received a letter from Dr. 0. C. Strong, 
Colden, informing me that there was in his neighborhood a case of inversion 
more than twenty years’ duration. The Doctor had been called in to pie- 
scribe for the patient during one of the attacks of flowing from which she had 
suffered ever since the birth of her child, now twenty years old. Aot content 
the assertion that she was “ bleeding to death,” and seeing hex exsanguine 
feeble condition, the Doctor resolved, if possible, to ascertain the cause of 
le hemorrhage, before undertaking to prescribe a remedy, upon instituting 
f.cuu’eful digital examination, he recognized what no one who had preceded 
J‘rn in the treatment had ever suspected—complete inversion of the uterus. 
soon after wrote me on the subject, asking whether I would be willing to 
Undertake its reduction, etc. Considerable time elapsed before the patient 
be made to believe that there was any hope of her relief from a malady 
wldch had prostrated her for more than twenty years. At lengt b uoug i the 
of her physician, Dr. Strong, she was induced to invite me to under- 
take its reduction. The case was reported by A. T. Livingston, M.D., assistant 
Pkysieian in the New York State Lunatic Asylum, in Utica, and from his notes 
the following extracts:—1 . ... ~ . 
, kke history of the patient, prior to the time of the operation, has been 
obtained principally from a thesis presented to the faculty of the Buffalo 
Medical College, in February, 1871, by Dr. 0. 0. Strong, of Colden, N. Y. Mrs. 
1 Buffalo Medical Journal, August, 1872. 888 
J. P. WHITE, 
A. D., then aged twenty-four, and residing in Buffalo, gave birth to a 
child, July 15,1850. The midwife who attended her in her confinement, expel'1' 
enced some difficulty in the removal of the placenta, but finally succeeded in 
pulling it away. This act was followed by so much hemorrhage as nearly 
destroy the woman’s life. From this time until the day of the operation she 
suffered a continual loss of blood, which twice a month amounted to flooding 
She consulted various physicians in relation to her condition, hut received 
no benefit from any of them. This is not surprising when we are told that? 
until Dr Strong was called to see her in 1810, no physician had ever proposed 
to make an examination per vaginam with the view of determining the catise 
of the hemorrhage. 
March 2, 1810, Dr. Strong was called to attend Mrs. D, He found bel 
lying upon a bed, about which were evidences in abundance of the terribD 
flooding which had just occurred. Upon making a digital examination, he 
discovered a tumor about the size and shape of a small pear, occupying the 
vagina, which, after a careful specular examination, he diagnosed as an inverted 
uterus. Dr. S. informed his patient that he considered that her condition 
permitted the use only of palliative measures, and advised the use of tonic® 
and local astringents. Afterwards, learning of Dr. White’s previous, successful 
operations for chronic inversion of the uterus, a correspondence arose between 
that gentleman and himself, with reference to the case of Mrs. D., which re- 
sulted in an invitation to Dr, White to visit the patient, and, if upon exaW1' 
nation he should think it advisable, to attempt the reduction of her uterus. 
June 23, 1812, Prof. White, with Profs. Julius F. Miner and M. Gr. Potter? 
Drs. Geo. N. Burwell, W. C, Phelps, and the writer, whom he kindly invited 
to accompany him, proceeded to the residence of the patient in the town 
Golden, N. Y. She was found to be feeble and very anaemic, and slight hemor- 
rhage from the tumor was then occurring. Prof. Potter, who was requested 
to take charge of the anaesthetic, administered some chloroform to the patient? 
and the tumor was then examined b}r several of the gentlemen present. P 
resembled in size and shape an ordinary hen’s egg, and was suspended in the 
vagina by a long, narrow pedicle continuous with its upper and smaller ex- 
tremity. This appearance, particularly the small and elongated cervix, led 
some who examined it to doubt its being a uterus at all, and to consider it 
rather a polypoid growth. But a probe could not be passed along the pedicle 
into the os, as might have been done had the tumor been a polypus, nor cotdd 
the uterus be detected by palpation over the abdomen. A uterine sound passed 
into the bladder could be felt by the finger in the rectum above the tumor, and 
by the hand placed over the hypogastrium ; also the finger, passed up the rectum? 
came in contact with the anterior abdominal wall as felt by the other hand* 
All these diagnostic means proved the absence of the uterus from the situation 
which it ordinarily occupies. By these negative proofs, Dr. White was entirely 
convinced that the tumor was the inverted uterus, and he therefore proceeded 
to attempt the reposition of the same in the presence of the above-named 
gentlemen, and of Drs. Strong, of Golden, G. H. Lapham, of Aurora, and Davis? 
of Boston, Dr. Potter had produced anaesthesia by chloroform, which he 
exchanged for ether, with which he kept the patient anaesthetized during the 
operation. Dr. White assumed a kneeling posture in front and between the 
legs of the patient, who had been placed upon the side of the bed with her hip® 
projecting a little beyond its edge, and her feet resting in the laps of Drs, Miner 
and Phelps, who sat on either side of Dr. White, each supporting a knee and 
holding a hand of the patient. Dr. White then introduced his right hand into 
the vagina, and began manipulating the tumor. This manipulation consisted m 
compressing the uterus, which relieved its congestion and rendered it more 
pliable, and in making gentle pressure in the line of the axis of the pelvis by 
the use of the uterine repositor. After continuing this a short time the doctoi 
brought the tumor down to view, when a glance sufficed to assure the doubting 
of its true nature. By the pressure which had been exerted the neck had been CHRONIC INVERSION OF THE UTERUS. 
889 
sl*ortened and dilated, the bcnty and fundus reduced in size, the superior angles 
9io\y inferior) were distinctly seen, and altogether the tumor then presented 
he normal outline of a uterus of small size. The repositor was again intro- 
duced, and a pressure of eight or ten pounds exerted by it, and, at the same 
hue, compression was made Iry the hand within the vagina upon the portion 
the uterus protruding beyond the os, the same hand also retaining the fundus 
hteri and the repositor in coaptation, whilst the left hand was employed in 
Pressing above the pubes or through the rectum. When, in this manner, the 
Cei'vix had been made to embrace the fundus, the uterine repositor was substi- 
tuted by a large rectal bougie, with which pressure was continued until the 
of the operation. 
At the end of an hour and fourteen minutes, Dr. White was obliged to dis- 
continue his efforts on account of the benumbed condition of his intra-vaginal 
Pand, caused b}r the pressure upon it of the narrow and unyielding vagina, 
the fundus was at this time within the cervix and above the os, and the doc- 
tor considered the reduction substantially accomplished. He requested Dr. 
.tiner to continue the manipulation, which he did, and in sixteen minutes, or 
Jhst one hour and a half from the beginning of the operation, Dr. Miner en- 
joyed the satisfaction of announcing that the uterus, which for twenty-two 
years had been completely inverted, was now as completely reposited. Two 
hours after the operation, when we left her, the patient was quite as comfort- 
have been anticipated. An opiate was administered, and direc- 
tions were given the attendants to keep her peifectly quiet for at least a 
fortnight. By letter dated June 27, Dr. Strong reports; “Mrs. D. doing 
?etter than we had dared to expect.” July 2, Dr. Strong writes: “ Our patient 
Is doing well, and nothing has yet interfered with her progress toward re- 
covery.” July 19. “Since the operation upon Mrs. D., nothing has traus- 
pii'ed to mar the beauty of the result. Ihe pulse has at no time exceeded 
hiuety per minute.” At this time a careful examination “shows the uterus 
°ocupyin(t its normal position, the intra-vaginal portion of the neck presenting 
ordinary appearances of mild cervicitis. The patient is now about upon her 
eet some portion of her time, and everything points to a rapid, and 1 think, 
Infect cure. She has had no sanguineous discharge since the operation. 
On the 23d-of August, two months after the operation, the following letter 
received : 
~ Mv Dear Doctor Allow me to congratulate you on the perfect success of your opera- 
JlOti upon Mrs. D. I have delayed writing thus long that I might not be required to retract 
statements made in regard to the success of the operation. ic mos N. ', , 
have expected so good a result. She now does her own work, goes on foot to the 
eighbors’, rides ten miles and returns over the hills, and in fine now se 1 . I , , 
Jei'form her part in life. At the expiration of four weeks from the operation she had a 
menstrual discharge, which seemed perfectly normal both in regard and 
lat>acter. Your obedient servant, 
lu order to ascertain her subsequent condition, I addiessed a note of inquiry 
0 Hie doctor, and received the following reply : _ 
Golden, Jan. 20, 1874. 
My Dear Doctor;— Your note of inquiry is received. In repl} P6™'* 
D. is in the enioyment of good health ; that her menses are legulai , that in her 
Prespn+ euju\uieuu ui g ’ faie of those twenty-two long years 
of S appearance one can see nothing to tel Hhe tal nothing to show that 
' . nothing that speaks of terrible tlooclings , aim, > p 
e ever possessed an inverted uterus. Very truly yours, 
, It Would seem an unnecessary expenditure of the time of this learned 
to detail the remaining nine cases. Those related tanly illustrate 
tile state of the organ at the different periods of the accident, and the 
m°de of operating"for its restoration. The result has been in all the 
?ases encountered, restoration by manipulation on the first trial, and as 
18 Relieved without serious injury to the tissues thus confirming the 
c°bviction that all cases are curable, irrespective ot then duration. 890 
CASE OF RETROVERSION OF THE GRAVID UTERUS; 
TREATMENT BY PUNCTURE; RECOVERY. 
BY 
THOMAS F. ROCHESTER, M.D., 
PROFESSOR OF PRINCIPLES AND PRACTICE OP MEDICINE IN THE MEDICAL DEPARTMENT OF THE 
UNIVERSITY OF BUFFALO. 
On December 17, 1874, three children, the eldest ten years of age, 
were attacked with a severe form of scarlet fever. Their mother, with 
characteristic maternal devotion, was almost their only nurse, although 
at the time of their seizure she had commenced the second month of her 
fifth pregnancy. She was on her feet a great deal, and very frequently 
lifted and bathed the children, although herself of slight and delicate 
frame. To this she ascribed the unusual pressure and bearing down ex- 
perienced in the recto-vaginal region, such as she had never felt in her 
previous pregnancies. 
A little after midnight on March 17, 1875, her husband informed me 
that his wife feared a miscarriage, as she was in great pain, and flowing 
profusely. Visiting her immediately, and making a digital examination, 
I found the vagina filled with an elastic, globular mass, as large as the 
foetal head at full terra. Nothing like an os uteri could be found. The 
sub-pubic space was tightly filled, as was also the perineal; it was im- 
possible, by rectal exploration, to pass the finger above the lower segment 
of the tumor. The hemorrhage was free, and was found to emanate 
entirely from the urethra. A catheter was introduced with considerable 
difficulty, the instrument taking a backward and downward direction, 
and serving for the evacuation of about six ounces of very bloody urine. 
So impacted wTas the vagina, and so strong was the pressure upon the 
rectum, that it was impossible to make the vesico-rectal exploration by 
the catheter and finger. 
The case was presumptively one of retroversion, or rather of complete 
eversion of the pregnant uterus, at or exceeding four months. The con- 
dition was so grave that the attendance of my colleague, Prof. James P* 
White, was obtained in consultation as soon as possible. He made a 
most critical examination, and was, like myself, unable to find the os 
uteri. We concurred in the opinion that it was either complete eversion 
or an immense hsematocele, and that, in the former event, any attempt 
at restoration was out of the question on account of the strong pressure 
and great size of the tumor, and that the attempt would probably be' 
followed by metritis or rupture, or both. 
It was resolved to puncture the mass with a small exploring trocar, 
and the tumor was accordingly pierced at its most depending portion, 
when about four ounces of clear, straw-colored fluid passed through the 
canula. There was no blood, the fluid being evidently liquor aninii* 
Half a grain of morphia was administered, and the patient was left to 
obtain a few hours of much needed rest. At 5 P. M. the patient was 
very comfortable. She was now placed in the knee-face position, and an 
endeavor was made to lift the fundus; but this could not be done. The RETROVERSION' OF THE GRAVID UTERUS. 
891 
bloody urine was still passed, but not as frequently or as painfully as 
before. The morphia was repeated. 
On the morning of the 19th, slight labor-pains set in, and increased in 
force and frequency very gradually. With each pain the mass sensibly 
contracted, and the everted fundus was lifted a little toward the rectum. 
Shortly after midnight, on the 19th, the pains became forcing, and, at 8 
A.M., a flattened sphere, the foetal head, emerged under the pubic arch. 
•At 4 A. M. a male foetus, nine inches long, was expelled, and very soon 
atter was followed by the placenta and membranes. The intra-vaginal 
tumor was now diminished about one-half in size, but still retained its 
completely capsized position, and it was still impossible to feel the os 
Teri, It was not thought proper to make any immediate effort towards 
restoration. At 5 P. M. eight ounces of urine, slightly tinged with 
blood, were removed by the catheter, and during the two following days 
the urine was drawn, morning and evening, constantly improving in ap- 
pearance. 
On the 22d, copious alvine evacuations followed a soap-suds enema, and 
on the evening of the same day the os uteri was distinctly felt under the 
pubic arch, and the fundus had receded to the sacral hollow. From this 
time forward the catheter was not used. On the 22d, there was an 
abundant lacteal secretion, which disappeared spontaneously in about 
ten days. The patient was instructed to lie upon her face and sides, and 
to avoid straining at stool. By April 5, she was apparently perfectly well, 
the lochia had ceased, and there was no vesical or rectal irritation. The 
Uterus became gradually reduced in size, but still retained its retroverted 
position, and it was still thought safest to defer attempts to replace it. 
The patient was in fact too well to he disturbed, and had manifested no 
serious symptoms, except local ones, during the seveie oideal through 
which she had passed. She was always bright and hopeful, suffered little 
Pain, and had at no time any febrile movement; her pulse was only ac- 
celerated to 100 for the two days preceding the expulsion of the foetus. 
She was instructed to use warm vaginal and rectal enemata daily, to 
Maintain the recumbent or semi-recumbent position, and to await the 
proper time for interference, which she very patiently did. 
On May 1, her menstrual period came on, and lasted five days. On 
May 13,Simpson’s sound was passed in, to the depth of thiee inches, and 
the uterus was by its aid placed in the proper position, from which, how- 
ever, it fell back within a day or two. This operation was repeated, once 
a week, until the second period returned, which was on May 31. On June 
10, the uterus was placed in position ; on the 19th, it had receded again, 
Was restored with the sound, and was now retained in position with a 
cradle-shaped, hard-rubber pessary. This was worn with entire comfort 
for six months, and was then removed, dhe uterus has since retained 
its proper position. The patient is apparently perfectly well, but has not 
been again pregnant.1 
Remarks.—This case has been presented, certainly not foi its novelty, 
but to illustrate the successful result of a method of tiea ment. v\ hen 
1 June 11 1877. The patient is again three months advanced in pregnancy. She con- 
sulted me at the end of the second month, when the uterus was again found retroverted. It 
wus replaced by the repositor, but it was found necessary to retain it in situ by a pessary, 
and the three-winced instrument of Thomas was employed successfully, after failure with 
|;he cradle-shaped°oue previously worn. At the present date, gestation is progressing 
favorably. 892 
ROCHESTER, RETROVERSION OF THE GRAVID UTERUS. 
we consider the number of fatal cases on record, and when we further 
consider the serious injury that has frequently resulted to both bladder 
and womb, either from entire neglect or from repeated and protracted 
attempts at restoration, and when we remember that in the greater pro- 
portion of cases of retroversion of the gravid uterus, even if the organ 
is replaced by posture and manipulation, the operation is almost always 
followed by abortion and metritis, may not the procedure which has been 
described be more safe than the treatment usually adopted ? I do not 
wish to be understood as advocating puncture or tapping of the womb, 
through its walls, in preference to separation or rupture of the mem- 
bra nes through the os uteri, when this is accessible; but only when, as 
in the case reported, the os cannot be reached. 893 
SECTION ON OPHTHALMOLOGY. 
PRESIDENT OF THE SECTION. 
R. BRUDENELL CARTER, F.R.0.5., 
OF LONDON. 
Y I C E-P RESIDENTS. 
WILLIAM THOMSON, M.D., HENRY W. WILLIAMS, M.D., 
OF PHILADELPHIA. OF BOSTON. 
SECRETARY. 
JOHN GREEN, M.D., 
OF ST. LOUIS. 
°N THE COMPARATIVE VALUE OF CAUSTICS AND ASTRIN- 
GENTS IN THE TREATMENT OF DISEASES OF THE 
CONJUNCTIVA, AND ON THE BEST MODE OF 
APPLYING THESE REMEDIES. 
BY 
HENRY W. WILLIAMS, A.M., M.D., 
PROFESSOR OF OPHTHALMOLOGY IN HARVARD UNIVERSITY. 
The conjunctiva, one of the least in extent, but one of the most im- 
portant, of the mucous membranes, is the seat of affections singularly 
Wrious in form and degree—from the simplest transient congestion to 
most violent inflammatory processes and most persistent structural 
alterations. On the treatment of these depends, often, the preservation 
°r the loss of the most important of our special senses, and the fairest 
Prospects in life may be blighted by either mismanagement or neglect. 
In preparing the paper which I now offer to the Section on Ophthal- 
mology, I have avoided a recapitulation of every theory as to pathology 
treatment, and offer simply a few practical suggestions, with no wish 
P unduly depreciate the value of other means and methods than those 
°r which I express a preference. Skilful men will know how to use 
Widens instrumentalities to attain good results. Nevertheless, it is desi- 
-1 ble, and important, to discriminate among the agencies at our com- 
prtnd, and to select such as practically prove best adapted to the cure, 
cito, etjucunde, of the diseases which we are considering. 
A considerable number of conjunctival affections require little or no 
reatrnent, and are injured rather than benefited by the use ot other 
„ rtn the mildest remedies. The hype rue mi a caused by the presence of a 
°i'eign body subsides upon its removal; the injection depending on 
or other defects of refraction, disappears after the selection 
suitable eye-glasses; the sub-conjunctival ecchyrnosis following a blow, 
the rupture of a small bloodvessel, is re-absorhed, perhaps quite as 
rapidly5 without our interference. If, in these cases, we prescribe a lotion 894 
H. W. WILLIAMS, 
or a collyrinm, it, should he quite unirritating. So also in traumatic 
injuries of a simple character, and after operations for strabismus or 
pterygium, the healing processes go on without assistance from applied 
remedies. Chemical injuries, because of their graver nature and the 
degree in which the cornea may be involved, oftener require our aid; but 
even here, emollients and sedatives rather than active stimulants are 
most useful. 
With the above-named exceptions, and apart from certain complica- 
tions hereafter to be considered, diseases of the conjunctiva may be 
divided into two classes requiring essentially different management. The 
first includes a comparatively simple, limited, and benign, though some- 
times chronic, affection ; the second embraces several conditions of gene- 
ral and often severe conjunctival inflammation. The prominent feature 
of the first class is the development of small elevations or papulxe, one or 
several in number, usually situated at or near the border of the cornea, 
though they may form elsewhere on the ocular conjunctiva. The sum- 
mits of these may be whitish, as if containing a minute quantity of pus 5 
more frequently they are red; and they may vary in size, but are commonly 
about that of a hemp-seed. Usually a fasciculus of vessels runs to each ox 
these papulse ; but there is no general injection of the conjunctiva, except 
as far as may be the result of friction of the papulge against the inner sur- 
face of the lid. Children are the most frequent subjects of this disease. 
The tendency of this affection is towards a disappearance of the symp' 
toms at the end of a few days, even when no treatment is employed- 
Therefore, no active remedies of caustic or astringent nature are needed, 
and they tend to delay rather than hasten the recovery. Calomel or other 
insufflations are similarly useless. All annoying remedies are moreover 
objectionable on account of the age of the majority of the patients, Simpi® 
lotions, cold or tepid, with water, or milk and water, may be used. Tvy° 
or three times a day, a few drops of a solution of ten grains of borax xxx 
an ounce of water, or of camphor water, may be dropped into the eye 
from a teaspoon or a drop-tube. This usually proves a soothing and 
refreshing collyrium, grateful rather than painful to the patient, and 
appears to have a sufficiently astringent and stimulating effect to pi’o' 
mote absorption of the papulae. Although the ordinary duration of these 
small pimples rarely exceeds ten days, it is not uncommon, whatever 
treatment has been employed, to find successive crops of them, at inter- 
vals of a week or two. This disposition seems to be best obviated by 
continuing the use of the borax collyrium, once or twice a day, for some 
time after recovery, so as to modify the condition of the conjunctiva. 
Where the papulae are slow in disappearing, the application of a crayoll 
of alum, once in a day or two, to the inner surface of the lower lid, 
often useful and is nearly painless. The astringent reaches the affected 
spot as the lid returns to its place, and seems sometimes to excite a more 
rapid resolution. The papulae themselves should never be directly touched 
with caustic or astringent crayons or solutions. 
Yei’y rarely, the disease takes a more chronic form, the papulae being 
as large or larger than a split pea, and sometimes umbilicated at the 
centre. Though persisting longer, and for a time intractable to treatment, 
the prognosis is always favorable. Tonic general remedies, and some- 
times change of air, are useful adjuvants to the mild local applications. 
Solutions of atropia have of late been too much in vogue in the treatment 
of this form of disease. Though far less dangerous than the strong caus- 
tic remedies which were formerly indiscriminately employed, yet an DISEASES OF CONJUNCTIVA. 
895 
Unnecessary resort to them has grave disadvantages. In cases of corneal 
ulceration they may be of much service, in lessening the irritability and 
photophobia; whilst in these less serious conjunctival affections their 
action upon the pupil does but increase the intolerance of light, and, 
by exciting strong contractions of the lids, creates a disposition to cor- 
Ueal ulceration as an effect of friction. 
The second class of conjunctival affections comprises catarrhal con- 
junctivitis in its acute and chronic forms, trachoma, purulent and 
gonorrhoeal conjunctivitis, ophthalmia of new-born children, and diph- 
theritic conjunctivitis; each of which conditions has an importance 
claiming distinct consideration. 
When the conjunctiva becomes affected from exposure to cold, dust, 
or other simple causes of irritation, the first symptom is injection with 
an increased flow of tears—soon followed by a velvety thickening of the 
palpebral conjunctiva and a slight mucous secretion. These phenomena 
uiay occur so suddenly that the patient feels sure that something has 
teen blown into his eye ; but the scarlet, velvety appearance of the lining 
of the lids, as distinguished from the mere vascular hyperaemia excited 
by the presence of a foreign body, renders the differential diagnosis suffi- 
ciently easy. At this stage, caustics and strong astringents are alike to 
be avoided, or used with great reserve. Frequent bathing with cold or 
tepid water according to the sensations of the patient, with applications, 
four or five times a day, of a few drops of a solution of ten grains of 
borax in an ounce of camphor-water, or of five grains of alum or one grain 
of sulphate of zinc in an ounce of water or rose-water, will generally cut 
short even a sharp attack and remove the symptoms within three or four 
days. Occasionally this form of conjunctivitis is epidemic, large numbers 
of persons being attacked within a short time. Similar, with perhaps 
somewhat more active, means, are here called for; one or two touches 
inside the upper lid with a crayon of alum, or, very rarely, a single light 
touch with a crayon of sulphate of copper, acting as useful auxiliaries in 
arresting the symptoms in an early stage. If neglected or if too actively 
treated, the thickened conjunctiva assumes a more or less granulated 
aspect, and a chronic phase of disease is established which requires more 
active measures. The lining of the lids, especially the upper, from 
hypertrophy of the conjunctival follicles, now resembles in appearance 
the surface of a raspberry, and the sub-conjunctival tissues become so 
Infiltrated that the lid-movements are difficult. The secretions are 
greatly augmented, causing abundant flow in the daytime, and aggluti- 
nation of the lids at night. Here, as in another affection next to be 
described, the mild remedies, sufficient for the lesser degrees of inflamma- 
tion, are of little avail. Caustics or astringents, of consideiable potency, 
seem to be our only resource. _ ...... 
Trachoma differs widely, pathologically,from catarrhal conjunctivitis, 
though often coexistent with and complicating it. It essen- 
tially in a neo-plastic formation; at first in small, oval-shaped, semi-trans- 
parent masses, resembling grains of tapioca; and sometimes increasing 
Until the conjunctiva, with its subjacent textures, is largely transformed 
into a dense, nearly structureless mass, which, as xecovery takes place, 
is not replaced by normal tissue, but is followed by contraction of the 
conjunctiva and incurvation of the tarsal cartilage. Here, the prognosis 
is less favorable, the recovery slower, and the dangei of secondary lesions 
of the cornea much greater than in the catairhal foim of conjunctivitis. 896 
H. W. WILLIAMS, ' 
But the local treatment of the two affections has much similarity, 
may he either caustic or astringent, or both. 
Nitrate of silver is the caustic most relied on in the treatment of con- 
junctival affections, though other means have from time to time been 
tested and enjoyed ephemeral reputation. The methods of using it, and 
the means employed to limit its effects, vary with different ophthalmolo- 
gists. The crayon of pure nitrate and the nearly saturated solution, 
formerly much used, are now rarely employed, but have given place to 
the lapis mitigatus, as it is termed, in which one part of nitrate of silver 
and twTo parts of nitrate of potassium—or two parts of silver and one of 
potassium—are fused together; or to solutions of nitrate of silver of 
from ten to forty or more grains to an ounce of water. The caustic Is 
applied, in most cases, to the surface of the everted, upper lid, more or less 
lightly or extensively, the stick of lapis mitigatus being preferred by 
some, the solution of nitrate of silver by other authorities. When 
thought advisable, the action of these substances is limited by the imme- 
diate application of a neutralizing solution of salt and water, or pure 
water, or both of these, to the cauterized surface. The frequency of the 
repetition also varies greatly, in the practice of different individuals: 
once, twice, or thrice a week, daily, or oftener, according to the intensity 
of the.symptoms or the preferences of the practitioner. Moreover, some 
rely wholly on this means; others employ auxiliary treatment. Theories 
as to therapeutic effect also vary with different observers, some seeking 
to destroy the apices of the granulations, while others, deprecating such 
an effect, use the caustic with more reserve, and, virtually, as a strong 
stimulant only. 
In the class of astringents employed as topical applications by the 
physician himself, may be named, crayons of sulphate of copper ; the lapl3 
divinus, composed of equal parts of sulphate of copper, alum, and nitrate 
of potassium moulded into sticks ; crayons of alum ; and strong solutions 
of tannin in glycerine. Gf these, the crayon of sulphate of copper for in s 
the best type; as combining the several qualities of convenience, effi- 
ciency, and safety. The alum crayon has an excellent effect in nffld 
forms of conjunctivitis, but is inefficient in the severer and chronic affec- 
tions. The lapis divinus seems less reliable than the crayon of pare 
sulphate of copper. Tannin and other vegetable astringents, from which 
theoretically we should expect so much, have always proved, in mf 
hands, in whatever proportion or combination, inferior to the mineral 
astringents; whether as a means of energetic action upon the conjunc- 
tiva, or as used in collyria to produce milder continuous effects. 
The sulphate of copper cannot be fused in moulds, like nitrate of silvd 
and lapis divinus, but the crayons have to be shaped from crystals ot 
the substance. Unfortunately, these are generally much broken at the 
laboratories in packing for the market, but if good crystals can be found 
it is easy to cut from them crayons of convenient size. The harder part8 
of the crystal, free from pores or water of crystallization, are to be chosen. 
Nothing would be needed to obtain ample supplies of the crystals, or ot 
crayons already shaped from them, but the knowledge that there was a 
demand for them, as they are easily made from crystals obtainable at the 
laboratories, and they require no care in keeping, being little changed 
by exposure to air or light. A single crayon lasts a long time, and inay 
be used, like a silver probe or a bistoury, for successive cases, care being 
of course taken to wipe the crayon after every application. The crayou 
of sulphate of copper should be applied, as a rule, rather lightly to the DISEASES OF CONJUNCTIVA. 
897 
ponjunctiva of the everted upper lid ; this lid, in which the circulation 
more readily congested, being usually more diseased than the lower 
dissolved by the moist surface over which it is passed, is carried by the 
Movements of the lids to every part of the conjunctiva. In sluggish 
oases the crayon may be applied more heavily, or may be more frequently 
Repeated. 
Used as above described, the crayon of sulphate of copper does not act 
°n the conjunctiva as a caustic, but only as an energetic astringent and 
stimulant. In the more acute cases, the pain, after the first or even after 
several applications, may continue tor some time; though it is much less 
severe and enduring than when caustic has been used. Bathing the eye 
■with water shortens and mitigates the smarting. While the pain is 
touch prolonged, the crayon should be used lightly and perhaps less 
frequently than after the eye has become more tolerant of the remedy. 
The touch may then be harder, and may be repeated daily or less often, 
According to the judgment of the physician. When the crayon is wrell 
borne, cases often improve the more rapidly according to the greater 
frequency of its application; this being especially observed in many 
chronic cases, trachomatous, and other. 
That many cases of muco-purulent or trachomatous forms of conjunc- 
tivitis mav be successfully treated with nitrate of silver, pure or combined, 
does not admit of a doubt. Its action requires to be carefully watched, 
told good judgment must be exercised in determining the frequency and 
of its application, and in neutralizing at once any excess ot the 
caustic. More benefit is obtained from its moderate than from its too 
free use. Care must also be taken not to continue it too long, as not 
infrequent instances have occurred in which the conjunctiva has acquired 
toi indelible, olive stain, or even become quite black, from the prolonged 
distillation of a moderately strong solution. If employed, caustics should 
Dot be solely relied on, but should be supplemented bj- othei milder 
remedies of stimulating or astringent nature, which may be moie oi less 
frequently applied by the patient or his friends. _ . 
The use of caustic as an application to the ejm is not without its 
dangers. Its active properties render it a destructive agent in unskilful 
bands; and it sometimes disappoints even thernost experienced oculist. 
The application of the crayon of sulphate of copper involves no such 
consequences as are inseparable from the use of nitrate of silvei. It it 
happens to be injudiciously employed, no special harm is done and no 
Ito mediately destructive effects ensue from its use. It is, theiefoie, a far 
Bafer agent in inexperienced hands. 
It remains to consider whether the general results of tieatment will 
be more successful under the one or the other plan. . 
My own experience, which has included careful personal o iseivation ot 
fhe practice of nearly every European oculist who has had celebrity 
"dthin the last thirty years, has satisfied me that better and quicker 
Results, with far less danger and suffering, are obtainable tiom the use 
°f astringents than from the use of caustics. Many yeais since, I made 
c°toparative tests of the value of these two classes of remedies in severe and 
chronic forms of conjunctivitis, on a large numbei ot patients. Selecting 
cases where both eyes were equally diseased, I treated all the right eyes 
with nitrate of silver, and all the left eyes with sulphate of copper. Of 
course, no differences of constitution could influence the effect produced, as 
toight, perhaps, have been alleged had merely a ceitain number of patients 
57 898 
H, W. WILLIAMS, 
been chosen for each mode of treatment and the same remedy used 1,1 
both their eyes. The uniform result was a more rapid gain in the eye® 
treated with the crayon of sulphate of copper. Some of the eyes treated 
w7ith nitrate of silver went on tolerably well, though slowly; but other9 
did so badly that, after vain attempts to succeed by varying the strength 
of the caustic applications, I wras at last compelled, in order to avert 
threatened loss of the eyes, to substitute the use of the sulphate ot 
copper, under which they recovered. In no instance was it necessary to 
abandon the sulphate of copper and resort to another remedy. 
A very important adjuvant to treatment, either by caustics or astrin- 
gents, as applied by the physician himself, consists in combining with 
these the more or less frequent use, at home, of a milder astringent °r 
stimulating collyrium. Of these, the mineral seem to be superior to the 
vegetable astringents, as also to the purely stimulating class of collyrnp 
such, for instance, as those containing wine of opium or corrosive subb' 
mate. Many substances have been employed with more or less advan- 
tage. Among those most in use may be mentioned solutions of nitrate 
of silver, sulphate of zinc, acetate of zinc, sulphate of copper, sulphate ot 
cadmium, alum, and borax. Of these, the sulphate of zinc seems by 
the best for the forms of conjunctivitis which we are considering, as it 
appears to have a more astringent with less irritant action than eithei 
of the other remedies. The silver, copper, and cadmium solutions, are ton 
actively stimulating, with less of astringent effect; the alum and bora> 
are too mild. The sulphate of zinc solutions may vary from half a grain 
to four grains to the ounce of water or rose-water; and a few drops ina/ 
be poured into the eye from a teaspoon, a drop tube, or otherwise, two? 
three, or four times a day. In cold weather the spoon may first he 
dipped into hot water for a moment, so as to warm the collyrium, if the 
eye is sensitive as to the temperature of the drops. I have found the 
sensations of the patient a useful guide in determining the strength 
collyrium likely to be of most benefit to him. If a solution of a given 
strength, say of two or of three grains to the ounce, causes smarting 
more than five minutes, it should be diluted one-half, or until it n° 
longer gives more than a few minutes’ pain. Thus graduated, the colly' 
rium should be used often enough to keep up a moderate remedial infln- 
ence. 
Acetate of lead, in substance or solution, formerly much in favor even 
with the profession, and still in common popular use, should never he 
put into the eye. It has no special remedial value to warrant its ern_' 
ployment; and whenever the conjunctivitis is, or becomes, complicated 
with corneal ulceration, great harm is done; the acetate being decod1' 
posed, and an indelible deposit formed on the ulcerated surface, causing 
permanent opacity of the cornea. It is therefore better to erase it from 
the list of ophthalmic remedies. 
More actively virulent forms of conjunctivitis are found under the 
designations of purulent conjunctivitis, gonorrhoeal conjunctivitis, alll 
the conjunctivitis of new-born children. Purulent conjunctivitis, some' 
times termed Egyptian Ophthalmia or Ophthalmia of Armies, is marked 
by far more rapid sequence and violence of symptoms than the catarrha 
or trachomatous affections. In pauper asylums, schools, and barracks? 
it may speedily extend to a large number of persons by direct infection 
of healthy eyes with the purulent discharge from those which are dis- 
eased. This is largely conveyed through the promiscuous use, in siicn 
institutions, of articles of toilet, wash-basins, towels, etc.; and is some' DISEASES OF CONJUNCTIVA. 
899 
pies purposely introduced ; the fearful risk of blindness being incurred 
|°r the sake of avoiding military or other duty, or of obtaining some 
hospital privilege. Enormous tumefaction of the conjunctiva and of the 
Entire lid, and copious muco-purulent discharge, characterize this dis- 
use. Serous or even phlegmonous chemosis of the subconjunctival 
tissue often forms a dangerous complication, interfering with 
proper nutrition of the cornea ; and ulceration of that structure may 
lesult from the direct pressure of the swollen lid, or from the continued 
laceration in the copious purulent secretion. 
Gronorrhceal conjunctivitis is even more intense in its symptoms and 
I<apid in its course. Caused by infection with gonorrhoeal matter or with 
the discharge from an already diseased eye, it is more common in men 
than in females, the fingers being often the medium for conveying the 
Urethral discharge to the eye. One eye only is usually affected at the 
olJtset. The frequency of phlegmonous chemosis, and consequent danger 
t° the cornea, is greater than in the simple purulent affection. So rapid 
18 the course of the disease, that an eye may be lost by sloughing of the 
eornea within twenty-four hours from the moment of infection. 
Active cauterization of these forms of conjunctivitis, especially the 
gonorrhoeal, was formerly practised as an abortive treatment, in the hope 
substituting a less dangerous traumatic inflammation for the specific 
Election. This idea has been generally abandoned, and the modern 
G’eatment is in all respects milder. As general means, tonics, instead of 
e°pious depletion, are in favor; and, as regards local treatment, great im- 
portance is to he attached to the frequent use of mild detergents, injected 
beneath the swollen lids, to remove the abundant puiulent secietion. If 
Rustics are used, the applications should be neithei too stiong nor too 
Sequent, and should be at once neutralized as otherwise they tend to 
Ucrease the phlegmonous chemosis and perhaps destroy the cornea. They 
not be continued if corneal ulceration has begun. If the crayon of 
?hlphate of copper is applied at all during the active stages of tie disease, 
n should be lightly used; but it is most serviceable in removing the 
granulations which remain after the active symptoms are abated. Ihe 
application of cold compresses, constantly renewed, to the lids; frequent 
removal of the fast accumulating secretions; and the keeping up an mflu- 
ence on the diseased conjunctiva by means of mild astringent collyna, 
aPpear to form the most reliable treatment. Solutions of five grains of 
alum or ten grains of borax to an ounce of water may be injected several 
pes a day, and a solution of half a grain to two grams of sulphate of 
may be used three or four times in twenty-four hours. Ie app i- 
?ation of a crayon of alum to the inside of the lid, once oi wice a(ay , 
18 sometimes of great apparent benefit, and is safe y ant easi yapp iu, 
f8 an auxiliary to the astringent solutions. It is nearly pain ess, and 
p little stimulating action as compared with its astringent qualities, 
ij; should be used by "introducing it beneath the lid without evei ting it. 
the case is seen early, these means are generally effectual, mt unfor- 
tunately the vitality of the cornea is in many instances already destroyed 
J'W the patient first applies for advice, and the prognosis is then un- 
prable. ...... , 
disease of the eye imposes greater responsibilities upon the general 
petitioner than ophthalmia neonatorum, the conjunctivitis of new-born 
ehildren. Occurring within a few days after birth, under circumstances 
in a large proportion of cases, preclude a consultation with any 
Petitioner of special experience, the preservation or loss of sight must 900 
H. W. WILLIAMS, 
depend on the ski]] of the family physician, A slight conjunctival injec- 
tion and tumefaction, with some mucous discharge, is not uncommon in 
infants, and yields to simple means of cleanliness. But true ophthalmia 
neonatorum, preceded perhaps only by a slight reddish hue along the 
skin of the upper lid, becomes within a few hours an intense inflammation. 
The lids are tumefied, livid, sometimes projecting much beyond the 
supra-orbital ridge, or even completely everted from the enormous swell- 
ing of the conjunctiva. The chemotic infiltration of the cellular tissue 
beneath the ocular conjunctiva often causes this to overlap the cornea or 
even to hide it. The secretion is exceedingly abundant. This disease is 
one of the most destructive, but happily also one of the most manageable, 
of the affections of the eye. If neglected, or if treated with inert domestic 
remedies such as injection of breast milk, or with more harmful means 
such as the application of poultices, the result is too frequently the loss 
of one or both eyes. Equally baneful consequences follow the use of 
harsh measures. The great danger attending the use of caustics, in any 
form, or of very strong astringents, and the needlessness of resorting to them, 
cannot be too strongly insisted on. The symptoms invariably yield to a 
mild treatment, if reasonably begun and faithfully carried out. If, as is 
sometimes the case, the cornea has already become more or less cloudy 
before the attention of the physician is called to the eyes, this furnishes 
an additional reason for refraining from strong caustic or astringent 
remedies, which are never well borne when the cornea has become in- 
volved. 
The first indication is to insure the utmost attention to cleanliness. 
The copious, muco-purulent secretion should be washed from the eyes 
every two hours, every hour, or even every half hour if necessary. 
Should the great tumefaction of the lids prevent their being readily 
opened so as to permit free discharge of the pus, the nozzle of a small 
syringe should be passed beneath the swollen upper lid, and an injection 
thrown in to completely wash out the conjunctival cavity. For this 
purpose tepid water may be used in the milder cases ; in those of more 
severity a solution of alum, five grains to the ounce, may be alternated 
with the injections of water. These injections should be repeated hourly 
or oftener, according to the severity of the case, during the day, and two 
or three times during the night. They are nearly painless, and the 
nurse or mother should be taught how to make them. In a few days 
the discharge lessens and the swelling of the lids diminishes; but the 
treatment must be kept up, though with less frequency. The physician 
should not fail to assure himself, by daily inspection, as to whether the 
cornea retains its normal appearances ; and where the swollen condition 
of the lid prevents a view of the cornea, an elevator should be carefully 
used to draw up the lid. If the cornea is seen to be even slightly cloudy 
at its centre, a drop of a solution of sulphate of atropia, two grains to an 
ounce of water, should be put into the eye twice daily, to lessen the 
danger of hernia of the iris in case corneal ulceration and perforation 
should occur. This haziness and ulceration may come on very early in 
the disease, as a result of the continuous pressure of the lid upon the 
cornea, or as the effect of its constant immersion in the purulent secre- 
tion ; but this threatening condition may also supervene at a later stage, 
and after marked amelioration of the active symptoms ; so that the phy- 
sician, unless on his guard, may lose the battle in the moment of ap- 
parent victory. 
The use of tire nitrate of silver or of lapis mitigatus, is still reconi- DISEASES OF CONJUNCTIVA. 
901 
mended by some of the continental European oculists ; but the milder 
plan above described has been, for many years, almost exclusively in use 
at the ophthalmic hospitals of London, and especially at the Moorfields 
Royal London Ophthalmic Hospital, probably the largest institution 
in the world for the treatment of eye-diseases, and certainly the most 
distinguished for the celebrity of its medical staff. In my own experi- 
ence, success has always attended the mild plan of treatment; and I 
have seen so many examples of the destructive consequences of harsher 
methods, that I cannot regard them otherwise than as unnecessary and 
injudicious. 
Two classes of complications of conjunctivitis are worthy of our atten- 
tion, in their relations to the questions of remedial action which we are 
considering. In one of these classes the conjunctivitis results from other 
morbid processes ; in the other class the morbid conditions are the con- 
sequence of pre-existing conjunctivitis. In the first class, including 
cases where conjunctivitis appears as a symptom in keratitis, iritis, or in 
other inflammations of the interior structures of the eye, the conjunctival 
injection is not to be regarded as a disease, and its treatment, if any, 
must be subordinate to or modified by that ot its primary exciting cause, 
the removal of which often suffices for the cure of the secondary con- 
junctival symptoms. In most of these conditions the use of caustics and 
astringents is contra-indicated. Instead of relieving, they excite yet 
further congestion of the external membrane, and increase rather than 
lessen the deeper seated inflammation. Tepid, unirritating lotions, and 
eollyria containing a few grains of borax, may be used as sedatives, if 
the patient finds them agreeable. Active use of either caustics or astrin- 
gents is also to be avoided in conjunctivitis accompanying corneal 
ulceration, or the presence of papules on the epithelial layer of the cornea, 
in children; as also, especially, in ulcerations of the cornea in adults, 
occasioned by debility, in old age, or as a sequela of smallpox or other 
depressing disease. 
The second class of complications embraces those conditions resulting 
from conjunctivitis, usually from its chronic duration, as seen tor instance 
in pannus and secondary keratitis. Here, the attention must primarily 
be directed to the removal of the original disease, by such remedies as 
have been already indicated ; but we must be careful to make such modi- 
fications of treatment as may be required by the secondary symptoms or 
structural changes, while we avoid the error of regarding these as the 
essential morbid conditions and directing our treatment solely to them. 
For example, in the affection styled pannus, where the epithelial layer of 
the cornea has become so thickened and vascular as to resemble a piece 
of red flannel, it is useless to attempt to remove this vascularity by divi- 
sion or scarification of the vessels. The abnormal condition of the exter- 
nal layer of the cornea is the result of constant friction by trachomatous 
or other granulation of the lids, and is to be cured through the removal 
of these by the patient use of astringents. After the friction has ceased 
to irritate the corneal surface, the injection and cloudiness gradually fade 
away. If ulcerative or exudative processes have begun in the cornea 
itself, caustics are not admissible, but the use of atropia should be com- 
bined with the astringent remedies, the continuance of which in modera- 
tion is necessary for the removal of the granulations. A certain degree 
of vascularity is essential to the absorption of the cloudy transformations, 
and disappears as these fade away. 
Some other more exceptional complications should be briefly referred 902 
H. W. WILLIAMS, 
to. When chronic conjunctivitis accompanies obstruction of the lachry- 
mal passages, mild astringent collyria may be combined with the appro- 
priate means for the removal of this obstruction. When it is coincident 
with disease of the Meibomian glands or ciliary bulbs, these collyria may 
be used in connection with diluted citrine ointment, or other suitable, 
topical applications, along the edges of the lids. When it appears during 
an attack of herpes zoster ophthalmicus, or ensues after paralysis of the 
orbicularis, caustics are scrupulously to be avoided as being likely to pro- 
mote ulceration of the cornea, to which, in these circumstances, there is 
always a predisposition; only the mildest astringents should be used. 
In chronic thickening of the conjunctiva and eversion of the lids in old 
people, commonly called “ blear eyes,” attention should be given to the 
lachrymal passages, and the everted lid should be brought to its place by 
a frequent but mild use of astringents, patiently followed up. These 
should not be applied, nor should caustics be used, upon the everted and 
dry portion of the conjunctiva, as they only serve to harden, and, as it 
were, tan the surface; but the crayon of sulphate of copper or of alum 
should be applied, very lightly, to the non-everted portion of the con- 
junctiva. As this part becomes more healthy , the everted lid is drawn 
more and more to its proper place, the remedy can be applied more 
largely, and the improvement finally extends to the whole of the affected 
tissue. 
The conclusions which seem to be warranted by the facts presented in 
the foregoing paper, may be summed up as follows: 
I. In a considerable number of essentially transient affections of the 
conjunctiva, and in pterygium or other growths, no active treatment by 
caustics or astringents is required. 
11. When disease affects only a limited portion of the conjunctiva, as 
in phlyctenular inflammation, the mildest stimulating or astringent 
remedies are usually sufficient, 
111. In the acute and chronic forms of general conjunctivitis, astrin- 
gents are, as a rule, safer as well as more efficacious than caustics, and are, 
therefore, better adapted to the requirements of the general practitioner. 
Discussion on Dr. H. W. Williams’s Paper. 
After the reading of the preceding paper, Dr. C. R. Agnew, of New York, 
said :—I would like Professor Williams to say with more minuteness what he 
would do in a case of ophthalmia neonatorum in which the swelling was so 
great as to produce complete eversion. Suppose he were called to see a child 
ten days old, in whom the inflammation was such as to have caused complete 
eversion of both eyelids ; let him tell us what applications he would use, and 
how, and how frequently, he would use them. I agree mostly with Prof. Wil- 
liams's views; I recognize the force of his arguments in favor of mild treat- 
ment, and the propriety of his protest against the too heroic measures often 
employed ; but I want him to go further and tell us what he would do in such 
a case as I have described. 
Dr. H. W. Williams said :—I can hardly imagine a case more unpleasant 
to meet with than such an one as that supposed by Dr. Agnew: nevertheless, 
those cases in which the excessively swollen, upper lid covers the lower, and 
confines the discharge, are even more dangerous. I would, however, prescribe 
treatment similar to that which I have advised in my paper, but should glV® 
very close personal attention to the case. I have never known the most critical 
stage in such cases to last longer than forty-eight hours, and I would make three 
or four visits every day, and be sure at each visit that the lids if everted were DISEASES OF CONJUNCTIVA. 
leaped in position, and the child not excited by the use of painful caustic appli- 
cations. There is no difficulty in replacing the lid, but each time the child 
the lid becomes again displaced. The case should be faithfully followed 
'P with mild local treatment. I would use the alum crayon, three or four 
lines a day, as it causes little or no pain and does not distress the child, as 
w°uld any strong or caustic solution. 
I). E. Williams, of Cincinnati, said:—While I agree with the doctrines 
the paper just read in many particulars, I disagree with them in regard to 
s°nie essential points of treatment. It has been my custom to treat these 
t‘ases much more energetically than is advocated in the paper, and I have never 
la(l a single case of ulceration occur during treatment in an infant. I evert 
, lids, thoroughly cleanse them, and brush them with a solution of nitrate of 
Sllver of the strength of from five to ten grains to the ounce, washing it off' with 
®idt water. Scarcely without exception the patient returns the next morning 
Mth eyes greatly improved. I continue this for three or four days, once a day, 
aiHl when I have the disease under control continue the treatment by the use 
astringents. I believe that in some cases the sulphate of atropia is very use- 
but in infants half a grain to the ounce is as strong a solution as it is 
Prudent to use. 
Dr. H. W. Williams said :—I agree that in some cases it is well to use the 
astringents, and perhaps an application or two of sulphate of copper. 
°uietimes I find it necessary to use active astringents, but even then, when 
r auger is past, 1 return to the milder applications. I have known cases in which, 
UlJar caustic having been used by the family physician, the ej’es have been 
spoiled. 
Dr. C. R. Agnew said I would ask Prof. Williams how he would treat the 
°rst typical case of gonorrhoeal conjunctivitis, if called in within twenty-four 
P°urs, there being as yet no corneal lesion ? 
Dr. H. W. Williams saidl have seen cases of that kind, with serous blood- 
stained discharges, in which I have thought it well to apply a strong astrin- 
gent. I would say that I do not mean to limit myself oi any othei gentleman 
*°o strictly to the rules laid down. Every case must be treated by itself; but 
have aimed to lay down a rule which is generally applicable. 
. Dr. John Green, of St. Louis, said :—Prof. Williams’s paper convejs the 
lQlpression that in the purulent ophthalmia of new-born childien success is 
Uniformly to be expected if the case is treated early enough ; nevei theless cases 
?°nietimes occur which do not turn out so well. I have seen two such cases 
I*1 which the cornea was lost although carefully treated from the beginning of 
16 attack. 
Dr. George Strawbridge, of Philadelphia, said:—The modes of treatment 
Vvlueh have been advocated are totally different, and yet have both been pur- 
by gentlemen of large experience. I have faithfully tried both methods. 
Diat which Prof. Williams, of Boston, proposes, is a good method when it can 
„>e carried out, but it is impossible to do that except in a hospital, oi in a nch 
lamily, whereas these cases mostly occur among the poorer classes. My 
exPerience has been that after the acute stages have passed by, much benefit 
lxiay be obtained from the use of the mitigated nitrate ol sihei. 
, Dr. S. D. Risley, of Philadelphia, said;—I have been struck with the extreme 
ddness of the treatment recommended by Prof. Williams. In the ophthal- 
*ia of new-born children, it has been my custom to use the mitigated stick 
]°lltralizing any excess, as I can thus confine its action to the conjunctiva and 
JPare the cornea. One other application which I have used with equally satis- 
aOory results, is a twenty per cent, solution of carbolic acid in glycerine. It 
as the advantage of causing less pain than the nitrate of silyei. Although 
l)ainful at f}rsti paiu subsides in a moment, and the child is subsequently 
comfortable than after the use of the nitrate. 
Dr. George C. Harlan, of Philadelphia, saidl see many of these cases 
at Die Children’s Hospital. Until four years ago, I never used nitrate of silver 904 
H. W. WILLIAMS, DISEASES OF CONJUNCTIVA. 
of a strength greater than four grains to the fluidounce, but since then I have 
used as strong a solution as ten grains to the fluidounce, and so far from giv- 
ing excessive pain it seems to give relief, and the children are more at ease 
after the immediate effects have passed off. In addition, I give directions for 
the use of an alum solution of the strength of five grains to the fluidounce a3 
often as ma3r he necessary to prevent the accumulation of pus. 
Dr. J. H. Pooley, of Columbus, Ohio, said :—I employ the sulphate of 
copper, and it seems to me the better remedy for chronic conjunctivitis. lam 
not in the habit of using as strong solutions of nitrate of silver as Dr. Wil- 
liams, of Cincinnati; using but five grains to the ounce. Stronger solutions I 
think very objectionable, and the mitigated stick cannot always be used with- 
out leaving a scar on the conjunctiva. I prefer to cleanse the eyes with a 
sponge rather than with a syringe, and I order the use of cold water. 
Dr. E. Williams said :—I wish to say by way of explanation that, when I 
spoke of treating all infants uniformly, I did not mean to imply that I always 
employed solutions of the same strength. I have never seen more than two 
cases of diphtheritic conjunctivitis, and they were in children, not infants ; each 
lost one eye. When we invert the lids, we see on the surface a somewhat 
grayish and consistent film, but this is easily removed and is not at all connected 
with diphtheria. I make it a point always to get this off. In speaking of my 
success I do not mean to disparage that of any one else, but I have found my 
plan of treatment successful, short, and certain. 
Dr. William Thomson, of Philadelphia, said:—lt seems to me that there 
is no difference of opinion with regard to the successful use of nitrate of silver, 
but only as to the mode of its application and the strength of the solutions to 
be employed. Applications made to the whole conjunctival sac, and so coming 
in contact also with the cornea, should not be stronger than two grains to the 
fluidounce; and 1 believe that it is generally better thus to bring the solution 
in contact with the whole conjunctival surface, than to make stronger applica- 
tions to a part only of the diseased membrane. 
Dr. C. R. Agnew said :—I feel somewhat embarrassed in telling what my 
views are, because I find that when we come to the subject of the report, we 
find cases behind the paper in which mild applications are confessedly not 
sufficient. We should stand ready to treat particular cases according to 
particular phases. If I find the eyelids sticky, and without much purulent 
discharge, my common direction is to bathe with a solution of common salt* 
If I find inflammation increased, and the discharge more watery, and wine- 
colored, I take the head of the child between my knees, bathe the eyes with 
water applied by a sponge, apply a solution of nitrate of silver, and then gWe 
some simple ointment to prevent the adhesion of the eyelids and the collec- 
tion of pus. If the case goes on to a still worse condition, and it is evident 
that the cornea is to give way, I anticipate the evacuation of the aqueou3 
humor by paracentesis. With regard to gonorrhoeal ophthalmia, it is oftenest 
the case that it destroys the cornea within thirty-six hours, and that when 
it is not destroyed in this time, the case gets well. What we need to know 13 
what to do when the lids begin to stiffen, and the fluid turns reddish or wine- 
colored. In a case of that kind I would give an injection of morphia in the 
corresponding temple, and run a pair of scissoi’s into the external canthus, 
and cut down to the orbit, hoping to get a good spouting of blood. I would 
then pour water on the corresponding side of the head to encourage the 
bleeding, and finally repeat the application of morphia to produce sleep. Un- 
less there is a decided improvement, I evert the eyelids and make an applied 
tion of nitrate of silver, and afterwards apply iced cloths, which should be damp 
and cold, but not wet. 
The President, Mr.R. Brudenell Carter, of London, said:—The difference3 
in the treatment recommended are far more apparent than real, and would md 
away in the presence of individual cases. Prof. Williams without doubt 
desires to show the danger of very strong astringents and caustics, and I belicve 
that the Section will generally agree in his conclusions. 905 
ON TUMORS OP THE OPTIC NERVE. 
BY 
H. KNAPP, M.D., 
OF NEW YORK. 
A very limited number of tumors of the optic nerve has hitherto been 
W. Goldzieher, in a very valuable paper on the subject, 
Published in Graefe’s Archiv fur Ophthalmologic, 1873, states that in 
Modern medical literature he has found only six cases of the kind, to 
rhich he himself adds three others. I have found records of a few addi- 
tlQnal cases, and have seen three myself, two having been under ray own 
Cafe and one under that of Dr. E. Gruening at the New York Ophthal- 
mic and Aural Institute. I shall give a brief sketch of some of these 
Ca§es, in order to obtain the data necessary tor a general description of 
affection. 
Case I.—(Described by A. von Graefe, in his Archives, vol. x. part 1, p. 193 
etc-, 1864.) A farmer, set. 23, had first noticed, two years previously, diplopia 
ai)d protrusion of his right eye. The exophthalmos increased steadily, but the 
diplopia subsequently disappeared from the sight of that eye becoming lost. 
pain was felt until a few weeks before the patient was first seen,''when 
Secondary infiltration of the cornea set in. On examination, there was found 
exophthalmos of 9/;/, in the direction of the orbital axis; the lids could not be 
cksed; the mobility of the globe was restricted inward, but in other directions 
free; the centre of motion coincided with that of the globe. Behind the 
gP>be, a soft, elastic tumor was felt; S. =O. The retinal veins were tortuous 
and dilated, the arteries attenuated. The inner half of the optic disk was 
swollen, with abrupt, slightly overlapping borders, reddish, and concealing the 
bloodvessels; the outer half was level. 
Craefe diagnosticated a relatively benign, orbital tumor, probably of a fibro- 
nature. From the fact that the centre of rotation corresponded 
the centre of the globe, he concluded that a stratum of loose connective 
tissue separated the tumor from the globe. The freedom of the outer half of 
tbc optic disk led him to the supposition that the blindness was not caused by 
compression, but by the immediate transition of the tumor to the nerve, or 
Possibly by its origin in the nerve itself. The tumor being situated within the 
funnel, and surrounding the optic nerve, its extirpation with preserva- 
*oo of the eyeball, he said, could not be thought of. He enucleated the eyeball, 
yk the stratum of connective tissue in front of the morbid growth, laid the 
ytish-red looking tumor bare, and removed it without difficulty, dhe opera- 
tion was followed by alarming cerebral symptoms, intense headache and 
bausea; the pulse fell from 80 to 52 beats, and the temperature rose to 40° C. 
(104° F.), These symptoms subsided upon the appearance of an extensive 
suppuration in the wound. The patient recovered. 
Pile tumor, examined by Recklinghausen, was pear-shaped, a little larger 
I{*n a pigeon’s egg, partially soft and gelatinous, and partially fibrous. The 
ulk of the optic nerve lay as a compact cord on one side of the tumor, and 
Aas covered, together with the whole tumor, by a tough, fibious capsule. The 
iuiit of the nerve which looked toward the tumor, was ill-defined, ihe fibres 
yk the cord-like portion of the optic nerve were preserved in their whole course, 
>e others entered the tumor and were lost in it. I his condition was found 906 
KNAPP, 
in both the cut ends of the nerve, that is at its entrance into and its emergence 
from the tumor. The growth therefore was a myxoma of the optic nerve, 
originating in the inner sheath and perineurium internum. The swelling of the 
inner half of the intra-ocular end of the optic ner've was caused (according to 
the examination of Schweigger) “by a proliferation of indifferent (lymphoid) 
cells, as might be expected in so young a formation.” 
Case ll—(Described by A. Rothmund, Zehender’s Klin. Mon., 1863, S. 
261.) The patient was a healthy looking girl of fifteen years. At the begin- 
ning of her second year, her left eye began to be pushed forward and down- 
ward, and was excessively painful. She could see with that eye. In the 
course of four or five months the eye became blind, but kept free from pain ; 
yet the lids were swollen every now and then. From that time to her six- 
teenth year, she felt no annoyance from the eye, though it slowly but constantly 
grew larger. When seen by Dr. R., the orbit was occupied by a roundish, 
faintly fluctuating tumor, the size of a large hen’s egg. The tumor was 
totally covered by congested conjunctiva, but incompletely by the lids, and 
moved harmoniously with the healthy eye in every direction. Remnants of 
the cornea were recognizable at its apex, which was very tender to the touch. 
The palpebral fissure was two and a half inches in length, and the orbit was 
greatly distended. 
Dr, Rothmund removed the tumor in the manner of an ordinary enucleation. 
Its pedicle was severed near the optic foramen. In some weeks the orbital 
wound was closed by granulations. The patient recovered. 
At the posterior end of the tumor a piece of the optic nerve, 3'" in length, 
was preserved. The growth was a total degeneration of the optic nerve, con- 
sisting of fibrous tissue which inclosed smaller and larger cysts, the cavities 
of which were pervaded by a network of white, delicate fibres containing a 
vascular, gelatinous substance. The microscopic examination, made by Prof. 
Buhl, showed the characteristics of a myxoma, which is frequently met with 
in other nerves. The eyeball had been flattened by the tumor in such a way 
that the optic disk touched the cornea. 
Case 111. (A. von Graefe, Arch. f. Ophth,, x. 1, S. 201, 1864.) The 
patient was a young lady, set. 24, who for two years had noticed a slight ex- 
ophthalmos with amblyopia and contraction of the visual field of her left e}Te- 
With the ophthalmoscope Graefe discovered choked disk and spontaneous 
arterial pulsation. During the next five years the exophthalmos slowly in- 
creased, while sight was reduced to quantitative perception of light. The ex- 
ophthalmos measured 8"', and showed a marked deviation outward. Mobility 
preserved, but reduced in every direction. The centre of rotation corre- 
sponded approximately to the centre of the globe. A soft tumor was located 
immediately behind the eye, more on the nasal than on the temporal side. 
Between the upper and inner recti muscles it could be seen through the con- 
junctiva as a smooth, reddish-yellow intumescence. In the outer part of the 
field of vision, there was no perception of light. The optic disk was atrophic- 
The patient was operated on by Langenbeck, who first enucleated the e};e- 
ball, and then the tumor, which did not extend to the apex of the orbit. 
was as large as a pigeon’s egg. The optic nerve passed as a flattened cord 
along its nasal side, but a considerable part of it entered the tumor and was 
lost in it. The posterior part of the eyeball was flattened by the pressure 
from the tumor. 
The tumor, examined by Recklinghausen, was found to be a myxosarcoma 
of the optic nerve. Its anterior part contained a c}rst, around and behind 
which there was a soft, partly gelatinous substance, consisting of very delicate, 
interlacing fibres which inclosed round and oval cells. The gelatinous liquid 
which could be pressed out of the tumor grew very opaque on addition ot 
acetic acid. Larger portions of the tumor showed a substance almost entirely 
composed of cells, between which some larger bloodvessels ramified. 
Case IY.—(Described by E. Neumann, in Archiv fiir Heilkunde, xiii- S. TUMORS OF THE OPTIC NERVE. 
907 
10.) The patient, set. 20, had suffered from headache for six years, and had 
lotted a protrusion of her eye for three years. The mobility of the eye was 
Preserved, and was only a little restricted in an upward direction. The vision 
as almost normal. On palpation a hard immovable tumor was felt sur- 
°anding the posterior part of the globe on all sides. Dr. Jacobson, of Kbnigs- 
Uerg, removed the eye together with the tumor. 
• Ahe tumor was three-quarters of an inch in length, the size of a walnut, and 
behind the eye surrounded the optic nerve, which passed quite 
°osely across it. The neoplasm was connected with the outer sheath, which 
011 section showed itself as a distinct, white border-line. The inner sheath was 
smooth and shining. Between the two sheaths, delicate cords were stretched 
'T len the nerve was drawn away from the tumor. The microscopic exarnina- 
discovered that the structure of the tumor was partly compact, partly 
alveolar. The alveolar part had a stroma which resembled that of a cancer, 
accumulations of fusiform cells in concentric layers. The centres of 
tnany cells were inernsted. Teased preparations showed that these fusiform 
foments were flat endothelioid cells. The compact part of the tumor consisted 
coarse fibrils, here and there inclosing numerous accumulations of sarcoma- 
J-Qiis cells. The periphery of the tumor consisted of adipose tissue. The tumor 
18 styled byNeumann a psammoma, on accountof the prevalenceof the incrusted, 
arenoid bodies in the alveolar part of the tumor. 
Case V.—(Described by H. Knapp,in Archives of Ophthalmology and Oto- 
*°gy, vol. iv. pp. 323-854, 1875, with four plates.) Mrs. J. K,, set. 40, was first 
examined in August, 1871. Her left eye was normal in function and struc- 
ture ; the right protruded about s'" in a forward and slightly downward direc- 
tion. The protrusion had begun six months previously, and the sight of that 
®ye had gradually become impaired. She suffered from occasional headaches, 
always increased the protrusion of the eye. rlhe movements of the globe 
somewhat restricted, chiefly in an upward direction. Iheie was no pul- 
sion, nor bruit. S. with +lO Sn. TV* IF. complete. The optic disk showed 
a steep elevation, arteries small, veins dilated and tortuous. Ihe ophthalmo- 
scopic condition did not materially change for three yeais. In June, 1874, a 
hardish tumor was felt, on palpation, on the inner and upper side of the poste- 
ri°r part of the globe. It moved with the eye. A free space was felt between 
le tumor and the orbital wall. The globe was dislocated slightly outwaid, 
considerably downward (4"'-s'"), but mostly forward (6 ). Inversion 
as perfect, whereas the strongest eversion brought the coineal maigm no 
neai‘er than 2"' from the outer commissure; downward rotation was free, but 
rotation moved the eye no higher than the horizontal median plane, 8. 
F. complete. Media clear, pupil responsive. Papilla raised, with a irupt 
borders, like a “ lockey-cap.” Venous hypersemia marked, General health 
§°od. For the last years, great pain in eye and head. The diagnosis of orbital 
turnor could now be more specifically revised into that of a tumor of the optic 
bTve, and acting upon this supposition I attempted, on June_ > ’ ° e.nu" 
c^eate the tumor while preserving the eyeball. I succeeded in the lo owing 
banner: 
. 1 opened the conjunctiva by a circular section between the inner and supe- 
?l°r recti muscles, and laid the anterior portion of the tumor bare. Ihen I 
Introduced my left forefinger into the wound, and under its guidance freed the 
barclish tumor from the soft, surrounding orbital tissue. After that, I dis- 
puted the mass from the posterior part of the globe, with which it was con- 
nected by a thin layer of connective tissue. Further, 1 severed the optic nerve, 
a,n<* then introduced my finger as deeply into the orbit as possible. Not being 
al)1e to reach the apex of the tumor, which was close to the optic foramen, I 
Sllt the tumor across as near the summit of the orbit as I could reach. Aow 
1 stated the growth on its antero-posterior axis, and severed such connections 
its surroundino-s as had before escaped. All this was done with a pair of 
stl'abismus scissors. Then I introduced the closed blades of a stronger pair of 908 
KNAPP, 
scissors, curved on the flat, behind the tumor, and lifted it out of the wound. d 
produced sufficient free space in the orbit to enable me to remove the little pal 
of the tumor which had been left. I seized it with a pair of strong scissors, ha 6 
it drawn forward by an assistant, and excised it, always using my left forefiuger 
as a guide. The eyeball, which had been turned aside, was replaced, and to 
conjunctival wound closed by sutures. Though the tumor was located withi 
the recti muscles, none of them had been cut. The tension of the globe "a,s 
not changed. The inner half of the eye was anaesthetic, the outer half sensi- 
tive, though a little dull. The fundus gave a reddish reflex, but its detai 
could not be seen on account of irregular detachment of the epithelium fron1 
the cornea, giving the latter the appearance of frosted glass. 
The reaction from the operation was very moderate. The patient no 
totally lost her headache. On the third day the fundus oculi was visible, an 
appeared uniformly milky-white. A small whitish-gray infiltration was notice 
on the lower part of the cornea. On the fourth day this infiltration had m 
creased, but the fundus could be seen through the clear part of the cornea 
above it. In the milky surface two dark-red streaks were visible, which haC 
increased the next day, and proved to be the main branches of the retina 
veins. Every day new retinal vessels were filled with blood, and in som 
weeks there was a picture of very marked retinal congestion. (See Fig- 
Tab. IX., Arch. Ophth. and Otol., ISIS.) The fundus had so far cleared nP 
that only the region around the papilla and yellow spot appeared milky? 
remainder having its natural color. Gradually this milky appearance disap' 
peared, and then extensive retinal hemorrhage took place, which 
slowly, and left the retina and inner part of the choroid atrophic and degen6' 
rated. (See Plate X., loc. cit.) The infiltration on the lower part ot fll6 
cornea, which I have mentioned above, disappeared after the eye had been 
protected by carefully closing the palpebral fissure. The cornea has never 
since lost its lustre, and but little change took place in the interior of the eye 
for two years. Lately, some membranous opacities in the vitreous have ap- 
peared. The eye has its natural size, is a little more deeply set in the orb1 
than its fellow, squints somewhat inward and downward, but has not been 
cause of any annoyance. The cornea is bright throughout, though its in°el 
half is still as anaesthetic as immediately after the operation. At this tun6? 
two years and three months after the operation, the tension of the eye is c[l" 
minished, and there is some blood in the vitreous. The patient looks health}? 
and there are no sjmiptoms of a relapse. 
The tumor was a little above the size of a walnut (30 by 27 mm.), and uni- 
formly hardish. Its base was slightly concave, covered with a thin layer 6 
connective tissue which had united it to the sclerotic. The optic nerve pass 6 
through it. The outer sheath of the nerve was well recognizable, though it® 
fibres were more or less separated by the elements of the pseudoplasm. J-h 
intervaginal space was a little enlarged, and filled with the tissue of the growt n 
This, when well hardened in Muller’s fluid, was uniformity finely granular. A 
had no capsule proper, but was loosely covered with the adipose tissue of ty 
orbit. Under the microscope, the growth showed a typical specimen of sCir' 
rhous cancer. A stroma of fasciculated connective tissue inclosed alveo 
filled with epithelial cells, which had no more intercellular substance between 
them than was necessary to cement them. In the neighborhood of the nerve, 
a limited number of arenoid bodies (sand-globules) were seen embedded ia 
connective tissue, yet not numerous enough to give even a part of the tumor 
the character of a psammoma. The whole growth was very vascular, and a 
good part of its stroma had undergone colloid degeneration. The inner shear 
was thickened, and infiltrated with colloid and lymphoid bodies, nowhere wit 
cells of an epithelial character. The interfascicular tissue of the nerve was 
somewhat thickened. In it, and between the nerve fibrils, there were very 
numerous lymphoid cells, either single or arranged in rows and clusters? 
in flammation of the nerve. The same change was seen in the intra-ocular en TUMORS OF THE OPTIC NERVE. 
909 
°f the optic nerve—a, well characterized specimen of neuritis optica descendens. 
For a detailed description of the specimen, and remarks on many interesting 
points connected with this case, see Arch, of Ophth. and Otol., vol. iv., 1875, 
Pp. 823 et seq., and Plates IX.-XII. 
Case Yl.—(Described by L. Krohn in Zeh. Klin. Mon., 1872, S. 103-108.) 
A married woman, thirty years of age, had a tumor the size of a fist in the 
right side of her abdomen. It had begun six months previously with local 
Pain, which was followed by general debility, emaciation, headache, vomiting, 
and gradual loss of sight in both eyes. A tumor was also developed in the 
left side of the abdomen. The eyes, when examined six months after the 
beginning of the disease, were totally blind, and, ophthalmoscopically, exhi- 
bited marked pictures of choked disk, with some retinal hemorrhages. The 
Patient died eight months after the beginning of the disease. 
The autopsy showed carcinomatous tumors of both ovaries; all the other 
organs were normal; the cranial cavity in particular contained no morbid 
formation. There was a small intumescence in each optic nerve near the scle- 
rotic. The intumescence was caused by a new formation in the intervaginal 
space, consisting of a tissue which was rich in large round and polygonal cells, 
and had the arrangement of a cancer. The same kind of cells pervaded the 
inner sheath and the interfascicular connective tissue, and were very numerous 
around the central bloodvessels. Ihey extended in the neive and inter- 
Vaginal space as far as the lamina cribiosa, but did not enter the ej e. On the 
other end they could be followed a little beyond the optic foramen. The 
intra-ocular end of the optic nerve was infiltrated with lymphoid bodies. 
Case YU.—(Described by Y. Szokalski, in Annales d’Oculistique, t. xlv. p. 
43 1861 ) A boy of four years, healthy and well nourished, had a considerable 
forward' protrusion of his left eye, which was perfectly movable. His parents 
attributed this.condition to a severe contusion of the temple, received four or 
five months previously. The sight was good; by ophthalmoscopic examination, 
the retinal veins were found enlarged. The exophthalmos increased, the eye 
became very painful and sensitive to light, the lids could not be closed, the 
c°i’nea grew opaque, the eye blind, and the other eje ecame ie sea 0 
Pathetic irritation. There was no tumor felt between the globe and the oitotal 
Walls; but the orbital tissues were a little more prominent and elastic than 
hsual. None of the symptoms of a vascular tumor were present. Szokalski 
113ade the diagnosis of cystic tumor directly behind the eye, neai e°P 
Within the recti muscles. He extirpated the contents of the orbit. A»teiha>in 
Enlarged the palpebral fissure and made a circular incision aioun §■ ’ 
close to the orbital wall, he felt with the finger a hard, nodular, and mo\ah. e 
tl3inor behind the globe, which he isolated from its surroundings b}_ n c s 
along the orbital walls (rasant les parois de Vorhite); then he drew it for aid 
a strong hook, and, with scissors, severed it near the summit of t e t. 
A profuse hemorrhage was arrested by placing a piece o ice in 
The eyeball proved to be quite healthy. A centimetie behind the &lobe, the 
optic nerve entered into a nodular, transversely oblong tumor, the size of a 
filbert, through which the nerve passed in the direction of lt®s“^®ltl^ai 
bke a string through a bead. Its outer sheath passed directly ovei the tumoi, 
J-here it became thicker and more adherent. The substance of the tumor was 
Wd, grayish, fibrous, grating under the knife; it piesented undei the micio- 
s°ope, reticular areola, in the midst of which, caudate uni-nucleated or multi- 
!u,cleated cells were accumulated. The nervous fascicles, afte then enhance 
!nto the tumor, spread like a fan and were imperceptibly lost in its centie ;on 
other side they reappeared, and entered into the other end of 
thc nerve. The growth “ undoubtedly took its origin in the neunlemmatic 
Petition-walls of the optic nerve, and unquestionably was of the nature of a 
S(firrhous cancer.” Though the nerve was divided as near the optic foramen 910 
KNAPP, 
as possible, its transyerse, cut surface showed, by its gray color, that the 
pseudoplasm had already penetrated into the cranial end of the nerve. 
The wound healed so rapidly that the patient was able to leave the hospit&J 
at the expiration of three weeks. For almost five years the boy was in good 
health, but then a local relapse took place. When he presented himself again? 
the orbit was filled with a hard, somewhat elastic tumor, which projected in 
the shape of a small apple beyond the distended eyelids. The child was pale? 
but otherwise healthy, and complained of some lancinating, periorbital pain* 
The tumor was nowhere adherent to the orbital wall, and, therefore, easily 
removed. The patient did well enough during the next two days, but, on the 
third, convulsions and vomiting set in, and he died of meningitis on the sixth 
day after the operation. 
An autopsy revealed congestion of the pia mater at the base of the anterior 
lobes, and a greenish, sero-purulent exudation at the anterior part of the base 
of the skull cavity. Under the left anterior lobe, in front of the Sylvian fossa, 
was a tumor, as large as a nut, growing from the degenerated optic nerve 
without implicating the chiasm. The adjacent brain substance was softened* 
The tumor was dense and consisted of a scirrhous substance. 
The optic foramen was dilated and filled with a granulated, reddish sub- 
stance, which connected the cranial with the orbital tumor. The orbit was 
enlarged to about twice its natural size, mainly at the expense of the ethmoid 
and maxillary sinuses. The tumor removed from the orbit contained on its 
posterior side a large cyst, which had been opened during the operation and 
had yielded about two ounces of a yellow serum. Sections in different direc- 
tions through the tumor displayed a scirrho-cancerous, lardaceous substance, 
grating under the scalpel. Some softened portions of it contained a brain-lik6 
substance. 
I have made a detailed extract of tins case on account of its singular 
clinical and pathological interest. The original and secondary tumors 
are pronounced scirrhous cancer by the author, yet his description does 
not fully convince me. The original tumor may have been a fibroma, 
and the relapsing tumor a myxo-iibroma. According to the author, both 
tumors were scirrhous cancers, the secondary one having undergone par- 
tial softening in its interior. 
These seven cases, together with eight others, form the material from 
which I shall endeavor to frame a general description of the affection 
under consideration. 
Pathologically, the following species of tumor have been observed : 
(1) Myxoma, in five cases. 
(2) Fibroma myxomatodes, in two cases. 
(8) Sarcoma myxomatodes, in two cases. 
(4) Glioma myxomatodes, in one case. 
(5) Fibrosarcoma, in one case. 
(6) Psammoma (perhaps alveolar sarcoma or carcinoma), in one case 
(E. Neumann). 
(7) Scirrhous cancer, in two cases. 
(8) Secondary cancer, from primary cancer of ovaries, in one case. 
The majority of these tumors consisted either of pure mucoid tissue 
(five cases, 33 per cent.), or contained a considerable proportion of mucoid 
substance in addition to their prevalent tissue. In most of these cases 
the pseudoplasm originated in the inner sheath and the interfasciculai 
connective tissue of the nerve. To these should probably be added the 
case of scirrhous cancer of Szokalski, the recurrent tumor in which case 
contained also a large cyst. In three cases (glioma myxomatodes, fibre- TUMORS OF THE OPTIC NERVE. 
911 
sarcoma, and secondary cancer) the tumors may have sprung from the 
tlssi]e of the sub vaginal space and the inner sheath. Two tumors of a 
carcinomatous structure (Neumann and Knapp) originated in the outer 
sheath. 
Symptomatology .—The age of the patients varied from one and a quarter 
0 torty years. There is no decided preference for either eye. The 
Prevalent symptom is exophthalmos, either directly forward, in the 
( Section ot the orbital axis, or showing besides a secondary deviation 
Jn accordance with a greater development of the tumor on one side. 
Ihe motions of the globe are preserved, but more or less restricted. On 
Palpation, directly behind the globe a sottish tumor is felt, the move- 
ments of which correspond more or less to those of the eyeball. A free 
space can be recognized between the tumor and the orbital wall. Neu- 
rdis descendens is a constant symptom in the early stages, and atrophy 
°f the nerve in the later stages of the affection. The sight is more or 
Jess impaired, the field of vision being restricted when the pseudoplasm 
Paginates in the inner sheath and perineurium internum. Sight is less 
impaired, and the visual field remains complete, when the tumor springs 
the outer sheath. Intense and persistent pain has been noticed fn 
me cases of cancer (Neumann, Knapp, Krohn); in the other cases there 
was pain only when the eyeball was inflamed, with the exception of one 
ease of myxoma (Gruening) in which intense pain was felt after the pro- 
fusion of the eye had existed for four years without pain. 
The course of the disease shows in all cases a slow but steady increase 
of the tumor. The longest duration observed was fifteen years (Hey- 
mann and Rothmund). First, the posterior part of the eyeball is flat- 
bed, and the eye becomes hyperopic; then the eye protrudes, and 
sets in ; then opacity, ulceration, and perforation of the 
c°rnea occur; after which the coats of the eye are so much pressed 
fgether that the optic disk touches the cornea. The ultimate, sponta- 
Pecus issue cannot be known from the published cases, since the tumor 
ln all was extirpated, and recovery took place, except in one case in 
yhich a relapse implicating the brain occurred, and in which the patient 
u]ed from meningitis in consequence of a second operation. 
fhe observations on record are not sufficient to enable us to form a 
prognosis as to the natural course of tumors of the optic nerve. 
,JJ the cases in which the tumor was removed ended in recovery, which, 
itli the one exception of a fatal recurrence, seems to have been perma- 
lle,'t. Sight is, of course, destroyed in all cases. 
The treatment, until lately, consisted in the removal of the tumor, 
f get her with the eyeball, which operation offers no difficulty. Iwo 
ars ago, I succeeded in removing such a tumor, and preserved the eye. 
About one year since, Dr. E. Gruening did the same in another case. 
°lb of these cases have continued to do well. In one case (Graefe), the 
°p6ration was followed by suppurative inflammation in the wound ; in 
pother (Szokalski), the operation caused death by meningitis. In none 
the other cases was the operation followed by any unpleasant symp- 
bo conclusion, I may say that tumors of the optic nerve form, at pre- 
a sufficiently understood chapter of surgery, and that their difieren- 
(al diagnosis is quite possible. Extirpation relieves the patient from 
aisfigurernent and pain, and prolongs life. By improved modes of 
operative procedure, the tumor may be removed while the eye, which, 
lough blind, is better than a glass eye, is preserved. 912 
ORBITAL ANEURISM A L DISEASE AND PULSATING EXOPH' 
THALMIA; THEIR DIAGNOSIS AND TREATMENT. 
BY 
E. WILLIAMS, M.D., 
PROFESSOR OF OPHTHALMOLOGY IN MIAMI MEDICAL COLLEGE, CINCINNATI. 
The differential diagnosis between genuine intra-orbital aneurism and 
pulsating exophthalmia from other causes, is by no means easy. Til* 
recently, all cases of protrusion of the eyeball, with pulsation, were set 
down as orbital aneurisms as soon as encephaloid, meningocele, and ono 
or two other rare affections, had been excluded. A careful study of the 
literature of the subject, in the light of pathological anatomy, has un- 
settled this long established opinion. The case of so-called aneurism hy 
anastomosis, in the orbit, published by Travers in 1808, presented symP' 
toms, in common with many that have since been published, that are n(W 
known to be frequently present in affections of the vascular system en- 
tirely outside of the orbit. A wrarm difference of opinion prevailed a 9 
to whether these were cases of aneurism by anastomosis, or of circun*' 
scribed or diffused aneurism of the ophthalmic artery. But all locate** 
their starting point in the orbit. 
Such were the views generally entertained till the publication of Nela' 
ton’s celebrated case in 1856. True, Baron, in 1885, had presented to the 
Paris Anatomical Society a specimen of aneurism of the carotid in the 
cavernous sinus, in which the symptoms, during life, had been pulsating 
exophthalmos and intense murmur heard by the ear over the protruded 
eye. These were the typical symptoms that passed current for orbited 
aneurism, both before and after that time. The strong significance 0| 
this observation was not then noticed. In 1858, Aubry had the good 
fortune to secure an autopsy in a patient in wdiose case all the symptom9 
of orbital aneurism had been present, and that diagnosis had been made* 
No arterial lesion whatever wTas discovered. The ophthalmic vein 
greatly dilated and its branches enlarged, forming the “ bossy, vascular 
pulsating tumors observed during life.” The vein was as large as tb® 
little finger, and its coats very thin, and it freely communicated wit*1 
the greatly dilated cavernous sinus. The sinus terminated behind in 
cul-de-sac, the communication with the inferior petrosal sinus being cd 
off. Though observed in 1858, this case does not seem to have been pub' 
lished till 1864. In 1841, M. Gendrin made public a case with syrup' 
toms of orbital aneurism, in which a post-mortem examination shovvec 
this interpretation to have been incorrect. “The ophthalmic vein w**9 
varicose and distended with coagulated blood. The internal carotid ad 
origin of the ophthalmic arteries were surrounded by an adherent clot? 
CJ JL 1/ 1 I 
continuous with a clot infiltrated into the arterial tunics.” Mr. W aim 
Rivington very plausibly explains this condition as indicating an aned' 
rism of the internal carotid in the cavernous sinus, which had rupture* • 
Nelaton’s first case is so important in the pathological history ot thi 
disease, that I will transcribe it entire from Mr. Eivington’s resume o ORBITAL ANEUEISMAL DISEASE. 
ses in connection with his excellent paper on Pulsating Tumors of the 
pi'bit, in the Medico-Chirurgical Transactions for 1875. In that paper 
he gives the most complete collection of cases, and the most systematic 
?nd thorough criticism ot them, that I have met with. The case of 
is as follows:— 
. u Male, 21. Right eye. Thrust with the ferule of an umbrella in the left 
lower eyelid. Symptoms and Progress—Abundant bleeding from the nose, 
and ptosis of the right upper eyelid. Wound of the left eyelid healed rapidly, 
bat at the end of some days the right eye became more prominent, with diplo- 
ma and mydriasis. Two months later, left eye was healthy; right eye promi- 
-IJent; ptosis; dilated veins on the surface of the upper lid; pupil largely 
abated; external strabismus; absence of movements of the eyeball; diplopia. 
• . . . Patient blew blood habitually from the right nostril; paralysis 
the right third pair ; pulsation of the eyeball; bruit de souffle continuous, with 
during arterial pulse; absence of thrill. A little later, bruit 
miaulement, audible also to the patient. He continued to blow blood from 
the right nostril, and at times had epistaxis.” Nelaton diagnosed wound of 
the right carotid in the cavernous sinus. The patient died not long after from 
bleeding at the nose, and the autopsy fully confirmed the diagnosis. “ The 
h°cly of the sphenoid bone was fractured, and the right internal carotid was 
found torn across in the cavernous sinus. Ihe sphenoidal sinus communicated 
t'ith the cavernous sinus on the one hand, and with the nasal fossae on the 
other? and through this communication the hemonhage had taken place.” 
Hirschfeld, in 1858, had a case presenting similar symptoms, as the result 
°f injury, in which the diagnosis of effusion of blood compressing the 
hiotor nerves before their entry into the orbit was made. Heath occurred, 
and a. blood clot was found in the cavernous sinus, enveloping the third 
and compressing the ophthalmic nerve. The clot coveied a small circu- 
ar hole in the carotid, which looked as if it had been punched out, and 
Mdch was occupied by a string of decolorized clot about two inches 
nng, and passing into the mass of coagulura. The bones weie sound, 
phis case is of great value, as it proves that the usually accepted symp- 
-orns of intra-orbital aneurism may be produced by a lesion ot the caiotid 
Artery ; and also that a sharp blow on the face or head, without fracture 
the base of the skull, may cause a rupture, of the internal caiotid. 
had occasion to make a post-mortem examination ot a patient 
]}Those carotid he had ligated five years before for orbital aneurism. _ lie 
.°nnd a circumscribed aneurism of the ophthalmic artery at its ongin 
171 the cranium. In another similar case the post-mortem appearances 
filled to indicate the existence of an aneurism of the internal carotid, 
}vhich had ruptured into the cavernous sinus. These cases and others 
Educed Nunneley to look for the seat of so-called orbital aneurism rather 
1,1 the cranium than in the orbit. In a paper, in 1864, he says: n the 
eat majority of such cases of protrusion of the eyeball, there is no 
whatever in the orbit. The seat of it is most commonly mtra- 
Pranial. The protrusion of the eyeball is passive, and the other distress- 
symptoms are secondary, depending upon obstruction to_ le return 
blood through the ophthalmic vein. That this pressure m the great 
Majority of acute, spontaneous cases is caused by an aneurism of the 
as it emerges into the cranium, or of the ophthalmic artery in 
Sf iutra-cranial portion, near its origin, is I think now certainly proved.’’ 
we cases of traumatic origin he explains in a different way, but hj inju- 
rs and changes in the cavity of the cranium and not in the orbit. 
In Bowman’s case, in which “ all the capital signs ot orbital aneurism 
58 914 
E. WILLIAMS, 
were present in a high degree,” there was no aneurism found after death- 
The cavernous sinus, and the circular, transverse, and petrosal sinuses, 
were filled with clot softening in the centre, and the enlarged ophthalmic 
vein was plugged at its opening into the cavernous sinus. The great 
Nelaton had a second case, with the current orbital-aneurismal symptoms, 
following a fall from a carriage, where death occurred after ligation. He 
had diagnosed an arterio-venous communication in the cavernous sinus. 
A fracture through the body of the sphenoid bone and pars petrosa of the 
temporal, was found on both sides. On the left side a sharp point of the 
temporal bone was detached, and had probably penetrated the carotid 
and the wall of the sinus. At all events there was found a small hole in 
the carotid, below and externally, connecting it with the sinus, which 
was dilated ; and the ophthalmic vein was dilated and tortuous. In a 
case of Dr. Oettingen, the symptoms were much the same, excepting that 
the veins of the eyelids were not particularly affected, and that the bruit 
was audible only over the eye ; the patient died two years afterwards. 
arterial lesions were found, but there was partial obliteration of the orbi- 
tal veins. Dr, Oettingen attributed the symptoms during life to throm- 
bosis of the orbital veins, and alleges the case as proof that blocking of 
the orbital veins alone, with no trouble behind, may produce pulsating 
exophthalmos and bruit. In 1868, Wecker lost a patient fifty-two day 3 
after ligating the carotid. The symptoms were as usual. The post-mor- 
tern examination showed great dilatation of the ophthalmic vein, and 
extensive atheromatous degeneration of the inner coat of the carotid. A3 
no description is given of the state of the cavernous and other sinuses, 
Rivington thinks it not improbable that the extreme dilatation of tbe 
ophthalmic vein and its frontal branches, forming “the pulsatile thrill' 
ing” tumors observed during life, may have resulted from the existence 
of a fissure in the internal carotid, in the cavernous sinus, which wa9 
overlooked at the post-mortem examination. 
To aid in the differential diagnosis between orbital aneurism and other 
lesions which produce many of the same phenomena, I will give the par- 
ticulars of three cases, in two of which 1 think that this rare affection 
really existed. 
Case of Spontaneous Cure of Orbital Aneurism by Rupture.—Mrs. K., 
55, in good health, of medium size, rather spare in form, dark hair and eye3’ 
sallow complexion. In June, 1875, her friends noticed an unusual redness m 
the right eye. She had had no injury, pain, sudden noise, or anything what- 
ever to attract her attention to the eye, but remembers feeling some transient? 
neuralgic pains in the temple of that side. The injection of the eye increase0 
slowly till September, when undue prominence was noticed. The congestion 
of the eye was increased by hard work, but was not influenced by straining 01 
stooping. The exophthalmos had probably existed and increased for soine 
time before it was observed. 
The patient consulted me first in September. There was then a striking 
exophthalmos of perhaps a fourth of an inch, the ball presenting directly fQl' 
wards and the movements being perfect, except for a slight limitation in 
directions. Ao ptosis, no sluggishness of pupil, no diplopia, and Y.= 1. 
the most careful examination with the finger pressed between the globe and the 
orbital margin, no pulsating tumor was felt. But to the touch and to the e}’e 
there was a marked pulsation of the globe and the surrounding tissues. Th® 
subconjunctival veins were enormously injected and tortuous, forming a wreat 
around the cornea by their large and numerous inosculations. The ophtha - 
moscope showed the veins of the retina equally dilated and tortuous, with th 
usual appearances of choked disk, but I could see no pulsations. The artei'i®3 ORBITAL ANEURISMAL DISEASE. 
915 
not as straight as usual, but otherwise not altered. For want of time to 
famine the case further, the patient was told to abstain from all hard work, 
stooping, or straining, and to return for further examination in a few days. 
' hen she returned I found her condition essentially the same. For want of 
lrne, X again deferred further examination till another day, which was fixed 
I explained to her the serious nature of the disease, and wdiat might 
eventually become necessary. To my great regret, I saw her no more for five 
Months, so that I did not have a chance to watch the progress of the case. 
On the 12th of February the patient returned with the following history. Up 
0 three weeks before, her condition had continued the same as when I last saw 
ler. There had been no increased pulsation ; no enlargement of the vessels of 
the forehead or pulsating prominences around the eye ; she had never heard 
bruit with the pulsations, and was not conscious of the latter except as she 
the eye with the finger. She stated also that on January 20 the eye had 
eeorne somewhat painful and more prominent, had throbbed more strongly, 
and by the next day had become extremely painful. Then the globe was sud- 
denly pushed almost out of her head with excruciating pain and great redness. 
11 her own language she thought that the eye would u burst out of” her head, 
khe applied to her family physician, Dr. Fishburn, who reported to me in 
Siting as follows : 
K. first called my attention to her eye, in the evening of January 20, 1876. I 
171 ade a hasty examination at the moment, regarded it as a mild case of conjunctivitis, and 
guested her to call next day. On the 21st 1 was summoned to see her at her home. I 
and her face so much disfigured by a swelling over the l ight eye, that I hardly recog- 
nized her as the patient 1 had seen the day previous. The eye had the appearance of 
aviug received a terrible contusion Irom direct violence. Ihe swollen and discolored lids 
VVere so firmly closed that it was impossible to separate them, and the effort caused exqui- 
Slte pain. 1 directed the constant use of cold water and acetate of lead dressings, and a 
Saline purgative, to be followed by quarter of a grain doses of morphia every three hours 
the pain should be relieved. , , ~ , , 
, 22d. Patient worse: could not bear the cold water dressings ; removed them and applied 
Jfy heat, which gave some relief. 1 ordered four leeches, to be followed by fomentations 
poppy capsules 
23d. Found her very much improved; pain had moderated and swelling subsided con- 
drably. I was now able to separate the lids; found the conjunctiva in a highly inflamed 
Edition, and the tumefaction so great as to cause the ocular and palpebral portion to 
J|'°trude between the lids, while a chemotic swelling surrounded the cornea. Ihere was 
!t!0 great protrusion of the eyeball. Ordered a three-gram solution of atropia to be ap- 
P.Jed every three hours, and continued the anodyne fomentations, covering icm wi 
0lled silk. 
24th. Patient improving; treatment continued. ’ ~ 
25th. Improvement, and same treatment. In addition, I applied to the conjunctiva, 
J-h a brush, a few drops of a solution of nitrate of silver, gr. vj-t . + . 
26th. Swelling of the lids, and vascular congestion subsiding. Ihe same treatment was 
totltinned till Feb. 12, when the patient was again referred to Dr. W imams. 
■A-t this time the exophthalmos was much greater than when I had seen the 
Patient in September. The cornea stood half an inch in advance of its natu- 
!’al position, and was hazy, with extensive abrasion of the epithelium, and an 
**tense zone of circumcorneal redness. I attributed the iis o ic gua 
Eminence and exposure of the cornea. The patient said that her eye was 
less prominent now than three weeks before, after the severe attack of pain 
protrusion. Yision was very imperfect, explaine in par a eas ,le 
of the cornea. Movements of the eye much limited, but equally so in 
directions, and no diplopia; pupil dilated by atropia, which had been con- 
l used. There was now absolutely no pulsation felt anywhere over the 
fobe, or between it and the orbit. The eye could be pressed into the socket 
? llle or more, but did not pulsate in the least, neither was any built to be 
on auscultation. Fundus of the eye dimly seen by the ophthalmoscope, 
great swelling of the disk recognized. Ordeied liee use of atropia, and 
eJe to be kept closed by wet bandage and compress. 916 
E. WILLIAMS, 
Feb. 14. Improving rapidly ; exophthalmos much less ; cornea clearing j 
Y. = with -f- S. 40. Choked disk, and remarkable enlargement and ser- 
pentine appearance of the veins, extending to the extreme periphery of the 
retina, with isolated points of ecchymosis. The arteries are small, partially 
obscured, especially on the papilla, but pulsate distinctly when pressure 19 
made on the globe. 
Feb. 21. Ball receded decidedly; cornea clear ;Y. = and patient reads 
No. Bat 8" with -(- ; field of vision perfect ; external vessels smaller, and 
eye less red ; movements perfect. 
Feb. 26. Eye receding ; sclerotic less vascular, and showing white ; Y. = 30 j 
spots of effused blood still seen, especially at the sudden flexures of the retinal 
veins ; outlines of the disk not yet sharp. Through March all the symptoms 
continued to improve. 
April 8. The external vessels have disappeared above and below; the scle- 
rotic looks more natural, and the exophthalmos is reduced to barely one-sixth 
of an inch ; vessels of retina much smaller and straighter, and the hemorrhage9 
becoming absorbed. Patient feels no inconvenience from the eye, and is gam- 
ing sight with the general improvement. On the 10th of June the patient 19 
still better. Only two vessels forming a loop near the outer margin of the cornea 
attract attention. With this exception the eye appears as well as the other* 
There is a very slight degree of exophthalmos, not noticeable to the patient °r 
to her friends; movements perfect, and pupil of medium size, but sluggi9*’ 
like the other; Y. = |§ with -j- 36. Fundus greatly improved ; no traces <■> 
blood ; disk nearly natural; and veins reduced in size and but little winding* 
On September 29, the patient called, at my request, for examination. The eye 
was perhaps one-twelfth of an inch more prominent than the other, but tin9 
could not be noticed without a critical examination. No trace of the externab 
enlarged vessels was seen except two small ones with a slight loop on the out® 
side of the cornea. Y. =|§ with -f- 42, almost equal to the other eye. y1? 
ophthalmoscopic examination, with dilated pupils, I could detect no materia 
difference in the fundus of the two eyes, both appearing normal, and the arte- 
ries pulsating under same external pressure. By pressing the eye backward 
with the finger, it seemed to be checked by a-firm substance at the apex of tb® 
orbit, which did not exist on the other side. The patient was perfectly well* 
I wish now to consider the question of diagnosis. Am I justified, 111 
the present state of our knowledge on this subject, in calling this a ca&e 
of intra-orbital aneurism ? The symptoms of aneurism were, it seems to 
me, unmistakable. The pulsations of the protruded ball were syncin’0' 
nous with the systole of the heart, partly controlled by pressing tbo 
globe backwards against a yielding, elastic resistance, and complete1) 
stopped by pressure on the common carotid. I unfortunately lost tfi 
opportunity to investigate the bruit de souffle with the aid of the stet .' 
scope, but there is every reason to believe that it was there, and that 1 
could have been heard. An important point in favor of the theory0 
orbital aneurism is that the patient herself never heard any bruit* -v 
the great majority of intra-cranial aneurisms, the sound to the patient 
audible, and often very distressing. In orbital aneurism, further awa) 
from the auditory nerve and labyrinth, with little or no direct bony 9011’ 
duction, I apprehend that the pulsations are not heard bythe pati011 
himself. There was no paralysis of any of the nerve trunks which P 
near the cavernous sinus, and which are so often affected by direct pre® 
sure in cases of arterio-venous aneurism of the internal carotid. In 8/jol J 
all the symptoms were limited to the orbit, and all of an aneurisnu 
character. The aneurismal sac was not very large, else it would ha 
been felt by deep pressure of the finger; and it was not sufficiently nl’ 
to produce paralysis of the muscles and optic nerve by direct compr®Bßlo ' O KBIT A L ANEURISMAL DISEASE. 
917 
There was no dilatation of the branches of the ophthalmic vein, forming 
pulsating tumors, as in arterio-venous aneurism in the cavernous sinus. 
The only serious obstruction to the return of the venous blood from 
file orbit, was confined to the veins of the eyeball, external and internal. 
The trunk of the ophthalmic vein could not have been seriously com- 
pressed without manifestations in its frontal and other branches. The 
symptoms were therefore all arterial in their origin, and confined to the 
orbit and globe of the eye. hTo well-authenticated case of arterio-venous 
aneurism in the orbit has ever been demonstrated by post-mortem exam- 
ination. Besides, the. symptoms were not of a character to make that 
supposition possible, much less probable. Of course eucephaloid, menin- 
gocele, and venous tumors are excluded. It was not an erectile tumor, 
nor an aneurism by anastomosis in its restricted sense. The history, symp- 
toms, and termination, all point to a circumscribed aneurism of the oph- 
thalmic artery, in the orbit, which eventually ruptured, became diffuse, 
and was cured. Ido not think that anything but an arterial hemorrhage 
could have pressed the globe so far forward and produced such extreme 
tension. That the aneurism must have been sacculated, with thin elastic 
Walls and a small communication with the ophthalmic artery, is rendered 
probable by the occurrence of rupture and recovery without obliteration 
°f the artery. That the artery is not obliterated, is sustained by the 
fact that arterial pulsations are observed in the optic papilla when ex- 
ternal pressure is made on the ball. It could onlj be such a cause that 
Would fail to produce more serious pressure on the ophthalmic.vein, the 
rotatory muscles, and the optic nerve. That circumsciibed aneurism of 
the ophthalmic artery does occur, though perhaps very rarely, is proved 
by the post-mortem examination in Gfuthrie s case, in IhLo, where an 
aneurismal pouch was tound on the artery in each mbit. 
Some years a<m also I treated a case in which I feel confident that there was 
an intra-orbital aneurism. The case was that of a young man who was shot 
in the eye by a small pistol. The ball passed through the globe and lodged 
deep in the socket, causing the eye to collapse and atiophv. Ie pa len was 
treated by the late Dr. Blackman, and some months afterwards came to have 
an artificial eye inserted. On examination I found a round, pulsating, elastic, 
compressible tumor in the back and inner part of the oibit, a ion ie size o 
a pigeon’s egg. The man was not aware that anything was the matter till I 
called his attention to it. There was an aneurismal bruit heard with the 
stethoscope placed over the tumor, but not heard over tie iea< oi y ie 
Patient. It was exactly synchronous with the action of the heart and was 
completely stopped by pressure on the carotid. There were no venous enlarge- 
ments in the socket or on the forehead. The globe was reduced to the size of 
the end of my little finger, so that the tumor could readily be seen and fully 
examined by palpation. I put the patient in the recuin ent posi ion, wi i ie 
head raised; gave careful dosfes of digitalis, and had digital compression of 
the carotid tried for two days. It became irksome and painful to the patient, 
and my assistants gave out? So I called in Dr. Blackman, and we agreed to 
try instrumental compression of the carotid, which succee ec in comp e ey 
curing the disease; and 1 afterwards fitted the patient with an aitificial eye. 
■Sc lived till recently, and died of phthisis. 
These two cases are, I think, shown with reasonable certainty, by the 
symptoms and result of treatment, to have been genuine examples of 
orbital aneurism. In my case, published m the Medical Record, 1868, 
diagnosed as orbital aneurism and cured by ligation ot both carotids, 
thirty days apart, I am now satisfied that there was an arterio-venous 
aneurism of the carotid in the cavernous sinus. I have since seen a case 918 
E. WILLIAMS, 
with essentially the same symptoms produced by the passage of a 
wheel over the man’s head. I never saw the man but once, and kno" 
not what became of him. 
Case of Suspected Orbital Aneurism.—R. W., set. 24, of stout figure, 
health, and sanguine temperament, was injured by the horn of a calf on Jan“' 
ary 18, 1816. The point of the horn struck the lower lid, glancing inward 
and backwards and entering the orbit just above the tendo-oculi, causing an 
ugly contused wound and a severe concussion. The wound bled profusely? 
but healed in the course of a week, without surgical treatment. There was 
no bleeding from the nose, nor ocular hemorrhage, nor was the patient rendere 
unconscious by the shock. Sight was not affected, and there was no diplopdb 
headache, giddiness, nor other symptom of injury of the brain. There wa 
no protrusion noticed. About five weeks after the accident, while stoopin=> 
and driving a cross-cut saw, a sharp pain was felt above the right eye, running 
back over the ear to the temple. This sharp, peculiar pain came on at intervals, 
several times during the day, but was always provoked by stooping and 
ing, and soon passed off when the patient straightened himself up, and restet 
from sawing, 
There was no giddiness, throbbing, or bruit. Late in April it was »r 
noticed that the sight of the eye was misty at times, but without pain or othe 
symptom of trouble. For this" failure in sight a physician was consulted, wh 
first detected an undue prominence of the eye. From that period, about May 
1, till within the past four weeks, the exophthalmos increased slowly, bu 
varied very perceptibly between morning and evening, being always greate 
in the morning. Since then it has remained stationary. When 1 first sa 
this patient, three weeks ago, there was a striking exophthalmos of over one- 
fourth of an inch, with slight injection of the sclerotic conjunctiva, and so® 
serous, chemotic swelling within the external commissure. Corresponding 
this were seen some large, deep-seated, inosculating vessels on the scleroti • 
The pupil was larger than the other, and somewhat sluggish. The movennen 
of the globe were limited by the prominence and the stretching of the muscle; , 
but there was no paralysis. There was a divergence of when fixing 
the other eye, and the motion upwards and inwards was less excursive, ,n 
there was no diplopia, which I explained by the imperfect sight. Strong} 
marked features of swollen disk, and some neuritis; boundaries of disk obscure 
and veins very large and tortuous to their extreme branches ; slight 
of macula lutea, blurring its distinctive features. Vision very defective i 
consequence of a large central scotoma, which patient expresses as well define 
but not complete. 
Tension of the globe natural. No pulsation whatever of the globe nor or 
on auscultation. When the eyeball is pressed directly backwards, it is arres 
by a solid resistance. Diagnosis: Tumor of some kind at apex of orbit, 
bably of an aneurisrnal nature. In the complete absence of the three ® 
characteristic symptoms of aneurism, pulsation, bruit, and some degree 
elasticity on pressure, I rely upon the evident traumatic origin of the difficll } ’ 
its peculiar history ; the absence of inflammatory symptoms, and the eXC l'Sj.he 
of the symptoms of either benignant or malignant tumor at the apex ot 
orbit. The symptoms followed so soon after the injury, and in the beginJ*1 ? 
were so characteristic, as to make this opinion more probable than any 0 . 
The sudden, sharp, severe pain running backwards over the temple, and cau^fc 
by stooping and straining, coming on about four weeks after the blow, .fc 
be explained by the sudden rupture of the ophthalmic artery, directly a 
enters the orbit through the optic foramen. Its coats may have been wea 
by the original concussion, or the very slight rupture occurring there 
have been plugged by the formation of a coagulum. The history of se' 
published cases of supposed orbital aneurism, makes this latter suppositio 
least tenable. If the vessel then split or the plug was then suddenly dis ° » ORBITAL ANEURISMAL DISEASE. 
919 
by the increased congestion from stooping and straining, why did not imme- 
diate protrusion of the eye, pulsation, bruit, etc., occur? It may be that the 
opening was very small, and close in the narrow apex where rapid expansion 
and consequent protrusion were prevented. It will be remembered that not 
till this occurrence was the vision impaired; and that the troubled sight took 
the patient to a physician who first detected the exophthalmos. The imme- 
diate effect of a slow oozing of blood from a small arterial rent in the supposed 
situation, would, of itself, be pressure upon the optic nerve and very slow 
protrusion of the ball without pulsation. As the sac, fed by so small a source, 
enlarging almost imperceptibly, may be filled as it forms with coagulated 
blood, and make a solid mass without pulsation either from its own expansion 
or from impulse conveyed to it by the throbbing, small artery, the complete 
absence, as yet, of pulsation and bruit may be accounted for. The same ex- 
planation would account for the absence of any serious symptoms of pressure 
on the ophthalmic vein or other structures. Of course this theory of the case 
Oiust as yet be considered as open to question. The characteristic symptoms 
may yet be developed and make the case clear. My opinion, however, is so 
strongly in favor of an arterial lesion, that I believe that the symptoms can be 
relieved by systematic pressure on the carotid. As the patient is present, it 
gives me great pleasure to submit him to the Section for examination. I 
can only say that with one exception the symptoms are to-day what they were 
three weeks ago. The tension ol the globe is now minus. It was not so then.1 
[The patient was then presented.] 
In conclusion, I will sura up the symptoms which seem to justify the 
diagnosis of true intra-orbital aneurism, as follows; (1) If traumatic in 
origin, the nature of the injury. If it is by direct penetration of the 
orbit by a long, slender body, or a small shot or similar foreign sub- 
stance, the ophthalmic artery may have been wounded, as was probable 
in one of my cases. (2) If the injury to the head or face, though severe, 
is not attended by symptoms ot fracture ot the base of the skull, or, in 
the absence of the positive symptoms ot fracture, if the severity and 
character of the trauma are not such as to make such a lesion probable. 
(3) The strictly rhythmical character of the pulsations, if such exist. 
(4) The limitation of the region over which the bruit is heaid, to the 
eye and orbit. (5) The strictly intermittent character ot such bruit. 
(6) The fact that the patient himself does not hear the souffle, or, it so, very 
slightly. (7) The less frequent occurrence of paralysis ot motion or sen- 
sation, or of any symptoms indicating a disturbing cause in the cavity of 
the cranium. (8) The less frequent and less serious impaiiment ot vision. 
(9) The absence, except at an advanced period, and even then the less in- 
tensity, of the symptoms of obstruction in the ophthalmic vein, such as 
the existence of soft, thrilling, pulsating tumors around the eye, and of 
enlarged and pulsating frontal veins. (10) The complete curability ot the 
disease by direct compression through the eye; or by compression of the 
coninion carotid ; or by ligature of one (the corresponding) caiotid. 
The symptoms, till recently, accepted as characteristic intia-orbi- 
tal aneurism, are much graver and more extensivq in their distribu- 
tion. AVTen we submit them to the test ot pathological anatomy, as tar 
as such cases have been examined, it is seen that they depend on lesions 
1 This patient was seen again on April 15, 1877, when there was great protrusion of the 
eyeball with aggravation of all the other symptoms; a tumor could now be felt behind the 
fdobe. Enucleation of the eyeball was resorted to, when the tumor which was firm and 
fibrous in character and the size of a small pullet’s egg, was readily removed. It was 
situated between the optic nerve and the inner wall ot the orbit, but was not firmly con- 
futed with either. (July 5, 1877.) 920 
E. WILLIAMS, ORBITAL ANEURISMAL DISEASE. 
beyond the orbit. Of the 73 cases reported in Mr. Rivington’s paper, i'l 
12 only were autopsies made. Some of Mr. R.’s conclusions I will quote: 
“ In no single instance has aneurism by anastomosis, or cirsoid aneurism 
within the orbit, been verified by post-mortem discovery.” “In no sin- 
gle instance has an arterio-venous aneurism been found within the orbit 
at a post-mortem examination.” “In no case have the symptoms or 
intra-orbital aneurism been proved to be due to a tearing across of the 
ophthalmic artery at or near the optic foramen.” In the case of Guthrie? 
an aneurism was actually found in each orbit. In one case, no arterial 
lesion was found, but partial obliteration of the orbital veins, with evi- 
dences of previous inflammation in the orbital tissues. In the other ten, 
in which autopsies were made, the symptoms were caused by disease or 
the vessels just back of the orbit, in the cavity of the cranium. Of these, 
some were dependent upon obstruction to the return of the venous blood 
from the orbit to the brain. In one a small aneurism existed on the oph- 
thalmic artery at its origin from the internal carotid. In three there 
was rupture of an aneurism of the internal carotid, within the cavernous 
sinus. In one, “ simple dilatation and atheromatous degeneration ot the 
internal carotid artery in the cavernous sinus.” “In three, traumatic 
cases, a direct communication between the carotid artery and the cavern- 
ous sinus was found.” 
Finally, a word as to treatment. Compression, either direct, or of the 
common carotid, or both, is advisable in all cases, and succeeds in some- 
Coagulating injections may sometimes be successfully practised, bu 
require great caution. And finally, ligation of one or both carotids win 
be nearly always necessary for the extra-orbital cases. 921 
SPONTANEOUS CURE OF CONGENITAL PULSATING 
EXOPHTHALMOS. 
BY 
GEORGE C. HARLAN, M.D., 
SURGEON TO WILLS HOSPITAL, OPHTHALMIC AND AURAL SURGEON TO THE CHILDREN’S HOSPITAL, 
PHILADELPHIA. 
This case was reported at the last meeting of the American Ophthal- 
ftiological Society, but since then aneurismal tumor has sponta- 
neously undergone complete consolidation. The following abstract of 
the history, to-date of last report, is taken from the transactions of the 
society referred to;— 
L. L., let. 25. General health good. Left eye always prominent, and left 
side of head larger than right. Has always had a “ rushing sound in his head 
and eye.” Left e}re enormously protruded, forced downwards and outwards, 
and immovable. No useful vision. Whole left side of face hypertrophied. 
Mucous membrane of left side of mouth thickened, and left side of tongue 
twice as large as right. A localized tumor, probably a distended vein, above 
and to inner side of ball, and a doughy swelling of the soft parts extending 
about an inch above the orbit. There was strong pulsation, and an aneurismal 
bruit could be heard several feet from the patient’s head, five yeais after the 
first examination, the protrusion had slightly increased, but the bruit had de- 
cidedly diminished. The supra-orbital and frontal vessels were much distended, 
and pulsated strongly, and this aneurismal condition extended down the angu- 
lar branch of the facial, on the right side. 
On December 27,1875, the patient came to me complaining of pain 
*u the eye, and over the bridge ol the nose, and along tle couise ic 
angular artery on the right side. There was slight erysipelatous inflam- 
mation at the seat of pain, but not much change in the appearance of 
the parts. The bruit had entirely disappeared, and there was no thrill 
in any of the vessels, and no pulsation anywhere excep in ic oeanzec 
tumor above the ball. The supra-orhital vessels were scarcely percepti- 
ble. He had not been under any treatment, as he was not able to keep 
Up even occasional, intermittent compression of the carotid, on account 
°f the giddiness and faintness which it produced. Ihe continuous appli- 
cation of iced water was directed. , i i nnr] m. 
December 31. There was violent pain in the tumor and head The 
tumor was increased to at least twice its foimei size. s< ‘ 
Just perceptible. The exophthalmos was enormous, and the eye could 
uo longer be covered by the distended lids. _ The patient was admitted 
to "Wills Hospital, and anodynes were given m large doses, and dry cold 
Bubstituted for the iced-water applications 
January 2, 1876. The pain was somewhat relieved, and all trace of 
Pulsation in any part of the tumor had disappeared The cornea was 
completely anaesthetic, and was beginning to slough. The pulse was 
f«*«ble, and the pulsation of the left carotid was weaker than that of the 
right. From this time the pain and swelling gradually subsided, and 922 
HARLAN, PULSATING EXOPHTHALMOS. 
when the patient left the hospital, on February 2, the tumor was com- 
pletely consolidated, and had considerably diminished in size. 
Ho satisfactory wTay of accounting for this sudden and unlooked-for 
termination of the disease suggests itself to my mind. It is interesting 
as illustrating the possibility of spontaneous cure under circumstances 
that would seem to be about as discouraging as possible, and suggests 
the inquiry, what percentage of cases, if let alone, might end in the same 
way ? This question cannot be answered, as nearly all reported cases 
have been subjected to some kind of surgical treatment. 
I find records of five other cases of spontaneous cure, all but one hav- 
ing been of traumatic origin. 
Case I. Collard ; quoted by Erichsen (Science and Art of Surgery, Ameri- 
can Edition, 1869, p. 643). A man, 41 years of age. Injured by fall on back 
of head. Bruit, pulsation, exophthalmos. Symptoms entirely disappeared m 
three years and a half. 
- Case II Erichsen (Ibid.). Man, 44 years of age. Fall on head. Attacked 
by symptoms of aneurism of left orbit in most marked manner. Bruit, pulsa- 
tion, exophthalmos. Ligature of carotid urged by Mr. Erichsen but declined 
by patient. At the end of fourteen months the symptoms had, to a verj" great 
extent, disappeared. 
Case 111. Holmes (American Journal of the Medical Sciences, July, 1864)* 
Man, 23 years of age. Gunshot injury. Exophthalmos, chemosis conjunctive? 
bruit, pulsation. In about three months all the symptoms had entirely disap- 
peared, except slight congestion of the conjunctiva. 
Case IY. France (Guy’s Hospital Reports, 1853). Woman, 38 years of 
age. Point of umbrella thrust into orbit. Exophthalmos, pulsation of eye- 
ball, and defined, pulsating tumor above and to inner side of globe; complete 
blindness. All the symptoms but blindness disappeared in eight months. 
Case Y. Julliard, of Geneva (“Note sur un Anevrisrae Intra-orbitaire? 
etc.,” quoted by Rivington, Medico-Chirurgical Transactions, London, vol. 
p. 272). Woman, 69 years of age. Spontaneous. Enormous exophthalmos? 
pulsation, bruit, chemosed conjunctiva. In two months all the symptoms bet 
exophthalmos and blindness had disappeared. A few months later, the exoph- 
thalmos was also gone. 
In none of these cases was any local treatment resorted to, except that 
in two or three instances cold applications were employed in the early 
stages. In connection with the case reported to the Section by Dr. Wil- 
liams, and that now submitted, they make a total of seven instances ot 
spontaneous cure of this affection, , 
Though statistics prove beyond doubt that ligation of the carotid 
affords the largest percentage of cures, it is well, before deciding upon h8 
performance, to remember not only the possibility of cure by milder 
means, or even without resort to any surgical procedure at all, but to 
bear in mind also that, though one of the most brilliant operations in 
surgery, it is not without its chances of failure and its dangers of a fMa 
result. All the operations that I have been able to collect, including 
two of Dr. T, Gl. Morton’s, not yet reported, furnish sixteen per cent 0 
deaths and about the same proportion of failures, leaving only sixty-eigh 
per cent, of cures and partial cures. 923 
ARE PROGRESSIVE MYOPIA AND CONUS (POSTERIOR STA- 
PHYLOMA) DUB TO HEREDITARY PREDISPOSITION, OR 
CAN THEY BE INDUCED BY DEFECT OF REFRAC- 
TION ACTING THROUGH THE INFLUENCE 
OF THE CILIARY MUSCLE? 
BY 
EDWARD Gr. LORESTGr, Jr., M.D., 
OF NEW YORK. 
After a careful consideration of the above question, I have come to 
the conclusion ; (1) That hereditary predisposition, though undoubtedly 
u potent cause, is not only not the sole cause, but not even the predomi- 
nating cause, of progressive myopia \ and (2) that the action of the ciliary 
muscle, taken by itself, exerts but little influence on the production of 
myopia, and still less on the formation of the cone. 
The arguments on which these conclusions are based will be found in 
the following remarks:— 
The belief that “like begets like” has been formulated in the speech 
and crystallized in the proverbs of every people since the woild began, 
and although this uniformity of opinion exists as to hereditary predis- 
position and its influence on the organism in general, a great deal of 
doubt has been expressed as to the degree of effect which it produces on 
Particular and individual organs, and especially on those which fulfil 
the functions of special sense. Nor can it be doubted that grave objec- 
tions have from time to time been raised, and many weighty aiguraents 
advanced, which would go to show that the effect of direct transmission 
could not be so readily detected, nor so clearly demonstrated, in regard 
to the special senses as to the organism as a whole. Still, in later years, 
as proofs have gradually multiplied and apparent discrepancies have 
been reconciled,"the opinion has gradually become more genera that, 
beneath a mass of apparent contradictions and almost endless ex- 
ceptions, there lies a general tendency of inheritance which authorizes 
as in assuming that even with our special faculties there is a uniform, 
though perhaps, from want of knowledge, a rather flexible, aw, w nch 
controls, to a degree at least, their form and chaiacter. ... 
In none of these is it claimed that this law of transmission is made 
aiore manifest than in sight, the noblest and most intellectual of all our 
Acuities. Thus it has been assumed by the preponderance ot authorities 
that the specific type of the organ of vision has its varieties of form and 
perception, every one of which may owe its origin to the orce of he- 
redity. Thus it is held that color blindness, strabismus, hypermetropia, 
and myopia, are transmissible by generation, so that according to 
biUcas(l)1 there are families among which many of their members owe 
1 The numbers attached to the names of the authors refer to the bibliography at the end 
°f the paper. 924 
LORING, 
to hereditary influences alone the conformation of their optical appf' 
ratus, and the fact of their range of vision being short or long. It 19 
further claimed that the statistical results of Funari(2), supported hy the 
statements of Piorry(3) and Portal(4), have shown that most myopes are 
the sons or grandsons of myopes. It is certainly not necessary for me to 
remind the members of this Section that views, similar to, if not iden- 
tical with, those just quoted, as to the hereditary tendency of myopia? 
have held sway successively in England, France, Germany, and in this 
country, and indeed in every country. IST or would the time allotted to_ 
this paper allow me, even if your patience would, to cite the long list ot 
distinguished names through whose authority this wide-spread opinion 
has had and still has its existence; still, for the sake of the arguments 
which are to follow, I should like to be allowed to refresh your minds m 
regard to the opinions of a very few of those who in our own time have 
done so much towards moulding the prevailing opinion as to the heredi- 
tary nature of myopia. 
Thus Stellwag von Carion(s), in discussing the causes of myopia and 
the elongation of the eyeball, says “ the predisposition to this is of course 
congenital, and is, as a rule, hereditary,” and adds, in speaking of the 
staphyloma and its relation to the scleral protuberance, that the “exqui- 
sitely hereditary character of the affection can also be brought forward 
as a proof of this.” Jaeger(6), while emphasizing the fact that myopin 
is not the “ prerogative of industry,” declares that “ posterior staphyloma 
is hereditary to a predominating degree.” And Bonders(T), in speaking 
of the causes of myopia, affirms that “the predisposition is almost alway3 
congenital, and in that case it is, moreover, nearly always hereditary* 
Beer, Jtingken, Bohn, Yon Hasner, and many others, have referred to 
its hereditary nature, and I believe even that from time immemorial 
the conviction thereof has been general among the people.” Many more 
examples quite as explicit as these might be cited here, were it necessary* 
since, as you are well aware, every standard work on ophthalmology 13 
replete with them. 
It would be supposed, from the force of the expressions and the weight 
of authority from which they come, that these opinions in regard to the 
predominating influence of heredity in myopia would be based on exact 
and extensive statistical information which would embrace, certainly, 
wide a scope as from grandfather to father and from father to son. Yet? 
as far as I am aware, no such statistics exist, at least of such a nature as 
to satisfy the exacting demands of modern science. It is very true that 
both Bonders and Jaeger have—as indeed we all have—been struck with 
the frequency with which myopic parents bring to us their myoplC 
children; but, as you are well aware, the mind, in these matters, is more 
prone to be struck with resemblance than with dissimilarity, and n° 
account is taken or recorded anywhere, as far as I know, of how often 
the reverse holds good, that is, how often children with myopia are 
brought by parents who, on actual examination, are shown to have normal 
eyes, and whose ancestors on both sides, as far as known, were never 
near-sighted. Moreover, I found that among 715 well-educated and intel- 
ligent persons, whom I examined for this special purpose, the percentage 
of those who had normal eyes themselves, but whose parents were myo' 
pic, was nearly identical with the percentage of those who were not only 
myopic themselves, but who had myopic parents. That is to say, that 
the percentage of emmetropic children from myopic parents was as high 
as that of myopic children from myopic parents. FTo one more fully PROGRESSIVE MYOPIA AND CONUS. 
925 
recognizes or more freely admits than I the liability to error in statistics 
gathered thus as it were at second-hand. Nothing but the tabulated 
observations of three generations at least can be of much value as regards 
heredity, but as such do not exist, I offer the above for what they may 
be worth. 
These observations would, however, seem to be in accordance with 
those of others. Thus Cohn(8), in his investigations as to the refraction 
°t the eyes of school children, found that out of all the myopes there 
"’ere only 2.7 per cent, whose father or mother were myopic. I found 
that only 6.11 per cent, had either father or mother near-sighted. With 
both parents myopic, the percentage falls with Cohn(9) to 1.04 percent, and 
me to 1.11 per cent. Erisrnann(lO) found, however, from his statis- 
tics that 30.6 per cent, of the myopes had one or both parents myopic. 
Taking, then, Erismann’s percentage, which is an enormous increase over 
John’s and mine, .as a basis, we find, even then, that two-thirds, or 
scventy per cent., of the myopic children had parents who were not rayo- 
pic. This certainly does not show, as far as statistics are concerned, a 
Marked hereditary tendency, or warrant, it would appear, the expression 
°f so decided an opinion as that which we have quoted from the leading 
authorities. 
There are, however, in the absence of exact statistical knowledge, seve- 
ral factors of less importance, it is true, but still of sufficient force to aid 
Us materially in the solution of the problem, and amongst these the most 
important are necessarily those of an anatomical nature. For if in any 
case of disease it can be shown that an anatomical formation is pecu- 
liar to a certain disease, the presumption is that it is congenital as a rule \ 
and the earlier it shows itself the more likely is it to be heieditaiy. That 
both of these conditions have been fulfilled in regaid to myopia bj the 
change known as posterior staphyloma, is almost univeisally admitted. 
'Thus Stellwag(ll) declares that posterior staphyloma is due to congenital 
Malformation, while Jaeger(l2) says that “the increase in the axis is usu- 
ally accompanied with a cone which is mostly congenital, and frequently 
hereditary,” and adds that he has seen “ typical cases of it m the eyes of 
children both in life and after death ;”(13) and Donders(l4) only 
strengthens the almost universal opinion when he declares that iiom the 
frequency with which changes in the bottom of the eye have been observed 
Mith the ophthalmoscope, myopia and staphyloma have become nearly 
Synonymous terms. This statement he supports by a reference to 
%aefe(ls), who had previously declared that, in myopia o o 2, 
Jhnety per cent, showed that peculiar change in the fundus, and ac c s that 
he himself(l6) believes the proportion is much nearer one hundred per 
cent. Still there can be but little doubt that the general and rather 
sweeping assertion that posterior staphyloma is synonymous wit i niyopm, 
18 somewhat exaggerated. For out of 500 myopic eyes oun on y .0 
Per cent, affected with the crescent. Oohn(17) in 1004 cases of myopia 
between the same ages, that is, from 6to 21 years, founc _ e cone piescn 
M only 20 per cent.; while Max. Conrad’sQS) examinations in 1001 
Myopes showed 28.1 per cent. The average of these results would then 
show that only 22.3 per cent, of myopic eyes have the cone. Of my own 
Cases there were only one-fourth which showed any change whatever, 
Mule there were three-fourths of the eyes which showed no deviation 
from the normal standard. This is certainly at variance with the 
accepted views though it is corroborated as seen above by the extensive 
statistics of Cohn and Conrad, the unanimity between the results being 926 
LORIXTG, 
very remarkable. When, however, we come to the proportionate ft’6' 
quency of the cone in regard to the three classes of refraction, we fiud 
that it predominates to a marked degree in myopia. Thus I found of 
2265 eyes examined, that of the emmetropic eyes 3.33 per cent, had cones 
more or less developed ; of the hypermetropic 3.49 per cent. ; while in the 
myopic the percentage rose to 20.56 per cent., or six times as much as 
in either of the other classes. We are forced to conclude, therefore, that 
there is an anatomical variation predominating in myopic over other eyes? 
although the frequency with which it occurs has been, it would appear? 
much overrated—certainly for this country. Still, too much weight 
should not he put upon this fact as an argument as to the congenital 
and hereditary character of the cone, since, in the first place, an anomaly 
which makes its appearance in only about one-fourth of the cases, and 
under the most favorable auspices for its development, that is, in school 
children between the ages of six and twenty-one years, cannot be said to 
be strongly congenital. 
Moreover, it is a fact that, although, as stated by Jaeger(l9) and Von 
Hasner, well-marked cones are found in new-born children, they are, 
as known to all, and admitted by them, comparatively rare ; while they 
increase in frequency in after life, and with close application ; and often- 
times in eyes which have been shown by repeated ophthalmoscopic ex- 
aminations to have been previously free from the slightest trace. From 
these facts, and from the fact that myopia consists as a rule simply of an 
elongation of the globe, which would, from purely mechanical reasons, 
produce a crescent, a doubt has arisen, in my own mind at least, whether 
after all the cone was an expression of congenital malformation of the 
scleral protuberance, or indeed of any part of the scleral split. 
For, if it had any connection with the split, we should suppose it would 
be in reality what both its name and alleged anatomical origin imply’ 
that is, an actual protrusion of the sclera, or at least an excavation or 
limited thinning of this membrane, as is invariably the case with a true 
coloboma, as demonstrated as wTell by the ophthalmoscope as by dissec- 
tions, But I hardly need remind those of you who use the upright 
image that there is almost never the slightest difference in level between 
that part of the sclera which represents the cone and the adjoining 
portions, and this, too, no matter how large the crescent is. The cone is? 
in fact, not a true staphyloma; and it is only when applied to the entire 
posterior portion of the eye that the name is at all applicable, and we 
should be forced to assume that the whole posterior part of the eye was 
congenitally defective, or at least that parts were so which were widely 
separated from the scleral protuberance. 
The second anatomical variation which is supposed to be characteristic 
of the myopic eye, and one which has had great importance attached to 
it, is the peculiar conformation of the ciliary muscle, which is supposed 
to be congenital. From the labors of Iwanofl(20) it was shown that the 
ciliary muscle in highly myopic eyes varied from that in other eyes, not 
only in general outline, but also in its composite structure. In the 
drawing (Fig. 1), which is taken from Iwanoff, the shape and outline oi 
the muscle in the three classes of refraction are contrasted with each 
other. The solid line represents the muscle of an emmetropic, the dotted 
that of a myopic, and the broken line that of a hypermetropic, eye. I 
will be seen that the muscle in the myopic eje extends further 
along the sclera than in the normal eye, and is, moreover, broader. It wn 
be observed also that the short side, or leg, of the triangle, which rept®' PROGRESSIVE MYOPIA AND CONUS. 
927 
Septs the muscle as a whole, forms in the normal eye nearly a right angle 
the sclera, while that in the myopic eye forms an acute angle, with 
apex towards the inner portion of the eye. As to its component 
Parts, it was shown that the circular fibres found in the normal eye were 
either very much reduced or entirely wanting in the- myopic eye, while 
they were increased in the hypermetropic eye. It was, therefore, assumed 
that, inasmuch as the myopic eye from its structure had no demands for 
active accommodative efforts, the reason why the circular fibres were not 
Present was because they had become atrophied from disuse, so that the 
er*tire triangle marked A had disappeared. "While, on the other hand, 
the circular fibres had been so increased by active accommodative demands 
the hypermetropic eye as to occupy the superadded triangle B. It was 
further shown by Iwanoff that not only had the circular fibres become 
trophic, but that the longitudinal had become hypertrophied. From 
this it was assumed that the action of the muscle had been changed, and 
that, instead of being compound, the circular fibres drawing toward the 
axis of the eye while the longitudinal drew directly forward, the action 
had become solely the latter, so that the muscle had become what the 
Author calls a pure “ tensor choroideie.” If we should accept this 
would have the apparent reductio ad absurduM, as the authoi himself 
®afs, in the development of a force which he supposes to^produce active 
Accommodation, in an eye which does not require or use it; foi traction 
?U the choroid and consequent relaxation of the zonula is supposed by 
Helmholtz and other physiologists to be the important element in the 
production of accommodation. . . c . 
It would certainly lead me too far to enter in a discussion of this 
Object, but it seems as if a very important factor, and one which might 
Pr°duce a marked effect on the form and shape of the muscle in the 
Pfyopic eye, had been neglected in the consideration of this question. This 
the effect of distension of the investing membranes of the eye, which 
\n some cases is enormous, as, for example, where progressive myopia is 
developed very rapidly and to a very high degree. _lt would therefore, 
seem more natural to attribute the change in foini and structure 
tins than to any difference in function of its component parts. Thus if 
posterior pole of the eye should yield, the insertion of the muscle at its 
toroidal end would be drawn buck as seen in the drawing, and the angle 928 
LOSING, 
which, as we have seen, was a right angle in the normal eye would then 
become acute, since the insertion around the canal of Schlemm and adja- 
cent parts would remain stationary. The few so-called circular fibre0 
which form an anastomosing network, whose meshes run more or less 
perpendicular to the direction of the longitudinal fibres, would on being 
stretched assume precisely the opposite direction, and would then have on 
section the same general direction as the longitudinal, as would of course 
also the so-called radiating, fibres. Moreover, as the horizontal and 
vertical diameters also increase somewhat in these highly myopic eyes? 
the zonula would he stretched, and would then draw with a gentle but 
sustained traction on the muscle, the general direction being perpendicular 
to the axis of the eye. Thus the fibres of the muscle would have a 
tendency to draw apart, and the muscle to increase in bulk. This tension 
on the zonula would also account for the fact that the lens is flatter in 
high degrees of myopia than in the normal eye. Thus appearances 
hitherto supposed to be congenital might occur from a simple mechanical 
cause, acting during life in an eye which was not congenitally myopic? 
and with no hereditary tendency. 
Thus while not denying the hereditary tendency toAvards a too yield- 
ing sclera, I have become more and more convinced that there are many 
cases in which the cone is simply the expression of a purely mechanical 
effect, distension, from which all the peculiar appearances of the crescent 
might result without'there being the slightest connection between the 
cone and any congenital or hereditary tendency whatever. Does the 
inguinal ring never give way, or the fibres of the bladder become re- 
laxed, or the pleura distended, or ascites occur, or even the bony cavity 
of the head enlarge, except through hereditary tendency? and if these 
can owe their origin, as they often do, to exciting causes which are 
purely spontaneous and fortuitous, why may not that distension of the 
sclera, which is myopia, take place, especially when the growing and 
elastic membrane is subjected to over-use, without our being compelled 
to attribute it “almost invariably to congenital and hereditary influ- 
ences?” Clinical experience would point to such a conclusion, for it is_a 
fact that cases occur where myopia with all its characteristic signs i 0 
produced in eyes which were previously normal; that is, in the eyes or 
adults, who have passed therefore the period of development, and whose 
family history shows no hereditary tendency. This, too, notwithstand- 
ing Donders’s(2l) assertion that he has never seen “ myopia arise after 
the twentieth year in eyes which were previously normal.” I have seen 
several such cases, and I doubt not that most practising ophthalmolo- 
gists have had the same experience. 
If this distension of the sclera did take place, there would be, neces- 
sarily, a change in the refraction of the eye, and this would have a de- 
cided weight in determining the question of hereditary influence. For 
if it could be shown that normal eyes which, according to the theory or 
heredity, would presuppose normal, i. e., emmetropic, ancestry, or better 
still if it could be shown that hypermetropia, the direct opposite ot 
myopia, with the opposite hereditary tendency, could and did frequently 
pass into myopia, then it would be an almost convincing proof that 
myopia could be and often was produced in spite of hereditary influence 
against it. 
That an emmetropic eye can and does pass into a myopic eye, and that 
it has been proved to do so by direct observation, I think will be ad- 
mitted by the great majority of observers. But that a hypermetropic PROGRESSIVE MYOPIA AMD CONUS. 
929 
6ye can pass into an emmetropic or normal eye, and thence into a myopic 
eye, is still a matter of great doubt in the minds of some of the best 
authorities. Thus Donders(22) says: “I have never seen a hyperme- 
tropically constructed eye become near-sighted.” An opinion which he 
corroborates and strengthens in many other passages in his world-re- 
nowned book. Jaeger(23), however, makes a diametrically opposite 
statement, and declares that an interchange of refraction does take place, 
and that “'thus an hypermetropic as well as a normally-constructed eye be- 
comes a myopic eye through posterior staphyloma at the posterior pole 
°f the eye.” Stellwag(24) proclaims the same thing in very nearly iden- 
tical terms. Various authorities too numerous to mention have ranged 
themselves on one side or the other of these opposite opinions, though I 
think that the majority of the more modern observers are tending 
towards the view expressed by Jaeger, that an interchange of refraction 
from a hypermetropic to a myopic eye can and does take place. Still it 
must be admitted when it comes to actual demonstration, that the tew 
cases which have thus far been cited are not sufficient in number or accu- 
racy of detail to he of the slightest weight. One would certainly sup- 
Pow, d priori, that such cases would have been observed in great num- 
bers and the fact that they have not, in the past decade when retraction 
Pas been so minutely studied, would seem to point very strongly to the 
foofOiy of 
atoStoS wantrfS SkVchange in hypermetropk we are 
force? to the consideration of collateral ev.dm.cewhich it appears to 
me, if correctly taken and he prooffurnished by statil 
as that of actual observation which show the^propor- 
Jcs taken fr°m large n ‘ classes of refraction occur at different 
donate rate m wMch the difterent or Ucation of the 
imes of life, and with diftei = j 1813 an,j jn later years from 
eyes. From the statistics ot waie(2 ), T?nptpf29l and others 
those of Szokalski(26), SohUrnuayer(27) Jaeger(2B) W9) ami others, 
very important facts were obtained 
Myopia was more common in cities , ao,e an(j Amount of close 
creased in frequency and m degi to&the deleterious effect of 
application, while Ruete also called a factg were afterwards cor- 
ffisufficient and faulty illummati . , statistics extensive as they 
roborated by Cohn, but unfortunate y 0 r- the'manner in which 
are, are not suitable for our purpose, from them as to the 
they were compiled, no correct idea ca 'other the three different 
frequency with which, in comparison to each other, 
classes of refraction occur. attention are those made by 
The statistics to which I shall cal Y Qermany, and those by Dr. 
in Russia, Max Coni ( ) these as examples since 
H. Derby and myself in this> "esuffioient numbers were 
they are the only ones winch I k conditions of investigation were 
and where, at the same time, „ug tpe„ were all upon the eyes 
tbe same, or nearly the same, in eac . twenty-one years, and the 
cf school children between the aS®B twenty feet were the basis of the 
rial by glasses and Snellen s oomTnouly occurring degrees of refrac- 
tfaniination; while all tie m gt aqes were included. Every eye 
ion from the lower (go) ° pf the cases reported by Dr. Derby 
examined by the ophthalmoscope m r j j 930 
LO RING-, 
and myself. Erismann’s statistics were made in St. Petersburg on the 
eyes of 4358 scholars; Conrad’s at Kdnigsberg on 3036 eyes, and Dr* 
Derby’s and mine on 2265 eyes in New York. The results of these sta- 
tistics are arranged in a tabular form in the diagrams marked respectivly 
Russian, German, and American, Tables 1., 11., 111. The numbers at 
the foot of each chart represent the progression of the classes from left to 
right, that is, from the lowest to the highest, or, what is the same thing, PROGRESSIVE MYOPIA AND CONUS. 
931 
from the youngest to the oldest, as in the American diagram. This last 
is made necessary from the fact that the arrangement of the classes dif- 
fers in this country from that in the foreign schools. Since, however, the 
successive classes correspond almost exactly to the successive ages, this can 
make no practical difference, especially as both the Russian and German 
statistics were calculated in both ways, and no material variation found 
between the results of the two methods. As it is the result of the entire 
school term, that is from six to twenty-one years, which now interests 
us, and which is the same in all countries, the comparison between the 
different nations is a just and fair one. 
The numbers running longitudinally on the diagrams show the in- 
crease and decrease in percentage, each of the larger spaces representing 
ten, and each of the subdivisions five per cent. The line marked E 
represents the curve which emmetropia takes in the different years, M 
the myopic and II the hypermetropic curve. It will be seen on inspec- 
tion, that, however much these curves differ in degree in the different 
diagrams, and amongst themselves, they all show that the refractive 
power increases with the advance in life. 
Thus in the Russian diagram the frequency in which H occurs dimin- 
ishes from 67.8 per cent, in the lowest class to 36.2 per cent, in the 
highest, while M increases from 13.6 per cent, to 42.8 per cent. Emme- 
tropia increases a little, from 18.6 per cent, to 21 per cent. In the Ger- 
man1 diagram, H descends from 16.2 per cent, to 6.70 per cent.; M rises 
from 11.1 per cent, to 62.1 per cent.; while E decreases from 72 per 
cent, to 30.40 per cent. In the American diagram, TI rises from 9.47 
per cent, to 12.24 per cent.; M rises from 3.55 per cent, to 26.79 per 
cent.; E sinks from 86.98 per cent, to 60.97 per cent. It will be seen 
from the Russian diagram that the emmetropia remains about the 
same through the entire series of classes, while the myopia steadily 
increases. If we assume that this increase, which is equal to 29.2 per 
cent., is due to emmetropia passing to myopia, we are forced to assume 
that the balance is maintained by hypermetropia passing to emmetropia 
to supply the deficiency. According to this diagram a part of the 
hypermetropia must become emmetropia, and if a hypermetropic eye 
can become emmetropic by increasing its refraction, it would be absurd 
to deny that it could not, by a little further increase, become myopic. 
So too in the German diagram it is seen that the increase in myopia, 
which equals 51 per cent., is greater than the decrease of emmetropia, 
which is 41.60 per cent., that is, is greater by 10 per cent. It must conse- 
quently have taken this increase from the hypermetropia, which is indeed 
seen to have decreased 10 per cent. From the American diagram it will 
be seen that the emmetropia decreases 26 per cent., while the myopia in- 
creases only 23 per cent., so that in this case the myopia may have been 
derived from the emmetropia alone. The slight increase in the hyper- 
metropia may be explained by a small amount of latent II becoming 
manifest as the age advanced. The increase in refraction, however, 
though not so great as in the other two diagrams, is nevertheless very 
marked. It will, moreover, be seen in both the Russian and German 
diagrams that, while the lower grades of refraction E and II predominate 
1 Conrad also gives a separate curve, as determined with the ophthalmoscope. For the 
sake of simplicity and uniformity in the diagrams I have omitted this curve, and taken only 
those which were determined with glasses. The increase in refractive power is, however, 
more marked with the ophthalmoscope than with glasses. Still I cannot persuade myself 
that it is, on the whole, as accurate with the instrument as with test types. 932 
LOEING, 
in the lower classes, a complete change occurs, and M becomes the pre- 
dominating refraction, and that this change takes place at a compara- 
tively early age. Thus in the Russian diagram the line M crosses the 
line E at the fourth class, or what would correspond on the American 
diagram to the years 12-13. It crosses Hat 14-15, when myopia becomes 
the predominating refraction, being in the highest class twice as frequent 
as the normal eye. Precisely the same thing occurs in the German dia- 
gram, where M, rapidly rising, crosses both H and E, being in the highest 
classes twice as common as the normal ejm. In the American diagram, 
however, E remains all through by far the predominating refraction, the 
line E not only never crossing those of II or M, but remaining at a dis- 
tance amounting at its lowest point in respect to M at its highest, to 34 
per cent., and in respect to II at its highest, to 43 per cent. 
This would show, if the numbers were great enough to prove it, and 
I think they are, that not only is there less myopia in this country in 
school children than in either Russia or Germany, but that emmetropia 
is the normal eye in all classes, which agrees with what Donders(32) 
found among the Dutch. For it may be assumed that after the age ot 
twenty-one the refraction as a grand whole changes but very little, and 
that any slight change towards myopia in early adult life is more than 
counterbalanced by acquired hypermetropia in later life. Moreover, as 
we have taken as a standard the very class where myopia would be most 
frequent, that is in over-worked school children, it is fair to assume that 
the proportion of myopia would be less and not greater in other classes, 
especially in the lower and middle ranks of life. In order to make a 
better comparison between the three nations, as far as the myopia is con- 
cerned, the myopic curve of the three preceding tables has been trans- 
ferred to a separate diagram, Table IV. 
As an additional means of estimating the effect which the hereditary 
influence-has on myopia, a comparison was made as to the frequency in 
which myopia occurred in the three principal nationalities of which our 
public schools are composed, that is, among the pupils of German, Ame- 
rican, and Irish parentage. It was found that of all the German scholars 
24 per cent, were myopic, of the Americans 20 per cent., and of the Irish 
15 per cent.; so that even in this country, and under the same school 
influences, myopia occurs more frequently among the descendants of 
Germans than among either the Americans or Irish. The compara- 
tively low percentage of myopia among the Irish is certainly remark- 
able. It is, however, in accordance with the assertions of various 
authors as to the immunity from myopia among the inhabitants of Great 
Britain. There can be no doubt that as a nation the Germans show a 
strong tendency towards myopia. Whatever may be the cause of the 
trouble, it is certainly a fact that the statistics of myopia taken m 
German schools show a decided increase over those taken in this country, 
which can be seen by comparing the statistics taken by Dr. Cheatharn(3B) 
in Yew York, by Dr. D. B. Williams(34) in Cincinnati, and Drs, Prout 
and Mathewson(3s) in Brooklyn, with those taken in Germany. 111 
comparing these statistics the different basis on which they are compiled 
should be taken into consideration, especially with those of Cohn, as he 
did not include myopia less than g’g, while in those cited above and made 
in this country g’g was included. 
From the evidence furnished by such statistics made in different 
countries and by different observers, I do not, while admitting the heredi- 
tary tendency, see how we can exclude the fact that there are many eyes PROGRESSIVE MYOPIA AMD CONUS. 
Which, under prolonged tension of the accommodation, pass from 
Haetropia to emmetropia, and thence to myopia with all its attending 
Bigns and symptoms, and this too in spite of hereditary influence to the 
contrary. 
This factor of prolonged tension of the accommodation brings ns at 
pnce to a consideration of the second proposition of our subject, which 
18 whether posterior staphyloma and progressive myopia can be produced 
th rough the influence of the ciliary muscle. Before proceeding to discuss 
this, I would call your attention to the fact that the question does not 
refer to the entire act of accommodation, which implies the action of the 
recti muscles as well as that ot the ciliary muscle, but is limited to the 
tatter alone, and consequently I am desirous that it should be kept in 
mind that my remarks are confined to the share which the ciliary muscle 
ulone takes as an agent in the production ot myopia and the cone. There 
are two ways by which the ciliary muscle oould render an eye previously 
not near-sighted, myopic. The first would be by increasing the curvature 
°f the lens by active, that is, positive, contraction; and the second, by pro- 
ducing an elongation of the antero-posterior axis. That such an increase 
in curvature of the lens does, by contraction of the muscle, take place, 
With the effect of temporarily increasing the refraction of the eye, is now 
Universally admitted. The only question which interests us here is 
Whether the increased curvature of the lens through the agency of the 
ciliary muscle ever becomes permanent, and thus transforms an eye from 
an emmetropic or hypermetropic to a myopic eye. 1 hat such was the 
opinion of the earlier oculists I need not remind you, down even to the 
time when Cramer declared that there were myopic eyes in which the 
curvature of the lens corresponded to that in the normal eye when 
adjusted for near objects. Nor need X dwell on the ievulsion of feeling 
Which followed when it was learned from the labors of Helmholtz, Knapp, 
and Bonders, that this last fact was not correct, and that the cuivature 
of the lens in myopic eyes was shown to be if less than in the 
normal eye. .A revulsion of opinion which culminated in Bondeis s(ob) 
declaring, though formerly a firm believer in its occunence, that he bad 
never, since the true nature of refraction had been understood, been com- 
pelled to resort to an increased curvature of the lens as an explanation of 
niyopia, while Giraud Teulon declares that there never has been a single 
Well-authenticated case put on record. _ 
The opinion that myopia is never due to increased curvature ot the lens, 
has, however, been combated from thefirst by a few of the veiy best authoi i- 
ties, especially by Jaeger(37), who declares that “ frequently the sole cause 
of myopia is the increased curvature of the lens,” and by Stell wag(3B), who 
hi his last edition affirms that “increase in convexity of the lens is indis- 
putably an important pathogenetic cause of short-sightedness; and it Can- 
Hot be doubted that this opinion, certainly as regards the initial cause of 
Myopia, is gaining ground among the younger school, bull, notwithstand- 
ing the plausibility of the theory that increased curvature of the lens causes 
Myopia, there is, it must be confessed, but little actual proof of its existence 
from such a cause. Indeed it must, I think, be admitted that the proof 
both experimentally and clinically points just the other way. Thus 
experimentation shows that by actual measurement the curvature of the 
lens is less if anything in a myopic than in a normal eye. ihen comes 
the great clinical fact that in those cases of hypeimetiopia of a high 
degree, proved to exist in young children who are watched from year to 
year, the amount of the total hypermetropia does not decrease under 934 
LORING, 
accommodative efforts, while the manifest does increase year by year in 
spite of such efforts. Thus the patient is compelled to go, not from 
stronger to weaker glasses, hut from stronger to stronger, in spite of 
every effort to maintain the former amount of curvature of the lens. The 
very frequent occurrence, too, of adults with very high degrees of hyper- 
metropia, who have been straining their ciliary muscle to the utmost for 
years to overcome their optical defect, is decidedly against the view that 
the curvature of the lens becomes permanently increased by over-tension ; 
as is also the fact that in high degrees of hypermetropia where there ig 
little or no manifest, the total is revealed bj7 the ophthalmoscope, and 
then coincides with an amazing exactness with that produced by the full 
effect of atropine. Such facts as these, and many others might be quoted 
to sustain them, warrant us in the belief, until more convincing proof to 
the contrary is offered, that as a rule the action of the ciliary muscle has 
no effect in producing a permanent increase of curvature of the lens, and 
thus becoming a cause of myopia—no matter what the original condition 
of refraction. In regard to the second point in our investigation, that 
is, whether the ciliary muscle is capable of producing an elongation of 
the axis, thus causing myopia, it will be sufficient to call to mind that 
Young’s(B9) and Helrnholtz’s(4o) investigations prove the impossibility ot 
such a result. 
But it may be urged—as, indeed, it has been frequently, especially 
since Bobrowolsky’s(4l) investigations—that, even if the natural, or 
what may be called the tonic, contractions of the muscle, do not pro- 
duce myopia by directly increasing the curvature of the lens, spasmodic 
or clonic contractions do; and that the myopia first produced by in' 
creased curvature of the lens is followed by irritation of, and traction 
on, the deeper-seated membranes, which lead to true myopia—that is, to 
an elongation of the axis. If this were so, we should expect to find the 
signs of irritation more frequent where the strain of the ciliary muscle 
was the greatest—that is, in hypermetropic eyes. But it is an undenia- 
ble fact, as pointed out by Bonders, and confirmed by every observer 
with the ophthalmoscope, that the injection of the nerve and the signs 
of irritation are not any greater than in the normal eye. Moreover, we 
should find, if simple traction on the choroid could produce the cone, 
that these would be most frequent where the traction of the muscle was 
the greatest; and this, too, independently of any increase of the length of 
the axis—that is to say, in hypermetropic eyes. For, if simple traction 
on the choroid could produce the cone, it would make no difference how 
short the axis was; all that would be necessary would be an increased 
action of the muscle, and this we get in hypermetropia. Yow, not only 
clinical experience, but actual statistics, show, as has already been 
pointed out, that the crescent is found less frequently in hypermetropic 
eyes than any other. Moreover, if traction on the choroid could and did 
produce the cone, we should expect to find it in all eyes, no matter what 
their refraction, at the inside of the nerve, since this would be the place 
of all others in the circumference of the nerve where the traction would 
be soonest and most powerfully felt, for the simple reason that it is. the 
shortest line between the two points of attachment. Moreover, the 
crescent would have a rapid tendency to become circular. But ninety- 
nine times out of a hundred the cone is at the outside of the nerve, and 
there remains. 
But not only do we have positive proof in hypermetropic eyes that 
increased action of the ciliary muscle, per se7 does not produce the cone, PROGRESSIVE MYOPIA AND CONUS. 
935 
J,ff we have equally strong negative proof, in myopic eyes; for the greater 
foie myopia, the less the positive contraction of the ciliary muscle. 
A,1(l many cases occur of the development of the cone towards adult life 
ln eyes which were not at the time of development of the crescent using, 
had ever used, any active accommodation at all; that is, in eyes whose 
for point had always been from twelve to eight inches. Of all eyes 
these are the most prone, on over-use, to progressive myopia and the 
formation of the cone, while it is a clinical fact that, in many of these 
of rapidly increasing myopia, the myopia is at once checked by 
carrying out the far point by glasses which decrease the amount of con- 
vergence, but which increase sometimes to a great degree the demands on 
the muscle, especially where, as in young people, we completely neu- 
tralize the error in refraction. Ido not mean to say that the cone is not 
due to irritation and traction, for I am firmly convinced that traction on 
the choroid in the plane of its extent, and pressure on its surface, are the 
Principal if not the only causes of the cone. But what Ido mean is 
that this traction takes place from extension at the posterior pole of the 
eye, not by the contraction of the ciliary muscle at the anterior parts. 
It has never been demonstrated in the slightest degree that the ciliary 
muscle exerts the least traction on the posterior parts of the choroid, 
fodeed, the little experimental evidence which we have is directly 
°Pposed to such a supposition, as is indeed all the clinical evidence. 
There is, moreover, to say the least, a strong doubt whether the muscle 
exerts any traction even on the anterior portions of the choroid, and some 
of those who have been hitherto the most enthusiastic supporters of the 
theory of the meridional portion of the muscle being a direct “tensor cho- 
voidese,” seem to have modified, if not completely changed, theß views. 
Thus I wan off (42) latterly, after describing the anatomy of the meridional 
portion, and its mode of insertion into the L. suprachoroidea, says: 
u Now, with such a disposition of the meridional portion of the muscle 
vvith the L. suprachoroidea, and with such a structure of this lattei, is 
self-evident that the deep layers of the choroid (choriocapillaiis and mid- 
dle choroid) cannot be essentially stretched. Consequently, the entiie 
effect of the contraction of the ciliary muscle will limit itse to an 
extension of the ciliary body, which, as is known, is in the closest con- 
nection with the zonula of Zinn, while in the choroid itself, at the most, 
fo*ere will be only an extension of the L. suprachoroidea. I his is per- 
fectly evident when we bear in mind that that part of the choioi w nch 
situated behind the ora serrota has no direct connection vvhatevei with 
foie zonula.” Nevertheless, that enforced and maintained contraction 
°f the ciliary muscle should produce that nervous exhaustion and nnta- 
foon, with altered nutrition, which always occurs in the case of an over- 
tasked muscle, is most natural. That this irritation should extend to 
foe surrounding parts, causing increased vascularity, and, what is more, 
secretion, by which the intraocular pressure is augmented, 
pight, I think, occur ‘to some degree, in spite, too, of the assertion of 
Teber that‘the vascular supply to the ciliary muscle is so arranged that 
foie circulation is not impeded by its contraction, join what has 
afoeady been stated, I am inclined to believe that this increased intra- 
°eular pressure, which is so potent a factor in the production of myopia, 
°ccurs much more frequently from other causes, especially from faulty 
convergence, than from the simple action of the ciliary muscle. This 
*eads me to believe, although X appreciate most highly the labors of 936 
LOEING, 
Dobrowolsky,1 that spasm of the ciliary muscle, so well recognized and 
described by the elder writers, has been somewhat exaggerated by the 
younger school both as to its frequency and the amount of influence d 
exerts in the production of myopia. 
I have not the time to go into an extended discussion of this question, 
which it surely deserves, and must therefore content myself by pointing 
out the fact that it, would appear that two important conditions have 
been ignored in the works of Dobrowolsky and bis followers, Scldess-Ge- 
museus(43) and Dr. Derby(44) of Boston. The first is the physiological 
effect of atropine, which is to reduce the refraction to an amount which, 
according to Donders(4s), would be expressed by + A, or even 4- A- The 
ordinary emmetropic eye then under atropine would be a hypermetropic 
eye of A* Are we to assume, then, as Dobrowolsky does, that a de- 
crease of refraction which amounts to only Am TA, or even ].s 
the result of spasm, and not the action of the drug, when the physiology 
cal action is often equal to six times the amount; and especially are we 
to assume this when solid atropine has been used three or four times a 
day for three or four vrneks, or even months? 
Dobrowolsky(46) gives a table of 105 cases of myopia. In 69 of these 
there was a decrease after the use of atropine—that is, in seventy per cent- 
But of these cases, when we make an allowance for the physiological 
effect, only thirty remain. Of these thirty, after this allowance, six 
show a decrease of or less, twelve of TA or less, seven of s'n, three 
of and two of T's or less. So that there are only five cases in the 
entire number which show a moderate degree of spasm, and only two of 
these a high degree; and in all these five cases the myopia is of an exces- 
sive grade, varying between A and A* Now, these high degrees of 
myopia are just the conditions in which we always expect, whether there 
be any insufficiency or not, an apparent increase in the refraction, caused 
by an excessive muscular strain at convergence. This is invariably a<f' 
companied with a displacement of the relative accommodation inward, 
and the slight temporary decrease in the refraction caused by the use of 
strong atropine invariably returns as soon as the atropine is left on, 
unless the strain on the convergence is relieved by suitable means, Ex- 
ceedingly interesting in this connection are some of the results published 
by the earlier writers—Bonnet, Cuvier, Philips, and Jules Guerin—bid 
particularly the case related by Giraud Teulon(47), of extreme myopm? 
in which tenotomy of the external rectus suddenly diminished the 
myopia by A, or from to Had this amount of decrease in refraction 
been brought to light by the use of atropine, it would certainly have 
been put down by these observers as due to spasm; and it just as cer- 
tainly would have returned the moment the atropine had been discon- 
tinued, unless the strain on the intend had been removed. The analogne 
of this, the sudden development of manifest H, which had been pre- 
viously latent, after tenotomy, is too common an occurrence to need an} 
comment whatever. It strikes me, therefore, that want of attention t° 
these two points, namely, the physiological action of atropine and the 
associated action of the recti intend on the accommodation, has led these 
observers into a false estimate of the frequency of spasm, and its pre' 
dominating influence in the production of myopia. Certainly rny even 
1 I cannot agree with a recent writer, who says: “To Professor Schiess belongs 
credit of utilizing the researches of Dobrowolsky for ophthalmic practice.” 
there is of merit in this matter belongs, both theoretically and practically, entire y 
Dobrowolsky. PROGRESSIVE MYOPIA AND CONUS. 
937 
experience does not coincide with that of these observers, and I fail to 
find a frequent or great diminution, even in myopic eyes of young 
children, after the use of atropine. This I was glad to see had been the 
experience of Donders(4B), as expressed by him at the last International 
Congress. 
Up to this point we have been occupied with a consideration of the 
action of the ciliary muscle as a whole, but a theory has been started 
that contraction of the muscle can take place in the direction of one 
alone, or in different meridians in different degrees at the same 
time. Thus, according to Dobrowolsky(49), a complete interchange of 
kind and degree of astigmatism, as well as change of direction in the 
axis, may result from these meridional contractions, so that an eye which 
Was originally hypermetropic in one meridian may by a counterbalancing 
contraction of the muscle become an emmetropic eye, or an emmetropic 
eye an astigmatic eye, with M in one meridian alone, or M in all me- 
ridians, and more pronounced in one than the rest; and so on with a 
change in all the varieties of astigmatism which could be produced 
through positive accommodation. It is claimed that this is a fertile 
source of myopia. 
That a slight change in a meridian, whether of refraction or direction, 
should take place, would not appear strange; for there is nothing abso- 
lutely stable in the human body. This would, moreover, be in accord- 
ance with what has been supposed possible by many and corroborated in 
some degree by certain investigations made by Woinow(so). But any 
such remarkable changes as are pointed out by Dobrowolsky, either in 
kind or degree, I have never met with myself, nor do I know of any 
sufficient corroboration of them by others. Bor this reason I do not 
feel warranted in expressing an opinion in regard to them certainly 
not one which would imply a belief as to their active agency in produc- 
ing myopia. 
These views of Dobrowolsky were followed by those of Di. Thom- 
son(sl), of Philadelphia, based on the old theory of the antagonistic 
action of the two portions of the ciliary muscle. Accoiding to these 
views, not positive accommodation alone, as with Dobrowolsky, but 
oven negative accommodation took an active part, through the contiac- 
tiou of the radial fibres of the ciliary muscle as opposed to the circular 
kbres. Thus a defined traction in a meridional direction was brought 
f° bear on the choroid, which would naturally exert its influence at a 
corresponding point at its attachment at the circumference of tic disk. 
This would produce the cone, which would then lie in the plane and 
direction of this traction. 
I can only say in regard to this that our present knowledge of the 
Action of the ciliary muscle does not support this conclusion. lor not- 
withstanding the many attempts to prove the fact of negative accommo- 
dation, ever since the discovery of the ciliary muscle, not the slightest 
Uace of its existence has ever been demonstrated; while on the other 
kand the fact of its non-existence has been, it would seem to me, incon- 
testably shown. Until, then, the existence of negative accommodation 
kas been proved, it would be a waste of time to speculate on what would 
ke its effect on myopia, or rather what its effect is. We have no right 
to assume both the cause and effect too. Dot admitting the existence of 
negative accommodation to the fullest degree, oven to the extent that it 
Bdrpasses the positive, many facts would have to be explained before its 
offect on the cone could be admitted. Fiist, vhy is it that we see the 938 
LORING, 
highest degrees of myopia with immense cones, and either not a trace of 
astigmatism, or, if present, of such a very low degree as to preclude the 
idea that the cone is the result of the astigmatism? Secondly, why is it 
that we see such very high degrees of simple myopic astigmatism without 
a vestige of a cone? Thus in the past few months I have seen the follow- 
ing cases where there was no trace of a crescent: one case of £ c., two of 
c., one of 4 c., two of -|-c., one of T'¥ c., three of Fr c., and four of c.; 
all simple, myopic astigmatism. Thornson(s2) himself has reported some 
cases of excessive asymmetry of the cornea, in which, to use his own 
words, “it is worthy of remark that in this last case, with such high 
degree of myopia and the use for years of glasses so unsuited, there wa9 
not the slightest appearance of the crescent at the optic disk.” Again, 
it would have to be shown why it is that the cone sometimes runs 1° 
the same direction as the meridian of greatest curvature, and sometimes 
in that of the least, or again in neither. Then, too, if traction in one me- 
ridian had anything to do with the direction of the cone, why is it that 
it is limited so often to the outside of the nerve, and does not extend 
equally in the same direction on the opposite side? since it can hardly 
he assumed that these meridional contractions take place only in one-half 
of the ciliary muscle, and this, in the vast majority of the cases, the 
outer half. 
We should have also to explain why it is that in sections of myop’c 
eyes we find the choroidal pigment layer drawn away from the outer 
edge of the nerve and over the inner edge. In regard to the appearances 
of traction upon the vessels, and other details of the fundus as seen with 
the ophthalmoscope in astigmatism, I would say that this, as far as mY 
experience goes, corresponds to the distortion produced by the optica* 
defect of the refracting media, which causes the line of traction to appeal 
to be always in the meridian of greatest curvature. 
This brings me to the close of my remarks, from which I would uJ 
keeping with the condensed character of my paper make the following 
brief conclusions:— 
I. From the fact that there is so large a percentage of children who ar<? 
myopic, but whose parents are not near-sighted, while the myopia in' 
creases directly with the amount of increased tension of the eyes, and 
from the fact that an interchange of refraction may occur, whereby an eye 
which is not congenitally myopic may become so in spite of hereditary 
tendency, it would seem to follow that hereditary predisposition, though 
undoubtedly a potent cause, is not only not the sole cause, but is not 
even the predominating cause of myopia. 
11. In regard to the second question, as to whether the ciliary muscle 
acting through faulty refraction can produce myopia and the cone, d 
conclude that the action of the ciliary muscle, taken by itself, exerts 
but little influence on the production of myopia, and still less on the 
formation of the cone. 
1 cannot refrain before closing from asking you once more to bear u’ 
mind that the questions submitted were not as to what the causes o 
myopia were, but simply the influence of two fixed and defined factor9 
in its production. The briefest consideration of these two subjects whicu 
I could possibly make, has already led me beyond the limits of the tnue 
allowed, and I fear also of your patience. I have for these reasons been 
compelled to forego saying much which I am conscious that a just ceU' 
sideration of the subject would demand, and to discard much that I ha( 
already written. 939 
PROGRESSIVE MYOPIA AND CONUS. 
Bibliography. 
Lucas, P. Traite philosophique et pbysiologique. Tome i. p. 891, 1841. 
(2) Punari. Annales d’Oculistique.' Tome x. p. 145. 
(3) Piorry. Heredite dans les Maladies, p. 120. 
(4) Portal. Consideration sur les Maladies de Famille. 
(5) Stellwag von Carion. On the Eye. American Transl., 1813, p. 354, p. 103. 
(6) Jaeger. Einstellungen des diopt. Apparates, u.s. w., 1861. S. 11. 
(I) Bonders. Accommodation and Refraction of the Eye, 1864, p. 350. 
(8) Cohn, H. Untersuchungen der Augen von 10,060 Schulkindern, u. s, w., 
Leipzig, 1861. S. 63. 
(9) Ibid., p. 129. 
UO) Erismann, F. Ein Beit rag zur Entwickelungs-Geschichte der Myopie. 
Grade’s Archiv, Band xvii. Ab. 1. S. 1. 
Ul) Stellwag. Die Accommodationsfehler des Auges, 1855. Wien Sitzung- 
berichte der mathem-naturw. Classe der kais. Akademie der Wissen- 
schaften, Bd. xvi. S. 225. 
02) Jaeger. Einstellungen. S. 21. 
(1-3) Ibid., 31. 
(14) Donders, Accommodation and Refraction, p. 354. 
(15) Grsefe. Archiv fiir Ophth., 1854, B. 1. S. 394, 
(16) Donders. Accommodation and Refraction, p. 443. 
(II) Cohn, H. Untersuchungen. S. 61. 
(18) Conrad, Max. Die Refraction von 3036 Augen von Schulkindern mit 
Rucksicht auf den Uebergang der Hypermetropic in Myopie, Inaugural- 
Dissertation. S. 38. 
(19) Jaeger. Einstellungen, S- 31. 
(20) Iwanoff. Graefe’s Archiv, B. xv. Ab. 8. S. 284. 
(21) Donders. Accommodation and Refraction, p. 384, 
(22) Ibid., p. 349. 
Jaeger. Einstellungen. S. 104. 
(24) Stellwag, On the Eye. American Transl., 4th Edition, p, 123. 
(25) Ware, J. C,, F.R.S. Observations Relative to the Near and Distant 
Sight of different Persons. Phil. Trans. Royal Soc., 1813. 
Szokalski. Prager Vierteljahrschrift fiir pract. Heilkunde, 1848. 
(21) Schiirmayer, J, H. Handbuch der Medicin Policei. S. 61, 1856. 
(28) Jaeger. Einstellungen, S. 20. 
(29) Ruete. Untersuchungen iiber die Augenkrankheiten bei Schulkindern. 
Zeitschrift fiir Medicin, Chirurgie, u.s. w. Neue lolge B. v. Heft 
4. Leipzig, 1866. 
Erismann. Graefe’s Archiv, Band xvii. Ab. 1. S. 13. 
Conrad, Max. Inaugural-Dissertation, Konisberg. S. 16. 
Donders. Accommodation and Refraction, p. 341. 
Cheatham. Boston Medical and Surgical Journal, May 21, 1815, p. 633. 
(34) Williams, D. 8., Ibid. 
(35) Promt and Mathewson, Ibid. 
Donders. Accommodation and Refraction, p. 394. 
(81) Jaeger. Einstellungen. S. 26. 
(88) Stellwag. On the Eye, 4th Edition, American Jiansl., p. <O4. 
(°9) Young, Thos. Mechanism of the Eye. Phil. Irans., 1801. 940 
LORING, 
(40) Helmholtz. Karsten’s Encyclopaedia der Physik, 1856. 
(41) Dobrowolsky. Beitriige zur Lehre von den Anomalien der Refraction? 
U.s. w. Zehender klin. Monatsblatter. Ausserordentliches Beilago' 
heft, 1868. 
(42) I wan off, Grsefe, and Samisch. Handbnch der Augenheilkunde, Band *• 
Theil. l. S. 277. 
(43) Schiess-Gemuseus. Beitrage zur Therapie der Myopie, Basel, 1872. 
(44) Derby, H. Trans. American Ophth. Soc., 1874, p. 138. 
(45) Bonders. Accommodation and Refraction, pp. 174, 600. 
(46) Dobrowolsky. Zehender ausserordentliches Beilageheft, 1868. S. 37* 
(47) Teolon, Giraud. Ophth. Hosp, Reports, vol. v. p. 381. 
(48) Bonders. Report of fourth International Congress, London, 1872, p. 
(49) Dobrowolsky. Gnefe’s Archiv, xiv. Ab. 3. S. 50. 
(50) Woinow. Graefe’s Archiv, xv. Ab. 2. S. 167. 
(51) Thomson, Wm, Trans. American Ophth. Soc., 1874, p. 132. 
(52) Thomson, Wm. Trans. American Ophth. Soc., 1875, p. 310. 
Discussion on Dr. Loring’s Paper. 
After the reading of the preceding paper, Dr. J. Green, of St. Louis, said 
As bearing on the question of the influence of hereditary transmission, we 
remember that we scarcely ever see myopic children whose parents and grand- 
parents have been equally subjected to the general exciting causes of myoplJ>' 
Taking, therefore, into account this absence of exciting causes in the case of 
ancestors, it will not do to assume the absence of hereditary predisposition 
myopia even where there has been no declared myopia in parents and grand- 
parents. Again, in all our published statistics there is great imperfection a 9 
regards the recognition of astigmatism, and yet among the causes which pi’0' 
duce indistinctness of vision, and thus favor the development of myopia, ast'g' 
matism certainly holds an important place. The statistics are thus of lesS 
value than many suppose, in clearing up this part of the subject. It is a veiy 
significant fact that in such cases of myopia as give the patient trouble enough 
to lead him to consult an oculist, we find astigmatism oftener present tha° 
absent; hence, in investigating the causes of myopia, we must make m 0 
careful studies of the refraction, not merely with reference to myopia aJIC 
hypermetropia, but also with reference to astigmatism. , 
Dr. W. Thomson, of Philadelphia, said:—l think that Dr. Green has call 
attention to an important fact in alluding to the large number of cases of astig 
matism which complicate myopia. That myopia is very often progressive, ” 
know, but I think from observation that cases of myopia, pure and simpieJ 
are hard to find. High grades of myopia are, as a rule, characterized v 
astigmatism, and therefore we ought to consider whether most cases of Pl 
pressive myopia have not commenced as slight cases of astigmatism. D . 
accept the conclusions of the paper, the question of progressive myopia wO,l. 
be hopeless, and we would have nothing to do but to look on and see peOP 
growing worse day by day. If it is conceded that astigmatism is often *• 
efficient cause of myopia, we have then a remedy in cylindrical glasses, 
think that astigmatism is one of the active causes of progressive myopia. 
Dr. Loring said:—l would call attention to the fact that astigmatism 
not mentioned in the question for discussion, but I admit that it has someth 
to do with myopia. Dr. Thomson takes a gloomy view of the subject, 
believe that, if we go on as in Germany, the time will come when myopic 
fraction will predominate. In keeping children in school twelve hours a ( 
poring over books, a great hygienic principle is overlooked, and, as long 941 
this is done, so long will there be myopia, I cannot agree that the time will 
eyer come when myopia will be prevented by the use of cylindrical glasses. 
Dr. 11. W. Williams, of Boston, said :—Dr. Loring says justly that myopic 
Astigmatism is a form of myopia. I think it is conceded that hypermetropia 
aild astigmatism are hereditary. I know several instances in which persons 
are myopic in one eye, and emmetropic or hypermetropic in the other, and I 
?r°uld ask if there is a hereditary predisposition to myopia in one eye, and not 
111 the other? And I have seen such cases, in which at a later period the 
hiyopia has increased, and in which the hypermetropic or emmetropic eye has 
become myopic. lam satisfied that myopia is largely due to artificial causes. 
The President, Mr. R. Brudenell Carter, of London, said :—I remember 
case of a young lady who was brought to me with a low degree of hyper- 
ftJetropia in one eye, and a high degree in the other. In the case of her father 
aild mother both eyes were hypermetropic. Ido not believe that statistics will 
us to arrive with certainty at any conclusion upon this subject. In look- 
back I can recall a few cases of myopia which were the result of accident, 
remember at least one case in which this condition was produced by a blow. 
t Dr. Thomson said:—With regard to Dr.Boring’s second conclusion, I think 
the whole question resolves itself into whether or not the ciliary muscle is 
a single or a double muscle, and that new light is thrown on the subject 
’A an appeal to clinical observation, there is nothing to do but to accept this 
inclusion. lam convinced that the changes in the back part of the eye in 
Myopia have something to do with the existence of astigmatism, and that the 
aPpearances which they assume are largely dependent upon the direction of 
fche principal meridians of the astigmatic eye. If a conus is found in any part, 
there will be found to be a relation between the direction of the conus and that 
the cylindrical glass which gives the highest vision. I believe that I have 
established the fact that in many cases of myopia of high grade, say one-fifth, 
or one-seventh, in which neutralizing spheiical glasses have been 
worn, tho optic nerve is free from clistoition. £ind has no displace- 
but that when astigmatism, even of low grade, is found conjoined with a 
hgh degree of myopia, a conspicuous conus will be found. 
Dr. E. Williams, of Cincinnati, said:—l have seen seveial cases which I 
cite in confirmation of Dr. Thomson’s remarks. I remember the cases of a 
distinguished lawyer and of a merchant, both over fifty years of age, who had 
glasses since they had left school,and in neither of them was conus ound. 
\vhen we find a patient wearing the proper glasses, and seeing perfectly with 
[hem, we rarely find a conus, but when vision, even with the glasses, is more or 
ess indistinct, we may expect to find the conus. 
. Dr. S. D. Risley, of Philadelphia, said :—I think that we rarely see progres- 
Slve myopia with conus without astigmatism, and, on the other hand, that 
?°nus is not confined to myopic eyes, but is a very frequent occurrence in 
hypermetropic eyes with astigmatism. I recall two cases in which conus and 
ha(i appeared while under observation, and were attended by marked 
which was relieved, and further choroidal change arrested by the 
est afforded the ciliary muscle by a carefully adjusted, correcting glass. I 
'ft convinced, from clinical experience, that the ciliary muse e as muc i o o 
Dtp progressive myopia and the formation of the conus. . 
?r. Thomson said:_l know of a number of cases of asthenopia from msuf- 
h'heney of the internal recti, which bear upon this question. In one case, in 
the asthenopia had existed over a period of thirty years, and had caused 
distress, and in which the asthenopia was perfectly relieved by the use of 
P'oper prismatic glasses, there was absolutely no trace of conus in eithei eye. 
*>r. Torino said.—The use of concave glasses often stops the development 
? conus and the myopia, and, nevertheless, the use of the glasses forces 
more than when they are not employed. All admit that 
®^cave glasses are useful in myopia, yet concave glasses act directly upon the 
Ulary muscle. That the ciliary muscle has two antagonistic functions is, to 
the least, extremely improbable. 
PROGRESSIVE MYOPIA AND CONUS. 942 
ON THE RELATIONS BETWEEN CORNEAL DISEASES AND 
REFRACTIVE LESIONS OF THE EYE. 
BY 
GEOEGE T. STEVENS, M.D., 
OF ALBANY, N. Y. 
Of the various structures of the human body, few have been subjected 
to such thorough, critical, and we may add profitable, examinations BJ 
respect to the histology and pathology of their tissues, as has the cornea* 
The names of many of the most learned and illustrious investigators ai’e 
inseparably connected with this small structure, and the extent and vala? 
of their researches indicate its importance. Yet it must be conceded 
that of the advantages derived from the histological and pathologiea1 
studies of this part, comparatively few have reverted to the structure 
itself, and candid observers must agree that in the etiology of corneal 
diseases the advance has not been in proportion to the added knowledg6 
of its structure and pathology. 
A review of the history of the etiology of corneal diseases would sho*P 
that, since writers of half a century ago, after allowing for the agency p* 
mechanical and chemical injuries and the pressure incident to certap1 
forms of conjunctival disease, united in ascribing the cause of corneit13 
to scrofula and arthritis, few important advances have been made lIJ 
determining the causation of these diseases. To the genius of Mr. Hutch- 
inson we owe the discovery that in a clearly defined class of cases of cor- 
neal disease, the cause may be found in the diathesis peculiar to 
syphilis, and that if we would best meet the indications for treatment 111 
these cases we must directly attack the inherited taint. But the prop°r' 
tion of such cases is not large, and there remain after excluding thus® 
which arise from mechanical pressure, injuries, chemical irritations, 
a few other exceptional causes, the very large residuum of cases whhh1 
by nearly all authors are regarded as manifestations of struma. 
Of phlyctenulae of the cornea, the form of corneal disease which th 
surgeon most frequently encounters, a learned French writer of receu 
times1 says that the pustules are the first and the most frequent manilesta- 
tion of scrofula; they are, he says, benign scrofulous exudations. Althoug1 
this view is not fully accepted by some modern writers, it meets with hu . 
the mildest opposition, and the doctrine that the prevailing cause 0 
corneal diseases and especially of phlyctenulas is struma, is, I believe, 
one generally accepted. The truth is that the condition called struma 1 
far more frequently developed by corneal diseases than are corneal 
developed by struma. One of the most positive evidences of the exl& 
ence of struma, is supposed to be found in the presence of enlarged eer 
vical glands, but the enlargement of these glands does not usually prece 
the corneal disease, but is its result. 
The fact, well known to ophthalmic surgeons, that patients who ha 
been cured of corneal diseases are quite liable to return after a few mom 1 ’ 
1 Bazin, Lgqods sur la Scrofule. 943 
CORNEAL DISEASES AND REFRACTIVE LESIONS. 
°.r even weeks, with renewed attacks of the disease, showing conclu- 
sively an inherent tendency to such troubles, led me a year ago to seek 
*°r the cause of the tendency. The excessive nervous irritability, photo- 
phobia, and muscular spasm, and the general failure of nutrition in these 
|;ases, induced me to regard corneal diseases, especially of the phyctenular 
°rm, as a manifestation of functional nervous derangement. The fact 
the easy cure and the frequent recurrence of the diseases strengthened 
this opinion, and as I had at that time been led to the belief that many 
functional nervous diseases owed their origin to anomalous refraction of 
eyes, I turned to the eyes themselves to seek for the cause of irrita- 
tion. A few careful examinations satisfied me that a more extended 
Search should be made in this direction, but the difficulties encountered 
fo ascertaining the refractive condition of the eyes of patients suffering 
*r°m corneitis, especially from phlyctenular corneitis, are great; the in- 
folerance of light, the youth of the patients (for phlyctenular corneal 
troubles are most frequently found in children from two to eight years of 
a.ge), and their general irritability, all contribute to render such examina- 
tions tedious to both patient and surgeon. To these difficulties I attribute 
the fact that the well-known maxim among ophthalmic surgeons, to test 
the refraction of all diseased eyes, has been so far disregarded ; for the 
Practitioner whose time is fully occupied by the usual duties of his pro- 
fession, will find the attempt to examine a large number of these patients 
lQ this respect a severe tax upon his time and strength. 
I cannot better illustrate the result of my search in this direction 
than by relating the history of the following case. The first part of the 
history well illustrates the oft-repeated experience of every ophthalmic 
BUrgeon, while the second part will illustrate my own experience in 
Beveral cases since my attention has been specially directed to this subject. 
L. a bright boy seven years of age, was, about two years ago, brought to 
suffering from phlyctenular ulcers of both eyes. He had, previous to the 
® trouble, enjoyed excellent health, had passed through the usual expeiience 
of childhood in respect to infantile diseases with safety and ease, and was 
legarded as a perfectly healthy and robust child. I here was no histoiy of 
uphills or of scrofula in the family of either father or mother, both of whom 
"'ere perfectly healthy people. Treatment for a few days by means of ati opine 
aild stimulants applied to the mucous surface of the eyelids, sufficed to effect 
a speedy cure of the ulcers, and the boy remained well for about three months, 
;vben he passed through a similar experience which was repeated a thud and 
a f°urth time within a little more than a year. At the close of the second 
attack, I observed that the cervical glands were swollen as they had not been 
deviously and with each attack there was more general irritability and more 
evfoence*of defective nutrition. During an attack about a year since, his 
fo°thei- called ray attention to a defect in her own eyes, which, on examination, 
found to consist in hypermetropic astigmatism of Ac 
to test the refraction of the boy’s eyes. I found hy per metro pia A, Wlth* 
°ut astigmatism, and advised that he be required to wear +42 glasses when 
Staged in studies or in playing with toys. My advice was accepted, and the 
Vs eyes have since remained well, and with the correction of the refractive 
the so-called strumous symptoms disappeared. 
■nThe following case, which has been reported in another connection, will 
hstrate the relations existing between this and another form ot mani- 
estation of nervous trouble. 
i. F. A. R. of Minnesota, consulted me in September last in regard to his 
lttfo daughter’s eyes. She was a bright girl of ten years, with a defect in her 944 
STEVENS, 
speech, and was evidently suffering from chorea. On account of her nervous 
condition she had been kept out of school for more than a year. The troun 
for which I was consulted was the presence of a number of small ulcers at 11 
border of the cornea. On testing the refraction, I found astigmatism requll 
ing for its correction a -f- 36 cylinder. Glasses were procured, and after bn 
treatment for the ulcers, resulting in their cure, the father returned with tn 
child to his western home. In the latter part of March, of this year, he again 
presented the child for treatment, she being again subject to corneal ulceis- 
I learned that from the time of leaving Albany the child’s health had greatly 
improved, and her nervous symptoms had disappeared. A month or two pIG" 
vious to the last visit, however, her glasses were broken, and she was withou 
them for some time. The nervous symptoms began to return, and the cornel® 
were again affected with ulcers. 
In looking over the records of one hundred and fifty cases of corneal 
disease in which the refraction has been examined with as much accu- 
racy as the difficulties necessarily encountered would permit, I find tha 
in 80 per cent, there have been serious refractive lesions. Even in tw° 
cases which were typical of the physical conformation so clearly de- 
scribed by Mr, Hutchinson as characterizing the offspring of syphilitic 
parents, a high degree of hypermetropia was. found after the infiltrate 
corneas had become sufficiently transparent to allow of a determination 
of the refractive condition, and it is interesting to remember thatch 
flattened facial features described by Mr. Hutchinson are those recognize 
by ophthalmologists, and so well described by Prof. Bonders, as indica- 
tive of hypermetropia. In these cases, as in all others in which the re- 
fraction has been determined, after the cornea has been affected, alio"' 
ance must of course be made for changes in the form of the cornea whic * 
may have resulted from disease, but as in each of the cases alluded to n 
high degree of hypermetropia was found (T’g and T’?) the defect coul 
hardly be ascribed to this cause. 
In my efforts to determine the refraction in these cases, I have oft®11 
been obliged to be satisfied with an examination of the unaffected eye 
by means of test letters, or by the ophthalmoscope alone. In Severn 
instances the examinations have been made after recovery from tn 
disease. Among the refractive errors, hypermetropia seems to ram* 
first as a cause of corneal affections; second, astigmatism; and third? 
unequal degrees of myopia. A larger number of cases than I have ex> 
amined would be necessary to determine the relative frequency of these 
conditions. Simple myopia of equal degrees in the two eyes, I have 
not found except in young children in whose cases the refraction kaS 
been determined by the ophthalmoscope. In these cases, I suspect an 
astigmatism not recognized by this means of examination. # 
It is important to notice two conditions which are often associate 
with corneal diseases: First, the herpetic eruption which is so common 
in phlyctenular corneitis; and second, an inflamed condition of tn 
free border of the The herpetic eruption which appears abon 
the lips, cheeks, and nose, in cases of phlyctenular corneal troubles, J 
conceded to be the result of irritation of branches of the fifth nerve- 
That it is due to the reflex irritation from the ciliary nerves, I think 1 
reasonable to suppose, for I have often seen these herpetic eruption 
about the cheeks, nose, and lips, disappear quickly after correcting tn 
refraction of the eye, and with no further treatment. The blephari i 
would also in most instances seem to be one of the manifestations o 
reflex irritation from the same cause, as I have long observed ; and tn CORNEAL DISEASES AND REFRACTIVE LESIONS. 
945 
swelling of the lids, which is of itself sometimes the immediate cause of 
corneal lesions, is, I believe, one of the various results of the peripheric 
irritation beginning in the ciliary body. 
That a reflex nervous irritation, like that arising from the strain upon 
the ciliary muscle in erroneous refraction, can interfere in the nutrition of 
the cornea, there can be no doubt; and, if we watch the course of a cor- 
neal phlyctenula, we shall see that nutrition is disturbed first by irrita- 
tion of the vaso-motor nerves of the conjunctiva; for here we observe, 
before the appearance of any efflorescence of the cornea can be discovered, 
the fasciculus of red vessels, and indeed, if promptly met by appropriate 
treatment, this can usually be made to disappear before the herpetic pus- 
tule is developed at all. 
May it not be a mistake to regard the herpetic pustule as the centre 
of irritation around which the vascular injection of the conjunctiva 
forms an objective expression? Were this the case, would not the pus- 
tule appear first, whereas, frequently, it is entirely aborted? Is it not 
more probable that the condition of the vessels in this congested fasci- 
culus, is such as to clog the passages through which nutritive material 
should pass to supply certain portions of the cornea, and that the por- 
tion in which nutrition is most defective, suffers first from this inter- 
ference ? SECTION ON OTOLOGY 
PRESIDENT OF THE SECTION. 
CLARENCE J. BLAKE, M.D., 
OF BOSTON. 
ALBERT H. BUCK, M.D., 
VICE-PRESIDENT. 
OF NEWYORK. 
SECRETARY. 
H. N. SPENCER, M.D., 
OF ST. LOUIS. 
the importance of treatment of aural diseases in 
THEIR EARLY STAGES, ESPECIALLY WHEN ARISING 
from the exanthemata. 
BY 
ALBERT H. BUCK, M.D., 
OF NEWYORK. 
The object of selecting the subject of this paper for discussion by a 
body of men interested in otology, must be not to draw out the different 
opinions of otologists on the subject (tor there can certainly be but one 
opinion), but to have the attention of the profession at large directed to 
the importance of early treatment m aural diseases. The pleading of a 
sino-le individual would perhaps fall to carry conviction to the minds ot 
manv members of the profession, while the same statements, made by 
the same individual acting as the mouth-piece of such a body of skilled 
men as is here gathered together, may be likely to receive the thought- 
ful consideration which the subject demands. . , 
In discussing this subject, I shall take into consideration chieffy the 
acute purulent affections of the middle ear, as it is in these that judicious 
treatment proves so beneficial, and the want of it at times so disastrous. 
In catarrhal affections it might also he shown that treatment in the 
early stages of the trouble was in general productive of very satisfactory 
and marked results, while in the later stages it rarely proved ot any 
benefit whatever. It will be sufficient, however, for my present pur- 
pose, to make use only of those acute affections ot the middle ear which 
naturally end in the formation of pus, and which very often become 
The question of the frequency of chronic otorrhoea, is a difficult one to 
determine with any degree of accuracy. Owing in part to the prevailing 
Popular belief that it is dangerous to arrest a discharge from the ear, and 
in part to the answer which very many physicians give to the parents of 948 
buck, 
such patients—•“ your child will outgrow it”—hundreds upon hundreds 
of individuals never present themselves for treatment either in private 
(aural) practice or in the clinics of our public institutions. Hence we 
have no means of finding out accurately how large a percentage of the 
population of any given community is afflicted with this morbid condition* 
¥e know, however, that these cases constitute from twenty to thirty 
per cent, of all cases of ear disease that come under the aurist’s care, either 
in hospital or in private practice. We also know that among our ac- 
quaintances a certain number are troubled, and have been perhaps tor 
years, with a discharge from one or both ears. Again, if we inquire hoW 
the disease originated, we find that, in a large proportion of the cases, A 
is referred back to an attack of scarlet fever, or measles, or nasal catarrh. 
In this way we get hold of two important facts; first, that chronic dis- 
charge from the e.ar is a common disease; and, second, that taking cold, 
and the exanthematous diseases, are the chief sources from which ff 
originates. Two questions here present themselves: (1) Is a chronic dis- 
charge from the ear a sufficiently serious affection for either the physi- 
cian or the patient to give much thought to it? and (2), admitting the 
serious nature of the disease, can anything be done to diminish the pre- 
valence of such chronic otorrhoeas ? 
Satisfactory answers to these two questions will furnish the best eluci- 
dation of the title which stands at the head of this paper. 
I. Is Chronic Discharge from the Ear a serious Affection ?—I answer 
unhesitatingly, yes. In the first place, it is annoying to the patient and 
disgusting to those who associate with him. In the next place, it is an 
indication of the existence of a process which may at any time seriously 
threaten the patient’s life. Here, again, statistical proof of the correct- 
ness of my statement is not easy to furnish. Medical literature contain® 
numerous accounts of cases of chronic otorrhoea that have terminated 
fatally. Almost every practitioner, too, has met with one or even 
several such cases in the course of his practice. Many also have seen 
such cases terminate fatally under the form of meningitis, and have never 
once thought of the part played in the disease by the chronic otorrhoea. 
These are well-known facts, and admitted, I think, by all. But hoW 
does an inflammation of the ear pass into the condition of a chronic 
otorrhoea, and how may the latter cause the death of the patient? do 
render this clear, let me narrate to you the probable history of such a 
case. 
A strong, healthy boy, ten years old, is taken ill with scarlet fever. 
The disease runs a moderately severe course, and bids fair to subside 
without any serious after-effects. The tonsils are red and swollen, and 
the entire naso-pharyngeal region is evidently in a markedly inflamed 
condition. While in this state—say in the second or third week of the dis- 
ease—the boy begins to complain of an earache. The first night, warmth 
is applied to the ear, and in this way the boy gets some temporary rebel- 
The next day, however, the pain continues, and the family physician, 
who perhaps by this time has discontinued his daily visits, is consulted 
as to what shall be done to relieve the boy of his earache. Laudanum lb 
prescribed ; a drop or two of it to be instilled into the ear, and a piece 
of cotton-wool saturated with the remedy to be inserted into the outei 
canal. This too, perhaps deadens the pain a little, but still the boy 
passes a second night in suffering, and the third day finds him steadiy 
growing worse. By this time the earache proper has become merged 
a painful and throbbing sensation, involving not only the ear itself, bu EARLY TREATMENT OF AURAL DISEASES. 
949 
also the entire side of the head, and especially the mastoid and occipital 
Regions. The instillation ot laudanum is repeated, and perhaps sweet oil 
added. The third night is passed in miserable suffering, the boy 
obtaining a few snatches of sleep by the aid of opium administered in- 
ternally. On the fourth day—a large blister in the mean time having 
been applied behind the ear, only to add to the boy’s discomfort—a slight 
discharge makes its appearance at the outer orifice. As this discharge 
becomes more copious, the pain subsides, and in the course of a few days 
the patient finds himself able again to eat, sleep, and move about as when 
]e was well. For a year or more afterwards he remains free from serious 
pain in the ear ; the discharge, however, persists, and at times there is a 
sense of discomfort in the ear, perhaps not amounting to actual pain, but 
still sufficient to indicate the existence of a tolerably active inflamma- 
tory process. Finally, the patient some day contracts a bad “ coldthe 
otorrhoea ceases, the pain in the ear and corresponding side of the head 
becomes intense, the parts behind the ear become very painful and 
tender, there is fever—in a word, the inflammation of the tympanum has 
spread to the adjacent bony structures and to the meninges of the brain 
and death soon follows. Death may also follow in other ways but for 
our present purpose it is not necessary to describe other modes of fatal 
termination. 
Now, to appreciate clear!}7 how dangerous a disease an inflammation 
of the middle ear may become, and to understand fully the rationale of 
a successful treatment, it is necessary that one should possess a tolerably 
clear idea of the anatomical relations of the middle ear. These are in 
brief, the following:— 
The middle ear (or tympanum) is a small cavity about five-eighths of 
an inch in length, half an inch in height, and from an eighth to a quarter 
of an inch in breadth. The drum-head, or mernbrana tympani, consti- 
tutes the greater part of one of the sides of this cavity—the outer one— 
but at all other points (with some unimportant exceptions) its walls are 
of bone, covered by an exceedingly thin, vascular mucous membrane. In 
health, this cavity possesses an outlet (the Eustachian tube), but when 
Its lining mucous membrane becomes inflamed, this outlet undoubtedly 
doses, and we then have to deal with an inflammation occurring in a 
closed cavity, the walls of which are everywhere of bone, except at one 
spot, and here the resistance of a strong fibrous membrane must first be 
overcome before the fluid can escape, and before the conditions of a closed 
cavity can be done away with. 
Now let us suppose that inflammation has attacked this cavity. What 
takes place ? The vessels of the mucous membrane become gorged with 
blood, the mucous membrane itself becomes swollen and oedematous, and 
the valve-like tympanic orifice of the Eustachian tube becomes closed to 
all secretions that might otherwise find an escape through this channel. 
This is the first stage of the trouble, and it may last only a few hours, or 
tt may be prolonged for even three or four days. This is the stage in 
Which the application of a few leeches in the neighborhood of the ear 
rnay suffice to check the entire trouble. But, if the inflammation con- 
tinue, stasis will occur in the capillaries and veins, and serum will be 
forced by arterial (cardiac) pressure through the walls of the bloodvessels, 
through the surrounding tissues, and finally into the cavity of the tym- 
panum. After the cavity has become filled with the exudation, each suc- 
ceeding portion of fluid exuded must find room for itself by forcing the 
foembrana tympani outwards. The disease has now reached its second 950 
BUCK, 
stage. The tympanum is filled with serum, in which pus corpuscles are 
rapidly increasing in number, the membrana tympani is bulged out- 
wards and pulsates, capillary and venous stasis is general, and great pres- 
sure is being exerted upon all the soft parts contained not only within 
the tympanum proper, but also within the communicating system of 
bony cavities, the antrum and mastoid cells. If now the membrana 
tympani be not abnormally resistant, the pressure will soon cause a 
thinning, and eventually a rupture, of the membrane at some particular 
spot. The pressure, which is the chief source of the pain, then ceases, 
the exuded fluid becomes more decidedly purulent in character, and 
escapes through the perforation, and the parts in due time return to a 
natural condition. In a large minority of cases, however, the termina- 
tion is not so favorable. Owing probably to the great resisting power 
of the membrana tympani, the intra-tympanic pressure continues for a 
much longer period—perhaps even for several days—before a perforation 
is finally established. In these cases, it must be remembered that the 
tympanic mucous membrane is also functionally a periosteum. Hence 
the continued pressure is apt to result in superficial death of the under- 
lying bone in one or more places. Hut there are also other points that 
should be remembered : the bloodvessels of the tympanic mucous mem- 
brane communicate freely with those of the adjacent dura mater, which 
is separated from the mucous membrane by only a thin septum of bone, 
and the mastoid veins empty directly into the lateral sinus. 
If all these points be borne in mind—the anatomical and pathological 
conditions, and the impotent or even harmful treatment pursued—should 
any one be surprised at the terrible results that often follow inflamma- 
tion of the ear, or wonder any longer at the large percentage of indi- 
viduals in every community who go through life with an offensive dis- 
charge from this organ ? 
11. This brings us to our second question; Can anything he done to 
diminish the 'prevalence of such Chronic Otorrhoeas?—ln answering this 
question we shall confine ourselves, in accordance with the spirit of our 
subject, to the consideration of those measures which tend to prevent 
the inflammation from reaching what might be termed a third stago, 
one that is characterized by inflammation of neighboring organs, by pro- 
liferation of the soft tissues, and by carious processes in the subjacent 
bone. In a few cases, in the early part of the attack, warm applications 
and leeches are sufficient to prevent the inflammation from reaching the 
higher, second stage. In the majority of cases, however, we are unable 
to prevent this increase, and are consequently brought face to face with 
a middle ear in the condition of inflammation to which I have given the 
name of second stage. This is the time when paracentesis of the mem- 
brana tympani produces such beneficial effects, and the earlier it is per- 
formed, in this stage, the greater its efficacy. In this one slight opera- 
tion, which in itself is neither dangerous nor ver}- painful, lies the power 
to prevent the whole train of disagreeable and dangerous symptoms to 
which I have alluded so fully above. It is not far from the truth to say 
that every fatal case of purulent inflammation of the middle ear must, at 
some time in its course, have passed through a stage in which, by a 
resort to this operation, the progress of the disease might have been 
arrested, and the tendency of its course changed from an unfavorable 
to a favorable one. 
In illustration of the speedy relief from pain which often follows the EAELY TREATMENT OF AURAL DISEASES. 
951 
operation, especially in children, let me narrate briefly the following 
Cllilf’three/earB ®ld> been complaining of earache in the right ear 
had S'e ' ,I>a the, C'y- (For Beveral <’a3'B previous to this, she 
ad been suffering from a marked nasal catarrh.) The pain in the ear was 
Paroxysmal in character, and the child evidently had a high fever, though no 
Measurement of the temperature was made with the thermometer. As ni^ht 
C. te,"’ t P!“n, C“me “T Se™'e’ a”,cl tlle imervals between the paroxysms 
cMlfTwas great^suffedng.611 A^erTaminatio^with^theo^ c:ollsbauti 
>eflected light showed an .edematous and bulging.membrana tympani (pos“e™or 
la t ’ neighboring parts being very red though as yet but little swollen, 
n the most promment portion of the membrane I made an incision scarcely 
mernV m and inyolving simply the different layers of the 
Qembrana tympani. This was almost immediately followed by a watery dis- 
-1 large (without the aid of inflation), which ran down over the child’s 
the end of three or four minutes the child had ceased crvW and in less 
a?an a quarter of an hour she was fast asleep. At first the discharge was very 
oundant, and mainly watery in character, taut it steadily diminished in quan- 
and became thicker, until finally on the fourth day it ceased altogether 
un the tenth day the most careful examination of the ear could not detect any 
race of either the inflammation or the artificial opening. 
It would have served my purpose better, had I been able to offer in 
“lustration a parallel case of acute, purulent inflammation following 
Scarlet fever or measles; but unfortunately I cannot find in my records 
a single such case which came under observation as early as the second 
°r third day after aural symptoms had manifested themselves. The 
forbid process, however, is practically the same in both cases, and the 
)enefit to be obtained by early surgical interference cannot be materially 
ess in cases following scarlet fever than in those following an acute nasal 
catarrh. The tendency to desquamation, and the enfeebled state of health 
°llowing a moderately severe attack of scarlet fever, may, it is true, 
prolong the subsequent subacute stage of the aural inflammation for a 
weeks, but the prospect of ultimate complete restitutio ad integrum, is 
. as certainly secured by timely interference in the one case as it is 
111 the other. JSTo harm can come from perforating the membrane too 
early, but months or even years of annoyance and suffering may be 
upon the patient by resorting to the incision after the mischief 
a® already been done. It then often fails to relieve even the pain. 
111 calling special attention to this operation, I do not wish to be 
uderstood as advocating it as the only means of treatment in such cases ; 
simply choose it because it is the most important one, and because its 
Qnderful efficacy is susceptible of proof, 
j Ibis is perhaps the best place to comment upon the view held by the 
kte Mr. James Hinton, of London, respecting the efficacy of paracentesis 
the membrana tympani in acute affections ot the middle ear. In his 
|°rlc on “The Questions of Aural Surgery” (pp. 130 and 131), I find 
fle following: “Since the real relief of the symptoms depends upon the 
• S(“ape of the matter through the membrane, it would seem an obvious 
•l .rence that the membrane should be, at the earliest possible period, 
Seised. And this is recommended by almost every writer; but expe- 
. le>me of this method has left a doubt upon my mind. In the few cases 
which I have had recourse to it during the acute stage of an inflam- 
iatiou, I have not found the results very satisfactory, and in two in- 952 
BUCK, 
stances in which the inflammation existed on both sides, and I incised 
one membrane only, the progress of recovery seemed retarded rather than 
expedited; I mast, therefore, hold an undetermined position on this 
question.” Such an opinion, coming from one whose authority in oto- 
logical matters is so weighty, is calculated to prevent many from resorting 
to the operation, and that, too, notwithstanding the fact that in another 
part of the same work (p. 188) he says; “But whatever may be the best 
method of treatment in simple, acute catarrh1 of the tympanum, there 
seems to he no doubt that immense evil might be prevented by free 
incisions of the membrane in very many of the cases in which it becomes 
inflamed during the course of the exanthemata.” The example which 
Mr. Hinton cites, in evidence of the doubtful efficacy of paracentesis, 
furnishes at the same time a satisfactory explanation of the reasons why 
the incision failed to afford relief. In the first place, the incision consisted 
of a mere “prick with a cataract knife,” and, in the second place, it was 
not made until the eighth day of the attack, or, in other words, late 
in what I have described as the second stage. Under such circumstances 
it is certainly not to be wondered at that the paracentesis failed to afford 
the desired relief. 
My own experience leads me to recommend the operation unhesi- 
tatingly; in fact, without it, I believe the physician will be able to do 
comparatively little toward preventing those disastrous results to the 
hearing, to the general health, and even to life, of which I have already 
spoken more than once in this paper. 
On looking over my records of cases (in hospital and private practice), 
I find that I have had occasion to perform this operation seventy-six 
times, on fifty-eight persons, for the relief of pain. In each of these 
cases the membrana tympani was either “red and swollen,” or “ bulged 
outwards,” from the pressure of the fluid in the middle ear. In seven 
cases the paracentesis was performed on the 2d day of the disease, i'l 
four on the 3d day, in seven on the 4th day, in five on the sth day, in 
four on the 6th day, in two on the 7th day, in ten on the Bth day, in two 
on the 10th day, in six between the 11th and 15th days, in one on the 
20th day, in two between the 21st and 25th days, in one on the 30th day, 
in three between the 81st and 55th days, and in four at unknown periods* 
In twenty-nine cases, permanent relief from the pain was afforded witbh1 
a few minutes or hours; in six other cases immediate relief was afforded, 
but the pain returned, either the next day or on some subsequent day > 
in eight others, the pain did not subside until the 2d, 3d, or 4th day after 
the incision ; in four others, the operation afforded no appreciable relief 5 
and finally, in eleven instances, the patients did not return to report the 
result of the operation.2 Of the twenty-nine cases in which the opera- 
tion proved quickly successful in relieving the pain, six had reached the 
2d day of the disease, three the 3d, four the 4th, four the sth, two the 
6th, two the 7th, four the Bth, one each the 12th, 14th, and 15th days> 
and one an unknown stage of the disease. In other words, the operation 
1 Mr. Hinton’s “simple, acute catarrh” is nothing more nor less than an acute inflamma- 
tion of the middle ear, going on to the formation of pus, and to the exertion of a pressure 
equally great with that which takes place in the acute inflammation following the exanthe- 
mata. While, perhaps, the ultimate results are not quite as disastrous in the cases whicn 
develop in the course of a simple nasal catarrh as in those which accompany the exanthe- 
matous diseases, there is not a sufficient difference to justify any material difference in th 
course of treatment that should be pursued in the two classes of cases. 
2 These eleven cases all occurred in hospital practice. EARLY TREATMENT OF AURAL DISEASES. 
953 
be sal(' to have been quickly successful in cases chiefly of recent 
'■ ,0n ,the?thher ,haild. °f *0 eighteen cases in which the pain re- 
in ned or m which there was little or no relief from the incision, five 
'ere subsequently relieved by incision of the mastoid integuments, eio-ht 
>i subsequent incision (or incisions) of the drum-head, and two °bv 
eeches. In twenty-five out of the fifty-eight cases, the day (of the dis- 
pof) 011 whleh the discharge ceased was noted ; in the remaining cases 
itber no note was made regarding this point, or the patients did not 
eturn to report their condition In regard to the twenty-five, the facts 
«e as follows: in six eases the discharge ceased on or before the Bth day 
tfj»!j" fTU bet"neel“ ,th.e 9th a?d 15th da in two between 
' J6th and 22d days, in five between the 23d and 40th days and in 
;‘Ve between the 41st and 65th days. As far as the incomplete records 
SO, therefore, in not a single case did there remain a permanent chronic 
utorrhoea with perforated membrana tympani. 
Surely this record justifies me in recommending unhesitatingly the 
operation of paracentesis of the tympanic membrane. I am sorry to 
Say that I have never had the opportunity of testing the value of this 
operation in those very cases in which we have every reason for believing 
.eat it would prove of the.greatest value, namely, in those which occur 
111 the course of the exanthematous diseases, Hinton, however as we 
jJave seen, speaks in strong terms in its favor under these circumstances 
ai)d I believe that all or nearly all the authorities hold the same opinion! 
Having shown how serious are the results which often follow aii 
Un<diecked, or improperly treated, acute inflammation of the middle ear 
having also shown, as far as it is possible to demonstrate such a fact' 
that we are in possession of at least one means of preventing (in the 
§reat majority of cases, if not in all) these disastrous results, what more 
Gau I say to impress upon the profession “ the importance of treatment 
°t aural diseases in their early stages, especially when arising from the 
Exanthemata ?” The opinion expressed by Prof, Edward Clarke,1 of 
Boston, in 1858, and reiterated by Von Troltsch and Hinton—that a 
Physician who treated a case of exanthematous fever without inquiring 
JjVo the condition of the ear, was guilty of great neglect x(or words to 
that effect)—might be uttered with as much appropriateness to-day, I 
Jvould go still further, and say that a general practitioner who is unable 
,° obtain a view of the external auditory canal and membrana tympani 
V means of the speculum and reflected light, is not properly fitted to 
medicine. While it may not be necessary lor him to study 
otology, or to become skilled in aural manipulations, it is very necessary, 
he wish to fulfil his duty toward his patient, that he should be, able 
0 determine by actual examination, whether or not the membrana 
ftipani is being pushed forcibly outwards by the products of inflam- 
mation within the tympanum. If he be able to determine this point, 
a,lh an hour’s schooling will put him in possession ot the necessary 
jEchnical knowledge, I am sure that, where it is indicated, he will not 
V slow in taking successfully the second step, namely, the incision of 
membrana tympani. 
Hedical students are taught very thoroughly how to amputate a leg, 
a,1(l their knowledge of the relations, distribution, etc., ot arteries and 
will be found, at their examination for the degree of Doctor of 
Hdicine, to he quite perfect; but has the new graduate the slightest 
1 American Journal of the Medical Sciences, 1858. 954 
BUCK, 
practical knowledge of bow be should deal with an acute inflammation 
of the ear? Upon the medical schools, then, rests the chief responsi- 
bility for the prevailing indifference and ignorance among practitioners 
regarding these matters, and to the schools, therefore, the profession 
must look for assistance in bringing about a reform. 
In conclusion, let me recapitulate briefly the main points which a con- 
sideration of the subject suggests:— 
I. Chronic otorrhoea is at the present time a very common disease, due, 
in most cases, to the want of proper treatment during the acute stage of 
the affection. 
11. It is by no means a harmless affection. 
111. It may be fairly classed as a preventable disease, at least among 
those who possess a healthy constitution. 
IY. Paracentesis of the membrana tympani, if resorted to during the 
first few days of the acute attack, and if not carried out too timidly, i. e., 
if a free incision be made and not a mere prick, is almost a sure pre- 
ventive of the subsequent, chronic disease. 
Y. The Profession at large, and especially the medical schools, should 
give this subject more earnest thought than they have in the past. 
As some may be interested to ascertain further details regarding the 
cases referred to above, I append in a tabulated form the main points of 
interest in each of the fifty-eight cases, as far at least as my imperfect 
records furnish this information. And here I may say that it is not 
unfair to assume that the great majority of the patients in whom the 
result of the incision was not ascertained, failed to report their condition 
simply because they had been relieved of their sufferings, and did not 
feel the necessity of visiting the hospital again. EARLY TREATMENT OF AURAL DISEASES. 
955 
Tabular View of Fifty-eight Cases 
of Paracentesis of the Membrana Tympani. 
eS . 
g 
d 5 
*0. 
Condition of 
Condi- 
tion of 
r3 .2 £ 
• ci d 
g 2 8 
Age 
Cause. 
niembrana 
Relief from 
Remarks. 
tympani. 
mastoid 
a H 
pain. 
r—i j. 
region. 
p — P<o 
i 
17 
Expo- 
Red and 
Tender 
7 th 
Speedy. 
28th 
2 
21 
sure. 
Not 
bulging. 
Bulging, but 
Normal 
2d 
Immediate. 
Not 
Entirely 
stated. 
3 
32 
“Cold 
CEdematous 
Tender 
6th 
10th 
Paracentesis repeated twice (with 
in the 
and bulging ; 
free from 
or 11th 
equal benefit) in same ear during 
4 
6 
head.” 
Not 
neighboring 
parts red. 
Not 
2d 
pain at end 
of 6 hours. 
Speedy. 
Not 
following two years. 
5 
40 
stated. 
Sitting 
in a 
drau’t 
of air. 
bulging, red. 
Post, half red 
and bulging ; 
small perf. 
in the ant. 
stated. 
Tender 
14th 
Relieved in 
12 hours. 
stated. 
Not 
stated. 
Three leeches also applied at same 
time. 
6 
40 
Not 
inf. quadrant. 
Not 
8th 
Immediate. 
Not 
Subsequent fresh attack. Incision re- 
stated. 
bulging both 
anteriorly 
and 
stated. 
stated. 
peated. Result not stated. 
7 
23 
Not 
stated. 
posteriorly. 
Red, bulging, 
and 
Tender 
12th 
Relieved in 
a few hours. 
Not 
stated. 
8 
25 
Not 
pulsating. 
Not 
11th 
No marked 
26th 
stated. 
swollen. 
stated. 
relief till 4 
days later. 
Not 
stated. 
9 
32 
Caught 
cold. 
Post, half 
swollen and 
red; small 
perf. anteri- 
Not 
stated. 
8th 
Paiu 
gradually 
subsided. 
10 
11 
12 
6 
24 
33 
Not 
stated. 
Caught 
cold. 
Not 
stated. 
orly. 
Red and 
swollen. 
Red and 
swollen. 
Red and 
bulging. 
Not 
stated. 
Not 
stated. 
Not 
stated. 
6th 
About 
2ist 
3d 
Not known. 
Not known. 
Paiu 
gradually 
subsided; 
slight recur- 
Not 
known. 
Not 
known. 
14th 
Patient did not return to the In- 
firmary. 
Patient did not return to the In- 
firmary. 
Leeches also applied at the same time. 
is 
rence. 
30 
“ Run 
over hy 
“ Much in- 
flamed.” 
Not 
stated. 
8th 
Pain ■ 
gradually 
subsided; 
Not 
stated. 
14 
21 
gon.” 
River 
bathing 
Post, half red 
and bulging. 
Not 
stated. 
4th 
no return. 
Only tempo- 
rary relief. 
Not 
stated. 
On the seventh day, two incisions in 
the membrana tympani, one ante- 
riorly, one posteriorly; also leeches. 
On the thirty-seventh day opened a 
lo 
large abscess behind the ear. 
14 
River 
Not 
5th 
Pain soon 
Not 
16 
bathing 
and bulging. 
stated. 
subsided 
entirely. 
stated. 
27 
Not 
Tender 
8th 
Almost 
Not 
17 
47 
stated. 
“Severe 
cold 
bulging. 
Bulging. 
Slight- 
ly 
End of 
1st 
immediate 
relief. 
Within two 
hours. 
stated. 
In the 
course 
Leeches also applied at the same time. 
Two days later the other ear became 
similarly inflamed, and at end of first 
head.” 
tender-. 
days. 
day I incised membrana tympani in 
two places, affording escape, as in 
the case of the first ear, to bloody 
«mrnrn. Leeches also applied. Im- 
mediate relief followed. 
is 
Not 
2d 
At the end 
of a few 
minutes. 
7th 
On the fourth day the other ear became 
Not 
Bulging. 
painful. The following day incised 
stated. 
stated. 
the membrane and afforded immediate 
relief from pain, as in the case of 
the first ear. 
19 
49 
3d or 
4th of 
decided 
paiu; 
21st of 
Very slight 
if any 
relief. 
Relief obtained only by an incision of 
Not 
stated. 
Diffusely red 
background ; 
landmarks 
not 
recognizable. 
Very 
tender. 
stated• 
the mastoid integuments. 
2() 
8 
Not 
Membrane 
Tender 
disease. 
Not 
Not known. 
Not 
Patient did not retnrn to the Infirm- 
ary. 
21 
22 
34 
28 
stated. 
Not 
stated. 
‘‘ Took 
cold.” 
bulging. 
Bulging and 
red. 
CEdematous, 
and bulging 
Not 
stated. 
Not 
stated. 
Not 
stated. 
Not 
stated. 
Not known. 
Almost 
immediate 
relief. 
Not 
known. 
Not 
stated. 
Patient did not return to the Infirm- 
ary. 
posteriorly. 956 
BUCK, 
S'2'6 
p, • 
o ° ® S 
ce 
'A Q5 
Condition of 
Condi- 
.2 -22 S 
No. 
Age 
Cause. 
memhiana 
tympani. 
tiou of 
mastoid 
region. 
£*s< § ® 
ft ° ° * 
Relief from 
pain. 
® rH 
Remarks. 
23 
17 
River 
Red and 
Not 
3d 
Relieved 
18th 
Two days later (fifth day) membrane 
bathing 
bulging. 
stated. 
soon. 
again bulging and parts painful- 
incision repeated. No return of PalU 
afterward. .. 
24 
70 
Not 
Posteriorly 
Not 
About 
Pain miti- 
About 
Permanent relief not obtained until 
stated. 
and super!- 
stated. 
42 d 
gated, but 
60th 
after Incision of mastoid integument* 
orly, l ed and 
not entirely 
on about the fifty-second day. 
bulging. 
relieved. 
25 
3 
Not 
Post, half red 
Not 
7th 
Relieved 
About 
stated. 
and bulging. 
stated. 
soon. 
28th 
Relief obtained permanently only by 
2(5 
25 
Syphi- 
M embrane red 
Tender 
About 
No material 
About 
litic 
and swollen ; 
8th 
relief. 
20th 
an incision of the mastoid integu' 
naso- 
small perf. 
ments on about the fifteenth day- 
phavyn- 
anteriorly. 
gitis. 
27 
29 
Not 
Membrane red 
Tender 
2d 
Gradual 
About 
stated. 
and swollen. 
of acute 
exacer- 
bation 
(about 
53d 
since 
first 
attack). 
subsidence 
with no 
return. 
65th 
28 
19 
Not 
stated. 
Membrane red 
and swollen. 
Not 
stated. 
4th 
Gradual 
subsidence 
with no 
return. 
39th 
29 
57 
Not 
Red and 
Not 
10th 
Immediate 
Not 
stated. 
bulging. 
stated. 
relief, but 
stated. 
pain return- 
ed later, 
though not 
so violently 
SO 
22 
River 
bathing 
Posterior 
half bulging 
and red. 
Not 
stated. 
6th 
Soon after- 
wards. 
12th 
31 
49 
Not 
Post, half 
Not 
5th or 
But little if 
Not 
Poor health (syphilitic). Acute 
cerhation of an otitis med. pur. °g 
stated. 
bulging and 
stated. 
6th of 
any relief. 
stated. 
red ; small 
perf. anteri- 
actual 
two mouths’ standing. Four day 
pain. 
after first incision, which in tn 
orly. 
mean time had healed, pain again P 
came severe. Made a second an 
very free incision through posteri 
half of membrane. During following 
ten days, three more incisions, 0ac 
one affording only temporary reDf ' 
Permanent relief was finally obta1'a 
ed after an incision had been man 
through the mastoid integument’’ 
and, still later, one through the *k 
lining the external auditory canal- 
32 
Not 
Red and 
14th 
Not known. 
5 
Not 
Not 
Patient did not return. 
stated. 
swollen. 
stated. 
stated. 
Two days later pain returned, though 
with less severity than before. j 
33 
40 
Not 
Bed, parched, 
Tender 
3d 
Immediate. 
36th 
stated. 
and slightly 
bulging. 
seventh day of attack made a seco 
incision. Relief from pain lasf 
twelve days, when, the perforate 
having nearly healed, the pain * 
turned. It was not severe, howev ’ 
and may have been due to a furnn , 
in the meatus. After this, rapin a 
“Cold 
Bulging 
complete recovery. 
34 
7 
Not 
2d 
Speedy. 
Not 
in the 
posteriorly. 
stated. 
stated. 
head.” 
•35 
30 
Not 
clear. 
Red and 
swollen. 
No 
tender- 
4th 
Relief in 1 
or 2 hours. 
5th 
ness. 
On fourth day, I made a free incisi03 
36 
4i 
From 
Red and 
No 
3d 
Only slight 
Not 
use ol 
bulging. 
tender- 
(a mere 
relief. 
stated. 
through the posterior half of m0 
post. 
ness. 
prick). 
brana tympani. Entire relief ,a 
nasal 
few hours. 
syringe 
and salt 
water. 
37 
11 
Not 
Red and 
No 
20th 
Very little 
Not 
clear. 
swollen. 
tender- 
ness 
oyer 
mastoid 
but 
some 
over 
occiput. 
until after 
48 hours. 
stated. EARLY TREATMENT OF AURAL DISEASES. 
957 
II h 
i£|i 
No. 
Condition of 
Condi- 
;|ll 
3 g 2 8 
Age 
Cause. 
membrana 
tion of 
Eelief from 
'o |"'S 
Eemarks. 
tympaui. 
mastoid 
region. 
liii 
pain. 
S?l|l 
38 
7 
Not 
Eed and 
No 
3d or 
Not ascer- 
Not 
Patient did not return to the Infirm- 
known. 
swollen. 
tender- 
4th 
tained. 
ascer- 
ary. 
39 
ness. 
14th 
Not ascer- 
tained. 
42 
Not 
Eed and 
No 
Not 
Patient did not return to the Infirm- 
known. 
swollen. 
tender- 
tained. 
ascer- 
ary. 
ness. 
tained. 
40 
24 
Not 
Post, half 
No 
15th 
Speedy 
Not 
known. 
bulging ; 
small perf. 
tender- 
ness. 
relief. 
stated. 
41 
in ant. half. 
Not ascer- 
5 
Not 
Inflamed and 
Not 
Not 
Not 
Patient did not return to the Infirm- 
known. 
swollen. 
stated. 
ascer- 
tained. 
ascer- 
ary. 
tained 
Not ascer- 
tained. 
42 
54 
Blow 
Post, half red 
Tender 
About 
Not 
Patient did not return to the Infirm- 
on pres- 
30th 
tained. 
ascer- 
ary. 
sure. 
Not ascer- 
tained. 
43 
14 
Elver 
Much 
Not 
5th 
Not 
Patient did not return to the Infirm- 
inflamed. 
stated. 
tained. 
ascer- 
ary. 
tained. 
44 
24 
Elver 
Congested 
Not 
About 
Very little 
About 
Second incision on fortieth day, the 
bathing 
and uneven. 
stated. 
25th 
relief until 
2 days later. 
4Sth 
pain having returned. 
45 
47 
“A 
Tender 
8th 
Almost 
Not 
Pain returned next day, and on the 
cold.” 
on pres- 
immediate 
ascer- 
eleventh day, the membrana tyrnpani 
sure. 
relief. 
tained. 
Deing again in a bulging condition, 
I made a second and free incision. 
Leeches applied at same time to mas- 
toid region. Patient did not return to 
the Infirmary. 
anteriorly. 
46 
16 
Not 
Not 
8th 
Pain soon 
14th 
Pain returned on the eleventh day 
stated. 
swollen. 
stated. 
subsided. 
and was relieved by leeches. It re- 
turned again on the thirteenth day 
and was again relieved by leeches! 
Eapid recovery afterwards. 
47 
22 
Not 
5th 
Eelief in a 
In the 
stated. 
swollen. 
stated. 
few hours. 
course 
of a few 
days. 
48 
38 
Caught 
cold. 
Eed and 
bulging, es- 
pecially 
Not 
stated. 
5th 
Eelief in a 
few hours. 
13th 
49 
3 
Acute 
nasal 
catarrh 
posteriorly. 
Eed and 
bulging. 
No 
tender- 
ness. 
2d 
Eelief in a 
few minutes 
4th 
A year later the incision was repeated 
in the same ear, under the same cir- 
cumstances, and with equally bene- 
ficial and speedy results. 
60 
6 
No 
8th 
No relief 
Not 
High fever, apparently total deafness, 
stated. 
bulging. 
tender- 
ness. 
until 24 
hours later, 
when a dis- 
charge 
stated. 
and symptoms of general meningitis 
at time of making the incision. The 
other ear also involved. 
61 
appeared. 
14th 
25 
Not 
Eed, diffusely 
No 
8th 
Entire relief 
stated. 
swollen, and 
(edematous. 
tender- 
ness. 
(leech’s 
having 
failed 
to give 
in a few 
hours. 
62 
34 
From 
use of 
nasal 
(Edematous 
and slightly 
bulging. 
No 
tender- 
ness. 
relief) 
2d 
Eelief in a 
few hours. 
3d 
63 
35 
douche. 
Not 
No 
3d 
Eelief in 
15th 
Leeches failed to give relief on second 
day. 
54 
63 
stated. 
Not 
stated. 
bulging. 
Eed and 
bulging 
tender- 
ness. 
Tender 
on pres- 
4th 
less than an 
hour. 
Marked re- 
lief in a few 
minutes. 
Not ascer- 
tained. 
About 
65th 
5o 
50 
Un- 
known. 
posteriorly. 
Eed and 
bulging; 
sure. 
Not 
stated. 
10th 
Not 
ascer- 
tained. 
Leeches also applied. Patient did not 
return to the Infirmary. 
perforation 
56 
21 
Elver 
anteriorly. 
Diffusely 
Not 
About 
No decided 
relief until 
About 
64th 
Abscess formed behind the ear and was 
opened by an incision. By the sixty- 
eighth day, the abscess had also 
bathing 
swollen. 
stated. 
67 
20 
Not 
Not stated. 
Not_ 
8th 
later. 
But little 
relief. 
Not 
ascer- 
healed. 
Second incision on the eleventh day. 
Patient did not return afterwards to 
stated. 
tained. 
the Infirmary. 
58 
22 
Not 
Not stated. 
Not 
stated. 
6th 
Marked re- 
Not 
ascer- 
Second incision on the ninth day the 
pain having returned, and the’dis- 
stated. 
short time. 
tained. 
charge having ceased. Patient did 
not return afterwards to the Infirm- 
ary. 958 
ON THE BEST MEANS OF TESTING THE HEARING. 
BY 
CHARLES H. BURRETT, M.D., 
AURAL SURGEON TO THE PRESBYTERIAN HOSPITAL, PHILADELPHIA. 
In the following paper I shall endeavor to give a sketch of the known 
relation of hearing to the watch, the tuning-fork, and speech, the gene- 
rally accepted tests. After a consideration of normal hearing, it shall 
be my aim to show how the diseased ear is affected by these tests, and 
wherein they give information as to its state, and wherein they fail t° 
do so. Afterwards, a conclusion may be better arrived at as to the best 
form of test or tests for the hearing. It will be necessary to review the 
writings, discoveries, and opinions of leading physiologists and aurists 
of the last two or three decades, and by this means the ground of the 
best labors will be fully gone over. Nothing is promised as original on 
my part; rather shall it be my aim to bring together, at such a time as 
this, the doings of others, as impartially and completely as lies in my 
power. 
No precise standard of normal hearing has been defined. The normal 
ear hears all sounds which fall upon it; but it cannot be said, d priori, 
where good hearing ceases and defective hearing begins, for, in many 
senses, hearing is a relative term. Just as there is an average standard 
for the amount of food, excretion, etc., there might be an averag6 
standard for hearing. The sense of hearing must be regarded as com- 
posite, consisting as it does of the ability to perceive not only a great 
variety of sounds, musical or periodic, but also those which are irregular 
or noisy. All such sounds can be heard singly or together. Hence, the 
sense of hearing may be said to lie in a collection of elements, largely 
nervous, which can be aroused singly or together. The mere fact that 
more than one sound can be heard at the same time, shows that the organ 
of hearing is composed of a number of structures arranged so that each 
can receive its definite impression. 
The Watch. 
Some form of watch-work, or ticking apparatus, has been used a long 
time as a ready means of testing the hearing. In this way the pocket- 
watch, mantel-clock, metronome, or an especially contrived, ticking 
machine, has been called into requisition. Such a test has usually been 
all that has been deemed necessary, and in many cases has seemed to 
satisfy both patient and physician as to the amount or state of hearing* 
Gradually, as the anatomy and physiology of the internal ear became 
better known, the idea arose of assigning to the cochlea the hearing ot 
music or musical notes, and to the rest of the labyrinth, more especially 
to those parts in the vestibule, the perception of noises or irregular 
vibrations. When this theory obtained currency, the watch was classed BEST MEANS OF TESTING THE HEARING. 
959 
noises and not musical sounds, though its beats were regular in 
meir occurrence. 
faW6olhiS th/T7 °f *the Physi?logy of the two parts of the internal ear 
■ al eor true (it is not my province nor intention to review or criticize it 
nere), Oscar Wolf has shown that the tick of a watch is a low form if 
Pitch7 r ■ 6 t,BPmA t“Ua,Cal note’ with a not ea9>ly determinable 
1' Ch. Its impulse, therefore cannot produce irregular waves of sound 
(f1 watches metronomes, and the like, must therefore be classed under 
«0t wd ,°f lnBtrame"tS voiuoiugmusical tones, and of course each 
'atch, ticking apparatus, etc., has its own peculiar pitch. But at best 
hero metruments give out but two notes, of short duration, and decidedly 
F°or in harmonics. J 
This accounts for the inferiority of the watch, etc., as a test for hearing, 
t.nd ah(! explains why some affected ears appear to hear the watch bettor 
' ,an. others> and also whf lt 18 that there is so much difference in the 
eiative manner of hearing the voice and watch, on the part of those hard 
ur hearing. 
According to Wolf, the tick of a watch should not be classed under 
poises, for it is really a musical sound with very high overtones, the short 
duration and intensity of which fall in a few seconds from their maximum 
0 nothing. “With the ticking of a watch, we test the patient with but 
rpf° tones out of the whole scale, and those neither very pure nor precise 
,flJe hammer or anchor strikes upon the cog-wheel, and by its impact calls 
t(’rth two weak tones, which are somewhat intensified by the resonance 
the watch-case. The pitch of these notes is not easily determinable* 
ae intensity is measured by the observer according to the average dis- 
ance at which persons of normal hearing are able to perceive the tick.”1 
ghis has proven very unsatisfactory as a test, because it is often found 
.hat a watch is heard relatively better or worse than the voice, etc. This 
ls very easily explained when we reflect that with the watch we have 
tested the power of the ear to hear two relatively weak and impure 
,?nes. Wolf therefore says: “Should it happen that the patient has a 
hJsturbance of the nerve-fibres corresponding to these two tones, it is 
c°nceivable that, while absolutely deaf to the ticking of the watch, he 
niay hear other far weaker tones which hold a different position in the 
B£ale, anc|5 
on the other hand, that the patient may hear the ticking of 
vl6 watch at a relatively greater distance, and at the same time misun- 
e£stand certain spoken words, and even loudly spoken tones.” 
..Such a disturbance of fibres in the nervous apparatus of the ear most 
jkely happens even with the diseases of the middle ear, for Politzer2 has 
i°Wn that the tympanic vessels are connected most closely with the 
essels of the cochlea; hence, tympanic disease is more than likely to 
about labyrinthine disease. Therefore, the above test is just as 
applicable in diseases of the tympanum as when the disease is primary 
11 the labyrinth. 
The 2'ick of the Watch or Clock.—Even a child will tell us, “ The clock 
tick, tockto its ears, therefore, there are in the sound made by the 
“VauCJ?, vowel sounds of “i” and “o,” and consonant sounds of “t” and 
ck.” E"ow, vowels and consonants are musical notes of certain, definite 
and therefore it may be said that even in this simple way a watch- 
leE is musical. This view of the watch-tick, viz., that it is an alternation 
1 Archives of Ophthalmology and Otology, vol. iv. p. 69. 
2 Correspondence with the writer, 1876. 960 
BURNETT, 
of two notes simply, would explain in a measure why one clock is heard 
better than another by an affected ear. For, even when the intensity 18 
the same, one watch is apparently heard better than another. This is 
due to the fact that the pitch of one appeals more strongly than that oi 
another, to the ear which is being tested. 
The Stop-watch.—Of all forms of ticking apparatus, the stop-watch is the 
most useful. Besides its power as a test, we also possess in it a mean8 
of finding out whether the patient really hears the sounds of the watch, 
or whether he thinks he does because he knows a watch is being held 
near his ear. This means has often been the first to declare that tbe 
patient’s statements respecting his subjective state are not entirely reb' 
able. Such occurrences, while testing with the watch, serve to shoiV 
how unreliable this apparatus is, as must be all tests in the use of which 
the surgeon must accept the patient’s statement alone, as to how much is 
perceived, Hot only are adults of the greatest intelligence and fairness 
of intention sometimes utterly self-deceived by the watch-tests, but chib 
dren as a rule give entirely unreliable statements respecting their ability 
to hear a watch. This, of course, is perfectly well known to all aurists, 
and I am sure that they have long ago concluded that accuracy in the 
use of any form of ticking apparatus can only be obtained by the ei»' 
ployment of some form of stop-watch, since by this means they can fil'd 
out whether a patient really is aware of the going or the stopping of the 
ticking. 
o ... ,1 
Some observers have gained a similar end by alternately holding an(l 
removing a diaphragm of paper between the ear and the watch. 111 
some instances, even while the ticking continues, the patient who has 
been hearing it will state that he now no longer hears it. This may he 
a perfectly true statement, and is explained by the fatigue of the ear* 
Every one must have noticed that in some forms of chronic aural catarrh 
the ear seems to lose its power of accommodation, or, as one may say, the 
power of continued listening. This has been specially noted by soipe 
writers (Weber-Liel and others), and is explained as being due to a fa'h 
ure in the muscular functions of the middle ear. It appears not only 
when testing with a watch, but also with speech. It is more likely t0 
occur with a watch, however, because of the sameness of the test note, 
and the consequent continued use of the same parts of the hearing appa' 
ratus. Hence the watch may be a better test for this condition of the 
ear than the more variable vocal sounds, since the latter, playing up a"cl 
down a series of notes, allow momentary rest of some parts of the eat, 
while others are being called into action. 
Hot only can the smallest amount of hearing be detected by means pi 
a loudly ticking watch, but the same means may aid in prognosis 111 
chronic diseases. The watch which I have found preferable, can h© 
heard from 50 to 60 feet. If this watch'is heard by a patient only a fe'v 
inches, I feel obliged to give an unfavorable, or at best a guarded, pr°=>' 
nosis as to the recovery of hearing. In such a case of excessive imp"11’' 
ment of hearing, the loudness of the watch rather than the pitch of lts 
note is to be considered, for if the ear cannot hear such intense ticklll© 
as that alluded to above, it certainly cannot retain much of its function* 
In such cases, a small pocket-watch would be useless, for not only can 
not be heard by a very defective ear, but even an ear far from being very 
deaf cannot hear the faint sounds of a watch. Hence the intensity 
the sounds of a ticking apparatus is of more importance than the pilell 
of its poor musical tone. BEST MEANS OF TESTING THE HEARING. 
961 
The Use of the Watch in Bone Conduction.—The watch is heard, per ossa, 
poorly by most persons over fifty years of age. Hence, it must be ex- 
pected that the young will hear the watch much better by bone conduc- 
tion than the old. Bearing this in mind, the ticking apparatus, of what- 
ever form it may be, will generally give some clue to the state of bone 
induction in our patients. But the usual weakness of its vibrations 
Will interfere with its value as a test in this respect. The tuning-fork, 
however is able to communicate its powerful vibrations through the 
hones of’the head to the auditory nerve. 
Conclusions respecting the Watch.—It may, therefore, be said that the 
Watch beino- a low form of musical apparatus, giving out one or at best 
two notes, poor in harmonics and lying near each other in the scale, is 
a test of’only limited value. It may, however, lie of great use, if its 
intensity is increased, in judging of the quantitative hearing in a given 
°ase. In very defective hearing, it is to the small amount of hearing still 
what a lens is to a small object, for it enables the surgeon to 
find out ff any hearing be present, and about how much. As a test for 
hone conduction its value is limited, both by the age of the patient and 
hy the weakness of the notes. Although of some value in this respect, 
u falls far below the tuning-fork as a test tor the sound-conducting power 
°i the bones of the head. 
The Tuning-Fork. 
Little if anything, has been added to our knowledge of the use of the 
Sina.tWk in aural diseases since Politzer wrote his papers on this sub- 
Fct in 1868.1 Hr. Urbantschitsch, of Vienna, has pointed out what he 
°alls the deaf points {tauben Punkte) of the normal ear. These deaf 
Milts” he discovered while experimenting with the small tuning-fork 
Passing the latter to and fro past the ear. Any one can satisfy i mselt 
this matter by simply passing a small tuning- ork, with t-he.line of 
t]j(‘ vibrating tines at right angles to the side of the head, bac*. a_ ds- 
a,‘d forwards in the plane of the auditory canal. A point will be reached 
JWe suddenly the sound fades or disappears toHe heard ag- . 
|Le fork is moved either way from this point. This is p )1 J 
TV cal, and should be borne in mind in testing. t + , 
,Lhe tuning-fork, like the watch, may be used in two ways as atest- 
Ly the air, aerial conduction : this is a app i bones of 
apparatus and secondarily to the neive, (-) _ y nUCH+orv 
head, bone conduction: a test applied primarily to the audio y 
AeiWe, and secondarily to the sound-conducting appaia - • 
1118 used shows whether sound can be conduce a\ V from the sound 
I given case, or whether, being impeded in them escape fiom t L 
parts, the sound-waves are thrown back on the peiceptive 
' lpf the orgJ"; r I vprv loud and if the tines of the instru- 
h B the note of the fork be not very loua, aim x th.r 
be properly clamped, the sound will not be heard fuithei than a 
inchePffTomythe eaf Thus one ear can wtZ’ 
fcf r* <>f participation in “ A -Tlf iow IteTb withTeli 
<■* be heard 
1 Wiener med. Wochenschrift. 962 
BURNETT, 
bones of the head. For these reasons a tuning-fork is of value as an 
aerial test. But, while highly musical, it has the great disadvantage 
like the watch, of giving out only one note at a time, which may or fliaV 
not be heard relatively better than another note by the affected ear, an 
therefore, like the watch, the tuning-fork is of limited usefulness as 
test. _ . . k 
In order, therefore, to derive a wide advantage from the tuning-!0! ’ 
one must either he at the inconvenience of shifting the clamps on a sin 
gle fork, or else possess a large number, permanently graded in the1 
pitch. Such a set of forks, to be of real value, must be most carefu* 3 
graduated in order to correspond with the power of the ear to perceive 
the intervals between musical notes, otherwise certain fibres of the organ 
of hearing will be left out in testing. Such a set of tuning-folks ! 
testing is not only difficult to obtain, but extremely costly. The 
fork, therefore, though possessing many excellent qualities as a music* 
test, through the air, is limited in its practical application. 
It may be stated, as an axiom, that the normal ear hears the tunUR 
fork better through the air than through the bones of the head; °l 
chiefly in the latter way has it been used as a test. 
According to Politzer, E. 11. Weber first settled the point that 
vibrating tuning-fork, in contact with the bones of the head, was bett 
heard in that ear the external auditory canal of which was stopped j 
the finger. This phenomenon was long unexplained, until Mach, 0 
purely theoretical grounds, advanced the view that the reason of this w 
in the hindrance offered by the finger in the auditory canal, to t 
escape of the sound-waves from the ear. Politzer, having in mind 
phenomenon, thereupon made a series of experiments upon the huflt 
ear, and came to the conclusion that the above-named, augmented pe* 
ception of sound, upon closing the external auditory canal, was due 
(a) the reflection of sound-waves from the bones of the head through 1 
.air of the external auditory canal to the membrana tympani and au( 
tory ossicles; and (6) to the hindrance which the sound-waves, passt'A 
from the bones of the head to the labyrinth and tympanic cavity, nl 
in escaping from the ear. In the latter conclusion he was in entire aglC 
ment with Mach. 
If hearing a tuning-fork better on the deafer side is due to hindrau 
of the escape of sound-waves, even while the external auditory caiia1 , 
open, stopping up the latter with the finger should increase the soll'|p 
of the tuning-fork. Dr. Roosa' is of the opinion that if closing the ap 
tory canal by the finger does not increase the hearing of the deaf 81 ’ 
it is a sign that the nerve is affected. The late Mr. Hinton,2 of D°n' 
was inclined very strongly to the view that, when for other reasons, 
could diagnose a nerve-affection on the deaf side, an increase of hea1’ 
for the tuning-fork by stopping the deaf ear, was confirmatory of 
presence of disease of the auditory nerve. Politzer has shown (Joe. c 
that a nerve-affection may exist on the deaf side to such a degree 
the delicate noise of a ticking watch is not heard better on the deaf 81 
by bone conduction as long as the auditory canal is left open, but t' 
by increasing the quantity of sound made to impinge on the u°i . 
through the bones of the head, either by stopping up the auditory 
and forcing more sound from a given source, as when using a watcu, 
by increasing the original amount of sound employed in the test, 
1 Treatise, on the Diseases of the Ear. 
2 Questions of Aural Surgery- BEST MEANS OF TESTING THE HEARING. 
963 
'vhen a large tuning-fork is used, then the diseased nerve, which is too 
eak to reply to a small amount of sound, is stimulated into action by 
1?® Srfter amou.nt of fund-waves thrown on it. By remembering this 
atter fact the views of Roosa and Hinton are made to appear less at 
variance than they seem at first sight, for the correctness of the theory 
ot each of these distinguished observers is dependent upon the amount 
ut nerve-disease, since it will be found that Dr. Roosa is correct if the 
herve-is paralyzed, and that Mr. Hinton’s theory is right if the nerve 
ktill retains some ot its power. 
In alluding to sound-conduction through the bones of the head Moos 
says: “We have in it one of the most important means of makino- a ding- 
]s of disease of the internal ear.” He recalls the fact, already pointed 
°ut by Johannes Muller, that, in cases of bone conduction, conveyance of 
sound through the auditory ossicles and through the air must not be 
Jost sight of. “Since in every case of bone conduction, L in cases where 
cn.e vibrating tuning-fork is placed on the vertex, or brought in contact 
Vdth the bones of the head, sound-waves pass into the ear in these two 
directions, the tuning-fork cannot be used in this way as an infallible 
means of making a differential diagnosis between diseases of the' laby- 
rinth and diseases of the middle ear; for it is well known by experience 
that the tuning-fork fails to aid in cases of well-known disease of the 
labyrinth, as well as in those of disease of the middle ear,”1 
Three-limbed Auscultation-Tube.—To confirm or correct the patient’s 
statements, there has been advised the use of a three-limbed auscultation- 
tube,2 two arms of which are to be placed in the auditory canals of the 
Patient, and the third in the ear of the observer. If now a vibrating 
tuning-fork be placed on the vertex of the patient, the auscultator can 
Perceive the sound of the fork, streaming from the ears of the patient, 
-by alternately pressing the two arms of the apparatus connected with 
the patient’s ears, the auscultator can learn from which ear the greater 
aUiount of sound comes. It seems but natural to suppose that more 
sound-waves must come from the less obstructed ear. The latter will, 
as a rule, be the better hearing ear, unless its fellow be deaf, not from 
°bstruction in the sound-conducting parts, but from paralysis of the 
auditory nerve. 
The Interference-Otoscope.—A similar instrument, though one used in a 
different way from that just mentioned, has been devised by Prof. Lucse,3 
°1 Berlin, and is named by him the interference-otoscope. This instru- 
ment consists of a double stethoscope of Scott Allisoip the limbs of 
vhich, intended to fit snugly into the auditory canals of the patient, 
are eleven Paris inches long. At the junction of these symmetrical 
arrns is placed a T-shaped, glass tube, from the portion of which repre- 
Renting the standard of the letter, passes a rubber tube to a collector of 
mnnd, half paraboloid in shape. Here the vibrating tuning-fork is placed. 
1° the other end of the cross piece of glass'tube is fixed the rubber tube, 
two feet long, for the auscultator. Lucre’s experiments in this direction 
V'ere based on the fact that sound-waves, falling on a stretched mem- 
m’ane, are only partly taken up and transmitted by it. The supposition 
taen naturally follows that sound-waves entering the external auditory 
anal are only partly transformed into the peculiar, pendulum-like 
to-and-fro movements of the sound-conducting mernbrana tympani and 
1 Klinik d. Ohrenheilk., S. 41. 
3 Archiv fiir Ohrenheilk., Bd. iii. 1867. 
2 Moos, op. cit., p. 42. 964 
BURNETT, 
the ossicles. According to the greater or less extent to which the mem- 
bra na tympani takes up the sound-waves falling on it, this so-called 
reflection of the waves of sound will vary in amount. The investig*l' 
tions made tend to elucidate experimentally this reflection, and the 
probable influence on it of the changes of tension in the sound-conduct- 
ing apparatus ; also, from a study of these phenomena of reflected sound- 
waves, the endeavor is made to obtain an objective expression of the 
sound-waves taken up by the ear. 
Physical Experiments.—Physical experiments show that (1) A stretched 
and inclined membrane of India-rubber, placed in an artificial ear 
made to represent as closely as possible the natural organ, will reflect 
a certain quantity of the sound-waves entering the external auditory 
canal; (2) Closure of the Eustachian tube increases slightly this reflec- 
tion ; (3) Increased tension of the membrane shows that the reflection 19 
directly proportional to the tension; (4) This outward reflection 
sound-waves is greatest whenever the tension occurs simultaneously with 
considerable changes in the density of the air contained in the tympani0 
cavity. 
In order to make practical application of these laws, Dr. Lucre devised 
his interference-otoscope, by which the relative amounts of reflection from 
both ears, it is claimed, can be determined. The results obtained in the 
normal ear, by the use of this instrument, are thus given ; (1) The normal 
organ of hearing reflects a certain amount of the sound-waves entering 
the external auditory canal; (2) The reflection increases in all change9 
in the sound-conducting apparatus, especially those in the middle ear, 
which lead directly or indirectly to an increased tension of the membrana 
tympani; (3) The examination of persons with normal hearing, by mean9 
of the interference-otoscope, shows that the different sensibility of both 
ears, for the same tone, is caused by the different amounts of reflection 
brought about by different tensions in the two sound-conducting apparfl' 
tuses. Respecting the diseased ear, the conclusions are: (1) The interfe- 
rence-otoscope shows in the majority of cases of disease, in analogy with 
the observations made on those with normal hearing, a greater reflection 
from the diseased ear; (2) This is found in a number of cases in whim1 
the ear-mirror and the catheter reveal a disease in the external or midme 
ear; (3) In the numerous cases of ambilateral chronic catarrh of tbe 
middle ear, without perforation of the membrana tympani, the examine 
tion usually reveals a greater, though often a less, reflection from the 
worse ear; in the latter instance a simultaneous disease of the labyrintn 
may be supposed, and the prognosis becomes by far less favorable, 
(4) The greatest worth of the method lies in the not uncommon cases i‘ 
which all other diagnostic means fail to show morbid changes in tli° 
external and middle ear; here too, as a rule, a stronger reflection 19 
observed on the worse side, which points to a deep-seated disease of R1 
sound-conducting apparatus.’ Only in some few cases does the exam*11*1' 
tion reveal a less reflection from the worse ear, in which cases a prim*ll) 
disease in the labyrinth may be assumed with great certainty. 
Tuning-Fork Vibrating on the Parietal Protuberance in a Normal 
If a vibrating tuning-fork be placed on either parietal protuberance of ‘ 
person with normal ears, it will usually be heard in the opposite e**1' 
This is most easily perceived when a large fork of deep and heavy no 
is used. This phenomenon, if it may be so termed, will often lead 
confusion in diagnosis, inasmuch as the examiner would at first exp°° 
the fork to be heard best in the ear nearest to which the fork is place*' BEST MEANS OF TESTING THE HEARING. 
965 
As it is heard best in the more distant organ, a conclusion might he made 
that the latter ear was diseased in its conducting parts. Care must, there- 
fore, be taken to have the vibrating instrument in the central line of the 
head, either on the vertex or glabella, or held between or on the teeth. 
An explanation of the above is perhaps most satisfactorily sought for in 
Br. Lucie V demonstration that vibrations which fall perpendicularly on 
the membrana tympani produce much the strongest vibrations, and that 
hence a tuning-fork placed on the parietal prominence, or the side of the 
head, will be chiefly heard in the opposite ear. According to Dr. Lucre, 
this is best perceived when the meatuses are stopped. But it can also 
he perceived, as any one can find out, with perfectly open meatuses. 
Conclusions respecting the Tuning-Fork as a means■ of Testing and Diag- 
nosis in Diseases of the Ear.—It has been shown that the tuning-fork 
has a twofold use: {a) as a test through the air, and {b) as a test through 
the bones of the head; i. e., it is a test of the sound-conducting power 
°f the ear, and also of bone conduction ot sound to the auditory nerve, 
ar>d of the perceptive power of the latter. In the first instance, its 
advantages are that one ear may be tested without communicating the 
s°Unds of the fork to the other ear, since a properly clamped fork cannot 
he heard far enough when held before one eai to be perceived by the 
other. The disadvantage in the tuning-fork is that it gives only one 
note at a time, and, therefore, testing with that gives no information 
respecting the ability ot the ear to heai othei notes. Its applicability, 
therefore?is limited. Various notes may be produced by the same fork 
by dampino- the tines at different points. But this necessitates some 
delay. 
The tuning-fork finds its greatest usefulness in testing bone conduction. 
While it has&never fully realized in this way all that was hoped for it, 
as an aid in diagnosis, it is still the best means, and a very good one too, 
°f determining "how much sound is conveyed to the auditory nerve 
through the head-bones. Its musical nature, as well as its powerful 
vibrations, render it far superior to the watch as a test tor the conducting 
Power of the head-bones, unless the ticking of the watch is made to occur 
With great force. But should, the ticking of the watch equal in intensity 
the vibrations of the fork, the former could never approach the latter m 
Musical ness. The tuning-fork is a means comparison between the bone 
c°nduction and aerial conduction of sound in the same peison, 01 i le 
vibrating tuning-fork be held on the vertex until its note is no onger 
Perceived by the person examined, and then held bctoie ns eai, i ic now 
Perceive that the fork is still vibrating, it is fair to conclude that the 
®°Und-conducting apparatus is normal ; but it the oix, m en no on ei 
heard through the air before the ear, be heard as soon as it touches the 
Vertex, the conclusion is inevitable that there is some impel imein m ue 
Sound-conducting part of the ear. Ibis is all the moie convincing i i 
he borne in mind that there is being used the same note, and one, too, 
Rowing a little weaker all the time, because, it vibrations ot a tuning- 
fork cease to be heard in front of an ear by aerial conduction but are 
ahle to communicate themselves while growing cons an } weaker, rpug 
the bones of the head, the inference of great derangement in the middle 
0r external ear (aerial sound-conducting parts) cannot be avoided. 
Bone conduction, however, is of little importance to the patient, and 
°f great uncertainty as a guide to the aunst, because he is forced to rely 
1 Berlin klin. Wochenschr., No. 10, 1871. 966 
BURNETT, 
almost entirely on the patient’s statements as to what is perceived by 
the latter when the test is applied. Therefore, the tuning-fork as a 
means of testing bone conduction can never become of pre-eminent value* 
At best, it must he used in conjunction with other tests, and its result9 
carefully weighed. Then, too, the musical education of the patient 
most probably influences his answers respecting the sensations produced 
by the tuning-fork vibrating on the vertex. 
Speech. 
By hearing speech, the intellectual development of the human being 
is accomplished. There is no sound so familiar, nor so fondly longed f°r 
at times, as the sound of the mother-tongue. A person with good heal’' 
ing can never realize the feelings of a deaf person so vividly as when 
travelling in a strange land, surrounded by those speaking with each 
other happily, gayly, and with varying expressions, but in a languag6 
unknown to the lonely traveller. One falls into the position of an in* 
valid, is treated with a kind of pity, and, alas, finds himself growing’ a 
little suspicious and morose. 
The deaf person feels the loss of hearing the voice of others more than 
the loss of the power to hear anything else. To recover the ability t° 
hear the familiar tones of the voices of his friends, he would gladly give 
up all other hearing. So great is this struggle to hear what others say? 
that the deaf gradually learn to understand the thoughts and words ot 
others by watching the lips of the speakers. The power to hear other 
sounds well, may begin to fail without the knowledge of the patient, but 
all his endeavors are concentrated, almost unconsciously, to catch the 
varying sounds of speech. I have known young physicians to be almost 
deaf to the ticking of a watch without knowing their loss until it W&9 
accidentally discovered, for their ability to hear speech was retained* 
All aurists are aware that patients are constantly surprised to learn ho A 
deaf they are, as soon as their faces are averted from the speaker. Thu9 
the failure of hearing, in this respect, is detected very often, for the fii’9*' 
time, in the summer, when all are used to sitting either on the porch °l 
in the parlor, in the twilight and dark. As the light fades, and the face9 
of those around are no longer plainly visible, the hitherto apparently 
hearing person becomes aware that he is deaf. This is often assigned to 
the night air, but, in reality, it is due to the loss of vision in the approach' 
ing darkness. The surgeon will often gain great aid by a knowledge ot 
these facts, and also by observing the manner in which a partially deal 
person will look at the one he is addressing, and from whom he expect9 
a reply. Those of delicate sensibility soonest become aware of thej1 
inability to hear the voice, for speech is not only a delicate sound, but 19 
highly valued by the cultivated. Those of less sensibility are not awai’e 
of their loss of hearing speech, for they still hear loud sounds and even 
music, as the latter is more powerful than the notes of speech. Hence» 
it is surprising to find how large an amount of unconscious deafness exi9ts 
in the uneducated; they do not feel their loss as the cultivated do. 
Very often the deaf are, in a measure, unaware of their aural condi' 
tion, because they feel, instead of hear, so many sounds. Roosa ha9 
found that the deaf and dumb may hear, i. e., feel, at the diaphragm,11 
tuning-fork vibrating on the vertex. A man who had been struck 011 
the head, and in consequence had become totally deaf, informed me that BEST MEANS OF TESTING THE HEARING. 
967 
he could hear a tuning-fork vibrating on his vertex. This I doubted: 
t believe that he merely felt the vibrations. Whether he heard them or 
a°t, he could not hear the loudest shout into his external ear. The loss 
°f hearing speech was his great misfortune; this he desired to recover; 
and in his case speech became the great test. The tuning-fork was value- 
ess because unreliable. 
The human voice was considered an admirable quantitative test, long 
before the researches of Bonders, Helmholtz, and Wolf, showed it to be 
equally valuable as a qualitative test. Why it was that a patient could 
bear some words much better than others, though spoken at the same 
distance, was not explained and applied until 0. Wolf published his 
investigations into the acoustic characters of the various elements of 
speech. 
The human ear perceives as musical sounds, tones varying from 16 
vibrations to 20,000 vibrations in a second. Preyer (Jena, 1876) has 
lately placed these limits from 15 vibrations to 40,960 in a second. 
Speech embraces only eight octaves, according to Wolt,1 viz., 44 P” with 16 
vibrations, and 44 S” with 4824 vibrations in a second. In music, the most 
agreeable notes, with the most distinct pitch, lie between 40 and 4000 
vibrations per second, ?• <?., within the limits ot seven octaves 5 those 
Which are admissible in the widest sense as musical, lie between 20 vibra- 
tions and 38,000 vibrations per second, i.e., within eleven octaves.2 In 
this respect the ear far outstrips the eye, for the limit ot the perceptive 
power of the eye for vibrations of light raiely exceeds one octave. 
Blake’s experiments3 with Konig’s rods, have shown that the human 
ear, in some instances, hears distinctly, as musical, 35,000 vibiations in a 
second. The ability to hear these very high notes is greater in youth (12 
years) than in older persons. The former may distinctly hear a note of 
40,960 vibrations per second, at a distance of 34 feet; from 18 to 20 years 
of age, this note is heard only at 13-16 feet; and at the extreme limit 
of 34 feet oniy the tone of 86,864 vibrations per second is heard. I his 
ability to hear high notes greatly diminishes as age advances. Dr 
Blake says: 441n the majority of the cases of persons over fifty years of 
age, and possessing apparently normal hearing, who weie su ijec e o 
these tests, an examination of the rnembrana tympani siouci a vaiying 
degree of opacity of the membrane, corresponding to a thickening ot the 
Mucous coat.” All such sounds were heard much better when the mem- 
brana tympani was perforated, especially near the pos enoi supeiior 
Periphery. In one case, where a small band ot cicatricial tissue extended 
Born the posterior border of the perforation to the long process ot the 
Bicus, a tone of 65,536 vibrations per second was c me y lean . 
Wolfs Determinations respecting Hearing, Voice 
According to Wolf,4 it is impossible to establish the distance at which 
the separate vowels can be heard.because the sound—s from the 
speaker and the hearing of the listener vary in different individuals and 
also because the sound-waves are so dependent upon the condition of the 
atmosphere in which we are placed. At night we hear much tuithei 
than by day, because the ear is less distracted by a multitude of sounds, 
and because there is a much less number of Bound-waves each 
other than in daytime. (1) Vowels are 
Btrength of tone, i. e., they are heard and undeistoo a a distance at 
1 Sprache nnd Ohr, 1871. 
3 Trans. Araer. Otolog. Society, 18(3-18/.. 
2 Helmholtz, Tonempfindungen, S. 31. 
4 Op. cit., p. 58. 968 
BURNETT, 
which all the consonants are inaudible; and (2) The consonants differ 
very greatly in the strength of tone. 
(I) Vowels.—Vowel-sounds are composed of a number of beautifully 
harmonic overtones, which accompany the fundamental note, and 
strengthen the fundamental tone of the mouth. A good musician can 
hear a perfect accord when a vowel-sound, especially “A,” is uttered with 
clearness, which is said (Wolf and Appunn) to be specially observable 
when the sound is made in the open air, where the sound-waves can 
escape with greater precision than in a room. “A” (German, broad) has 
the most overtones, five, and is heard the furthest, i. e., at 360 paces 
(Wolf). The vowel “U” (“ Go,” English) has the fewest overtones, three, 
and is heard with most difficulty of all vowels. It can be distinctly 
heard only at 280 paces. The vowel u 0,” containing many beautiful 
harmonic overtones, is heard nearly as far as “A,” broad. German “E” 
(English “A”) is heard at 330 paces ; German “ I” (English “ E”) is heard 
at 300 paces; English “I” is somewhat more powerful than English “A,” 
and weaker than broad “A” or “O”; “Oi” comes close behind UE”; the 
weakest of all diphthongs is “Ou,” as in out; it is a little stronger 
than “Go.” 
(2) Consoyiants.—The investigations of Wolf have led him to classify 
consonants according to their acoustic and physiological laws, under two 
heads, viz., those which are self-sounding (selbsttonende:), and those which 
are sound-borrowing {tonb or gentle). The former class embraces those 
sounds which are formed by the apparatus of the oral cavity, with a 
sound which is independently audible, and which can be defined in its 
pitch, intensity, and timbre. The second class comprises those consonant 
sounds which attach themselves to a vowel-sound, and are obliged to 
borrow from it in order to be distinguished by the ear; musically they 
are to be termed the appogiatura, and note of complement to a vowel 
sound ; such consonants are H, L, M, IST, W.1 
“H” is the weakest of all consonants when pronounced without a 
vowel. It is lost at the distance of a few paces. Next in strength stands 
“ B”; “ Ba” is heard further than “ Ida.” “B” alone is heard at a distance 
of 18 paces. The deeper a note is, the less effect it has upon the ear. “ R,” 
with only 16 vibrations in a second, is not distinguishable further off than 
41 paces. “K” and “T” stand next; they are both heard about equally 
well at 63 paces. “T” resembles pretty closely a simple note, but it has 
a pitch which appeals more readily to the ear, and is therefore much bet- 
ter heard than “ B,” which otherwise is very similar to it. “K” is formed 
with relatively favorable circumstances—that is, by means of a powerful 
movement of the root of the tongue. The soft “F” is heard somewhat 
further than the foregoing letters, i.e., at 67 paces. “8” is perceived at 
a relatively greater distance than the foregoing on account of the pitch 
of its fundamental note, which appeals to the ear by its sharp character, 
especially when sharply pronounced ; and finally on account of its prop- 
erties as a sibilant consonant. uTo this latter property it owes its ability 
to express disapprobation in public assemblies, to cry down opposing sen- 
timents, and to enforce silence. Both its moral use and physical character 
are inharmonic.” “8” can be heard very distinctly at 170 paces. “ Sch” 
is heard furthest of all consonants, because it possesses a full and rich 
clang-tint, and is composed of three harmonic notes, which predominate, 
while the inharmonic overtones or noises recede. The composite conso- 
1 See Wolf, Archives of Ophthalmology and Otology, vol.iv. p. 78. BEST MEANS OF TESTING THE HEAKING. 
969 
nam “Sch” (nearly -“sh”) can be heard at 200 paces. “M” and 
*1 ’ unaccompanied by vowels, are only meaningless blowing of air 
pacesg? fhefnoBtrl>. .“Mama” and “Nana” are understood” at 180 
| sC.e.s’ Siea^ei distances the sounds of “ M” and “H” ore lost 
into0 re 7"’el “T ifst,il! heard-1 In calm weather it is extremely 
teres ing to ascend a high hill and listen to the voices of men below in 
o'? !fne>’ °r.t?wn- Words 'm longer distinguishable, or, at best, 
only those which are composed ot “M”and “N”aml vowels,as “Mama ” 
Nein, etc. Vowels m all the other words are distinctly heard, foliow- 
'lg each other in a curious interchange and with remarkable cadences, 
oecaese we are no longer able to join them together into words and seu- 
Xt is thus shown that in the component sounds of ordinary speech, a 
« de range ot tests, with different intensities of sound, is offered to the 
wb'm Such a numerous set ot sounds is needed in order to discover 
, lllch are heard best by an aifected ear. One sound is not sufficient 
°ecause an ear may be unable to hear some sounds while it hears others 
comparatively well. Hence if only one or two sounds should be em- 
ployed, as in the watch, just those notes, it might be, the ear could not 
fJoar as well as others. Therefore, speech becomes most valuable because 
lt: is very varied in sound-nature, and also because it is ever at the com- 
mand of the aurist, and the use of it is fully comprehended by the 
Patient. If one sound would do as a test, a sound-unit could be estab- 
lished ; but it is seen upon short experience that a solitary and fixed 
is not heard in the same way by all similarly affected ears, and 
||Jat, therefore, one sound cannot be assumed as a fair test. This throws 
He surgeon back on speech, as containing a variety of sounds, by means 
°f which an average condition of the ear can be ascertained. 
very often whispers and words spoken in low tones are heard much 
fetter than loudly spoken words, by an affected ear. This is due to the 
jumping of the vowels, whereby the consonants, which are less sonorous, 
. ave a chance to be heard. And thus it is that a person hard of hear- 
lag often asks not to be addressed loudly. Words may be heard, even 
hen the letters composing them, spoken separately, are not heard. 
'Jis is especially so for the letters B, P, T, K, and E. (Wolf). The 
Hasou of this is very apparent, for when letters are pronounced alone, 
■[ey are words. Thus “B” is composed of sounds of “b” and “ e,” “P” 
e a, or p e e, “K” of k a y, while “R” is equivalent to sounds of 
V - In the latter instance, “R,” when pronounced, is altogether of a 
ifferent phonetic value from that which it has when standing at the 
Hginning of a word, as in “rat,” or at the end of a word, as in “ tar.” 
Piiispering has au advantage over loud words in testing, since the for- 
, cannot be as easily conveyed as the latter through the bones of the 
ea(P to the auditory nerve. 
However, it must be borne in mind, that in Hr. Dennert’s observations3 
a(le in a case in which the cochlea had been lost by necrosis, the normal 
though artificially stopped up as thoroughly as possible, could yet 
kjar whispers at a distance of six feet. Patients often state that they 
Jear music either of a piano or of an orchestra, but that they cannot hear 
ffieech. This is due to the delicacy of the sounds of the human voice in 
peech. The most delicate sounds of a violin are far more powerful than 
1 Wolf, loc. cit., p. 63. 
3 Archly f. Ohrenheilkunde, Bd. x. 
2 Helmholtz, Tonempf., S. Hg. 970 
BURKETT, 
speech, and hence the ability of those hard of hearing to perceive instru- 
mental music much better than the component sounds of speech, as has 
been shown by Wolf. 
Variable Hearing.—ln some cases of chronic aural catarrh, the state- 
ment that the hearing varies with the weather, health, etc., is made by 
the patient. This is not always demonstrable, nor, if so, are the variations 
in hearing very striking. But in some other forms of aural disease, va- 
riable hearing occurs in a marked degree, and may lead to a knowledge 
of the nature of the disease. There are not many cases of the kind I 
allude to, recorded in aural literature. I have observed two cases; one in 
which the hearing varied greatly with the position of the patient, being 
least when he was in the upright position, and greatest when he lay 
down. This variability was due to movements of fluid in the tympa- 
num.1 The other instance of variable hearing occurred in a well-marked 
case of acute aural vertigo, presenting features which, like those in a case 
related by Hinton,2 naturally led to the conclusion that the disease as well 
as the variable hearing was due to derangement in the muscles of the 
tympanum; for the attacks of vertigo were ushered in by the onset of tin- 
nitus and hardness of hearing, which gradually increased in severity, cul- 
minating in half an hour in nausea and vomiting, which were gradually 
followed by relief of all the symptoms. During these attacks of buzzing 
in the ear, the hearing was diminished, as could be shown by the watch 
and voice. But as the function was restored as the attack passed off? 
the idea naturally arises that the symptoms might have been due to 
spasm in muscular structures in the middle ear. It also leads to tho 
conclusion that the term Meniere’s disease, by which such attacks haye 
generally been called heretofore, has been applied too widely, if by R 
disease only of the labyrinth or parts of it, has been meant. Aural 
vertigo should be the general term; Meniere’s disease may be limited 
to the labyrinth. It is highly probable that hearing, varying quickly 
within short periods of time, could in no case be referred to alterations 
in the labyrinth, for the latter, as far as they have been demonstrated to 
exist, have been permanent changes, and not recurrent. Recurrence, 
however, is a well-known feature in muscular spasms. 
Hearing Lower Tones better than Higher Ones.—ln many instances 
which have come under my notice, I have been informed by the patients 
that they could hear some kinds of sounds very much better than others* 
Thus, in two cases the patients voluntarily said that they heard thunder 
(bass note) better than the chirping of crickets, or high tones on the 
piano. And, on being tested with watches, one patient said that he 
heard that watch better which gave the tick of a deeper note. Experi- 
mentally, I have shown3 that a deep note has the advantage over £he 
high ones in cases of increased labyrinthine pressure. In an increase ot 
the pressure within the labyrinth, the stapes becomes more fixed, and it 
is at this point that the vibrations begin to grow less marked as the pres- 
sure in the labyrinth increases. In such a case it is manifest that 11 
vibrations from without be normally conveyed to the stapes, they rnu 
there meet with hindrance as they endeavor to reach the labyrinth* 
Only the most powerful waves are able to overcome this obstacle, and to 
force the stapes to undergo a to-and-fro movement with the rest of the 
1 See Philadelphia Medical Times, Oct. 17, 1874. 
2 Questions of Aural Surgery, pp. 262-263. 
3 Archives of Ophthalmology and Otology, vol. ii. BEST MEANS OF TESTING THE HEARING. 
971 
chain of ossicles. I have, therefore, thought that it might he asked ; 
Could not the inability to hear high notes, while low ones are heard 
almost normally, be construed into a sign that the stapes is impeded, 
cither by undue pressure in the labyrinth, or by catarrhal fixation in the 
°val window? That the cause of such a peculiar alteration in hearing 
Probably does not lie in an undue tension of the membrana tympani, 
appears from the well-known physical fact that the tense membrane is 
more sensitive or susceptible to vibrations of high notes than to those of 
low ones. 
Bo the position and extent of perforations in the membrana tympani 
cause variations in hearing-power for certain sounds ? This question may 
be answered in the affirmative, according to the experiments of Wolf. 
He divides defects of the membrana tympani into five groups, viz., (1) 
small defects in the lower segment of the membrana tympani; (2) defects 
as large as a quadrant in the lower part of the membrana tympani; (3) 
defects as large as a quadrant or a quadrant and a half; (4) defects as 
large as three-quarters of the membrana tympani; and (5) complete defect 
of the membrana tympani and loss of the malleus and incus. Vowels are 
beard invariably better than consonants in all of these cases. I have 
observed that defects of the membrana flaccida are always attended with 
great hardness of hearing. This is probably due to an implication of the 
Joints of the ossicles. > . 
In testing wg must consider the wuy in w iiicn the sound is 
conveyed to the ear, whether through the appaiatus of the middle ear, 
or by the bones of the head. The latter, without doubt, has more influ- 
ence than has generally been supposed.1 It is leally astonishing to dis- 
cover the amount that one may hear with a normal eai stopped up. d lug 
shows how much sound may be conveyed to the auditory nerve through 
osseous tissue. A want of proper appreciation of this fact has led to 
great errors in testing hearing, in cases of one-sided deafness. Merely 
closing the good ear, and leaving the poorer one open, is not su ficient. 
The hearing must be tested, first, in the better ear when stopped up and 
turned towards the examiner, the worse ear being open. When the 
amount of hearing in the better one, made artificially deaf for sounds 
through the air, has been determined, then we may see wia e ec 
opening and closing the deafer ear has on the healing o ie s oppec up, 
better one. The result will be the amount of hearing for the worse ear. 
_ A plan similar to the foregoing, and one which I have used for a ong 
time, in cases of one-sided deafness, is the following. ace ie pa ion 
so that the affected ear is towards the surgeon. Then stop, with the 
finger, the better ear, the ear not to be tested. This may be done by 
the patient or by an assistant; preferably by the a ei w icie giea 
certainty is desired. Then, with the affected ear open and turned to- 
wards the surgeon, let tests of its hearing-power be made When the 
bmit of hearing on that side is obtained, let the ear be closed as the 
other is, and then, with the ear still turned towards the examiner, let 
tests be made again. If the closure of the deaf ear the one turned 
towards the surglon, cause no difference in the hearing-distance already 
obtained, it is fair to conclude that whatever amount of hearing exists is 
not due to a passage of sound through the external auditory canal ot the 
car turned towards the surgeon. In such a case the conclusion must be 
that either sound goes more easily through the bones of the head on the 
1 See important papers by Dennert and Lucae, Archiv f. Ohrenheilk., Bd. x. 972 
BURNETI, 
affected side than through the meatus to the auditory nerve, which 
would be absurd, or that sound has reached the brain by the other ear, 
and that the affected ear is totally deaf. If, however, stopping the 
ear turned towards the examiner—the ear supposed to be the deafer—-■ 
make that ear still deafer, let the examiner approach the patient and 
repeat the tests till they are heard once more. The second hearing ot 
them is evidently due to conduction of sound through all obstacles repre- 
sented by cranial bones and the finger in the meatus, and must not be 
regarded as aerial conduction. The extent of the power of the ear to 
hear by aerial conduction will be expressed in the difference between the 
limit of the first test and the limit of the second. Thus a patient may 
hear speech as far off as eight feet, with the good ear stopped and turned 
away, and the affected ear Open. When the latter is stopped, speech is 
no longer heard at eight feet, but it may be perceived by the patient at 
a distance of three feet, both ears still being kept firmly stopped. I'l 
such a case, not the former distance, but the difference between it and 
the latter distance, viz., five feet, must be considered the amount of aerial 
conduction by the external auditory canal, for that represents the amount 
of loss of hearing caused by stopping the meatus. 
Wolfs Word-Tests.—ln testing the power of an ear to hear the human 
voice, it seems to me that we gain some very practical hints from Wolf’s 
system of word-tests. Wolf, in his very valuable work, has divided 
defective drum-heads into five groups (vide supra, p. 971), and in each 
of these he has applied a certain list of chosen words as tests. At the end 
of his observation ot the hearing in each group, he has struck an average 
of the words heard, and has thus, as it seems to me, made a practical 
suggestion. Printed slips with words containing the different vowels 
and consonants at the beginning, middle, and end, might easily be arranged 
in all languages, and the aurist provided with them could always dis- 
cover the ability of his patient to hear given vocal sounds. The average 
of the patient’s misses and successes would give his hearing power. 
A Conventional Sound-Unit.—A conventional sound-unit might be con- 
structed so as to be of uniform and invariable intensity, but “ intensity 
of sound-sensation and intensity of sound-producing vibration are two 
entirely different things. The first is a physiological phenomenon, and 
varies with individuals .like all such phenomena, and the second is a 
dynamical phenomenon. To assert that the first is proportional to the 
second, as all authors do, is to use d priori physics in which I have no 
faith.”1 Hence if such a sound-unit were made, it would possess only a 
limited value. It would also be open to the same objections as the 
watch, or the solitary note of any other test. One sound can no more 
become the test of hearing than one object can be the test of vision. 
Even speech itself, which affords the most convenient as well as the most 
ample test, will not fulfill all its capabilities unless it be studiously varied 
so as to bring into play all its elements, with their varied phonetic cha- 
racters and intensities. 
Kessel has laid down four conditions which any form of acoumeter 
should fulfill in order to satisfy the wants of the aurist of the present 
day: (1) The acoumeter must embrace a large range of tones in the most 
carefully graduated series; (2) The strength of the tones must be always 
the same; (3) The acoumeter must be able to test the hearing in one ear 
at a time, both respecting air and bone conduction ; (4) The intensity of 
1 Prof. A. M. Mayer; Correspondence with the writer. BEST MEANS OF TESTING THE HEARING, 
973 
«Ie notes must correspond as nearly as possible with that of the voice, 
esse has had an apparatus made which corresponds in the main with 
he above conditio.*,. The tones are produced by means of metal teeth, 
"Inch are set in vibration by keys placed in a brass cylinder, like those 
an ordinary music-box. The teeth give the notes of the scale of “C 
major,' throughout seven octaves, and, if desired, can produce even eW.t 
"ctaves. Discordant sounds may be produced by striking the notes of 
several octaves at the same time. _ The cylinder is turned l?y a handle, to 
"Inch is fastened a pointer which indicates on a dial the pitch of the note 
jdven out. The a,r conduction is eflected by means of a rubber tube, con- 
nected with the cavity of the apparatus. The latter is covered with poor 
conductors of sounds, and packed in a case, so that the sounds produced 
'? the apparatus are inaudible even at a short distance from it except 
through the gum tube. Bone conduction is effected by briim’ir,.- the 
mastoid process into connection with a metal prong or bar, passing from 
Clle back of the comb-like piece containing the teeth heretofore alluded to 
Since by this means the air in the external auditory canal is alternately 
and condensed, and thereby the tension of the membrana tympani 
and the pressure in the labyrinth altered, we have a means of finding 
°nt under which of these conditions the hearing is best. The apparatus 
also shows that when both ears are unequally excited by the same sound 
the latter is referred to the more stimulated ear, independently of direc- 
tion. Thus if the right ear he brought near enough to the to hear 
the sounds through the packing, and if then the rubber tube be brought 
ai’ound to the left ear, the observer will think the sound comes only from 
the left. 
I have never had any experience with the apparatus devised by Br 
Vessel, but it seems fair to assume, from what is known of the character 
°t the voice in speaking as a test, that the instrument alluded to provides 
the aurist with no better means of testing than he always possesses in 
the use of speech. 
There are needed, in any form of test, comprehensibleness, scope, deli- 
pacy, gradations without great intervals, convenience of application, 
Jnexpensiveness, and invariability. The watch and tuning-fork have 
been described, and conclusions drawn respecting them. The further 
the investigations have been carried, the more conclusive have appeared 
the reasons for assuming that the voice will render most aid in determi- 
ning the state of the hearing. JSTothing is more convincing of this than 
tlie tact that all artificial means, yet proposed, have been modelled more 
°r less after the voice, or some of the component sounds ot speech. 
Invariability would always be an argument in favor of any form of 
test, and it has been urged in behalf ot the watch, the tuning-fork, and 
°ther forms of artificial test-means. This certainly is desirable for com- 
parisons during treatment, no matter what form ot test be used. I3ut 
every aurist can learn to modulate his voice so as to be able to command 
a 1 ways the same degree of loudness or lowness in making tests with it. 
-Even if artificial means were as superior to the voice in invariability as 
s°nie have thought, the far greater range ot the latter as a musical appa- 
ratus especially adapted to the ear, would place it far ahead in the list 
°f tests for hearing;. 974 
THE FUNCTION AND UTILITY OF THE ARTIFICIAL 
DRUM-MEMBRANE. 
BY 
H. N. SPENCER, M.D., 
OF ST. LOUIS. 
I shall present a resume of this subject, as far as it has been possible, 
in a limited time and with the literature at rnjr command, to obtain it, 
and in addition I am happy in being able to submit so much of the p'e' 
sent status of the subject among aurists at home and abroad, as will be 
my privilege. 
With the desire to present something practical on a subject of such 
practical importance as this, and which would carry authority with it, I 
early addressed letters to as many of those who are engaged in this spe- 
cial field as my time allowed, submitting questions which appeared to 
me to cover every point, so that if possible I might be able from these 
advanced sources to obtain the material which would admit of a crystal- 
lization into truth. 
It would he desirable to know accurately the condition of the ear 
which indicates the employment of an artificial drum-membrane, the 
contra-indications, and the best form of membrane under varying cir- 
cumstances. It should not be a matter of taste, like the preference of one 
prospect or one piece of music to another. As scientists, we should, &3 
far as possible, have fixed laws to govern us; yet, dealing with forces 
which themselves vary, we recognize that this exactness is not alway3 
to be attained. 
It appears that Marcus Banzer, in 1640, first suggested the use of the 
artificial membrane, not with the view of improving the hearing, but a3 
a protection to the cavity of the tympanum in cases where it was ex- 
posed from loss of the normal membrane by ulceration. The construc- 
tion of his apparatus wTas exceedingly rude, consisting of a tube cut out 
of the hoof of the elk, with a bit of pig’s bladder to represent the menu- 
brane covering its proximal or inserted end. This was to be introduced 
to half the depth of the meatus. There are allusions to this apparatus, 
or to similar contrivances for the same purpose, in the writings of Re- 
schevin, 1763, Autenreith, 1815, and Lincke, 1840. The appliance ox 
Autenreith, a description of which he published in the Tubinger■ Bl<T' 
tern fur Naturwissenschaft und Arzneikunde,* consisted of a short tube 
of lead, very thin .and elliptical-shaped, the inner end of which was 
covered by a membrane made of the air-bladder of a fish, which was put 
on wet and varnished after it became dry. Lincke describes his apparatus 
in his treatise on diseases of the ear ;2 it is substantially the same as that 
of Autenreith. In 1842, Yearsley accidentally discovered an altogether 
new use of the artificial drum-membrane, viz., as a means of improving 
the hearing. I quote from a paper published in the “ The Lancet’7 (July» 
1848),3 entitled “On Deafness.” 
1 B. i. H. 2, S. 129. 2 Handbucb der Obrenbeilkunde, 1845, B. ii. S. 446. 
3 Yide Allen, “ On Aural Catarrh and Curable Deafness,” 2d edition, 1874, p. 366. Function and utility of artificial drum-membrane. 
975 
Up to the present time, no successful mode of treating perforations of the 
Membrane of the drum, or the relief of the accompanying deafness, has been 
discovered by the profession at large. The only means resorted to has been 
he removal of pus or mucus from the tympanal cavity by syringing, or ren- 
denng it free by passing air through the perforation, by way of the Eustachian 
:?be. Either of these proceedings will produce a temporary improvement of 
the hearing in cases where the tympanum suffers from obstruction, but in many 
others, when such a state does not obtain, they are of little if of any service 
A have, however, the extreme gratification of promulgating a mode of relief 
toi deafness attended by loss of the membrana tympani, which will cause oreat 
surprise among the readers of The Lancet, not less from its extreme simplicity 
extraordinary success which generally attends its employment. 
in 1841> a gentleman came from Yew York to consult me under the following 
circumstances: He had been deaf from an early age, and, on examination, I 
jound great disorganization of the drum of each ear. On my remarking this 
to him, he replied, “ How is it, then, that by the most simple means I can pro- 
duce in the left ear a degree of hearing quite sufficient for all ordinary pur- 
poses ? in fact, so satisfied am I with the improved hearing which I can myself 
Produce, that I only desire your assistance on behalf of the other ear.” Struck 
% this remark, I again made a careful examination of each ear and ' observing- 
their respective conditions, I begged him to show me what he5 did to that ear 
Which I should have unhesitatingly pronounced bejmnd the reach of remedial 
urt. I was at once initiated into the mystery, which consisted in the insertion 
of a spill of paper, previously moistened at its extremity with saliva which 
be introduced to the bottom of the passage; the effect of which, he said was 
‘to open the ear to a great increase of hearing.” This improvement vvould 
sometimes continue an hour, a day, or even a week, without requiring a repe- 
tition of the manipulation. 
Ur. Yearsley seized upon the idea which this case presented, and gave 
to the profession an artificial drum-membrane which is known as “Years- 
ley’s cotton-wool,” consisting of a small pellet of moistened cotton-wool 
Which is inserted to the bottom of the external auditory canal. Without 
detracting from the rude attempts which had preceded this, and without 
claiming for Yearsley that he had made a discovery, strictly so called, of 
anything previously altogether unknown, yet it is due to him and to 
ourselves, since discovery is a relative word, to credit him with being 
practically a discoverer, for bringing to our knowledge and for giving 
to the world this new use of a contrivance of which we otherwise 
Ought have remained in ignorance until now. In 1858, eleven years 
later, Toynbee gave to the profession another form of artificial mem- 
brane, which he described in his “Treatise on Diseases of the Ear,” and 
"which was composed of a vulcanized India-rubber disk (the thinnest 
layer of it that was procurable), through which was passed a silver wire, 
fastened in the centre by means of two very fine plates of silver, having 
a diameter of about three-quarters of a line. “The silver wire is of 
sufficient length to admit of the membrane being introduced or with- 
drawn by the patient, but is not perceivable externally except by special 
observation.” I shall have to notice hereafter other forms of artificial 
drum-membrane, which, while deserving a special mention, are not 
properly referred to in this connection. 
It will be interesting now to consider the conditions of the ear which 
admit of the use of the artificial membrane, and this will be profitably 
studied by passing in review the theories and practical thoughts, on this 
subject, of explorers in otology, from the period of Yearsley down to the 
present time, augmented by views which are entertained by men of to- 976 
SPENCER, 
day. To preface this step: It is not deemed necessary to refer to the 
function of hearing, further than to state in general terms that the con- 
ducting media involved are the membrana tympani, the machinery 
the cavity, and the membranes of the oval and round windows of the 
inner wall of the tympanum. Like the media through which vision is 
effected, there is so nice an adjustment of these forces that to have one 
affected injuriously, influences the efficiency of each of the others, and oi 
the whole machinery. This need not to be demonstrated. It will be 
understood, then, that, in considering what are the conditions of the ear 
admitting of the use of the artificial membrane, we have not only to take 
into consideration the membrana tympani and its functions, but what 
are the functions of the tympanic cavity, etc., which are influenced by 
every deviation from the normal condition of the membrane, and viM 
versa. The artificial membrane is designed to supply some force that is 
wanting, or that operates inefficiently, and this inoperative condition ot 
the conducting apparatus which can be thus measurably remedied, may 
be due to a variety of causes, such as solutions of continuity of the 
membrana tympani ; changes in the lining membrane of the tympanum, 
associated with perforation of the membrane ; loss of power in the ten- 
sion-muscles of the cavity, with partial or entire destruction of the mem- 
brane ; loss of two of the ossicles, the membrana tympani being gone, 
the stapes in situ ; flaccidity of the membrane ; solution of continuity 
the articulation of the ossicles. It may be considered, then, that it 
the design to show in what follows the rationale of the functional gam 
by the artificial membrana tympani in these conditions, which I have 
enumerated in the order of their frequency of occurrence. 
Toynbee reasoned that the artificial membrane “ confined the vibra- 
tions to the tympanic cavity, and concentrated them upon the labyrinth. 
This conclusion he founded upon experiments which proved to him that 
the guttural orifice of the Eustachian tube was closed “except during the 
momentary action of certain muscles,” which made the tympanum a 
shut cavity for all purposes relating to the passage of sonorous undula- 
tions, and next upon the experiment with the tuning-fork, which showed 
that the sonorous vibrations communicated to the bones of the head 
appeared much louder when the meatus externus was closed than when the 
orifice was open. This led to the conclusion that the sonorous vibrations 
imparted to the cavity of the tympanum, could only make their due im- 
pression on the membranes of the labyrinth when strictly confined to 
the tympanic cavity, and Toynbee’s artificial membrane was designed to 
supply this, which he considered was the office of the normal membrane- 
And in directing its application, he says : “ As will be imagined, great 
care must be taken to cut the membrane so that it shall fit the inner 
extremity of the meatus with exactness ; since if too large it would cause 
discomfort, and if too small it would not fulfil its purpose of rendering 
the tympanum an air tight cavity. It is not easy, in all cases, to fit the 
artificial membrane so as not to allow of any communication between 
the air in the tympanum and that in the external meatus; this howevei 
is the object which should always be aimed it.” This view of Toynbee s 
did not obtain for any length of time, as practical experience with the 
use of the artificial membrane soon showed that, to effect the improve- 
ment in the hearing, it did not require that the perforation should be 
closed ; and this should have been apparent earlier when we consider 
Yearsley’s artificial membrane of cotton-wool preceded Toynbee’s rubbei 
disk, and the increase of hearing effected by it could not be accounted Function and utility of artificial drum-membrane. 
977 
fm- by Toynbee’s mode of reasoning. As far as I know, Erhard and Von 
aid tlf’ W-re ‘li® ilrsft rho “ggestecl that the effect of this mechanical 
c.i 0 heannS fl'tl »ot depend upon its rendering the tympanum a closed 
«avity nor upon its affording a surface for the reception of sound nor 
upon its furnishing a conducting medium, but that it acted by virtue of 
Us pressure upon the stapes. This was first concluded when it was dis- 
eff'Vi I*jl 111 t.llf Poslt.lol' the greatest amount of improvement was 
stiected, and no philosophical explanation was essayed. It is but doiiiv 
toynbee justice to add that Ins views subsequently underwent consider- 
ate modification, as will appear from a statement of the conditions of 
the ear in which the artificial membrane will be found most efficient 
given in the supplement to the edition of his work, edited bv Mr’ 
dames Hinton - and which he was partly led to adopt, it is stated, by 
h ercou.se with Dr. Julius Erhard, “who, without any perforation, 
jound Ins hearing much improved by the use of cotton-wool and nub 
his experience in a paper entitled ‘ Deafness Curable by Pressure 5 ” 
J-bese conditions are as follows: J 
(?) Disconnection of the incus and stapes, the membrana tympani beino- 
entire, but the tensor tympani ligament, or the mucous membrane of the t ;i° 
Panum, being relaxed." (2) Partial or complete absence of the long process 
incus, the membrana tympani being entire. (3) Disconnection of the stapes 
an<3 incus, the membrana tympani being perforated, and the tensor ligament 
0r the mucous membrane of the tympanum being relaxed. (4) Partial or com- 
plete loss of the long process of the incus, the membrana tympani beino- Der. 
Drated, and the ligaments of the stapes being relaxed. ° 1 
Erhard2 says:—The improvement in the hearing is appreciated at the 
foment that the surface of the artificial membrane which is being introduced 
comes in contact with the surface of that which was formerly the conductino- 
apparatus, restoring the continuity which has been destroyed. 
Von Troltsch3 says:—lt is not yet determined definitely in which way the 
a,’tificial membrane produces its often astonishing effect. Various explanations 
°i its mode of operation are in favor. According to Lucie, it is the increased 
Pressure which is exercised upon the labyrinth-fluid, which is of outweighing 
Importance to everything else. Politzer refers the improvement in the hearing 
;° the removal of the irregular nodes {Schwingungsknoten) which are produced 
ht every perforated membrane—and also to the rubber disk acting like the 
l'Ue vibratory membrane, and serving to convey a considerable number of 
Derations to the ossicula. In the least number of cases is the increased hear- 
ts to be referred to the closure of the cavity, which was Toynbee’s theory. 
11 many instances we observe marked improvement where the rubber disk 
9°es not effect closure of the opening in the membrana tympani That 
le closure of the opening is not essential, and not the true explanation in 
s°lution of this enigmatical question, I was able to see in a case that presented 
ltself to me where I could close a very small opening in the membrane with 
milodion, or a thick solution of gum, without producing the least effect upon 
ae hearing; whereas a very marked and immediate improvement resulted 
,lom the introduction of the rubber disk, or of any other foreign body, so that 
ff would press upon the membrane. This pressure upon the membrane, or 
|’P°n the manubrium mallei, seems in most cases to be essential to effect the 
desired result. 
I‘olitzer, in a very interesting brochure, entitled “ Leber das kiinstliche 
Pommel fell and seine neneren Modifikationen,” which first appeared as an 
i 1868. p. 452. 2 Krankheiten des Ohres, 1875, S. 230. 
3 Lehrbuch der Ohrenheilkvmde. Fiinfte Auflage, 1813, b. 400. 
62 978 
SPENCER, 
article in the Wiener Medizinal-Halle, 1864, after a statement of the views 
of Toynbee, says:—Although the phenomena upon which he founds his expla- 
nation present themselves to every practical physician as correct observa- 
tions, on the other hand, it must be allowed that they cannot altogether clear 
up the question of mode of action of the artificial membrane. Opposing views 
to those of Toynbee have been urged by other authors (V. Trdltsch, Erhard)? 
and are in more general favor at the present time. It may be stated posi- 
tively that the view entertained by the latter author, i. e., that the artificial 
membrane operates principally through pressure upon the remnant of the 
membrane and the chain of bones, is the true explanation in the majority oi 
cases; this is more evident when we regard the pathological changes which 
occur in the tympanum as a result of the catarrhal process, and which have 
been more fully appreciated since Toynbee made his observations upon this 
subject. If a post-mortem examination be made of a person who has suffered 
from a suppurative, middle-ear catarrh, with perforation of the membrane, 
there will be found in many cases that the ossicles are fixed through adhe- 
sions, or are enveloped in adventitious tissue-formation. In other cases the 
ossicles have become so loosened in their articulations from the inflammatory 
process, that the slightest touch with an instrument causes them to fall apart. 
It is evident that in such a looseness of the articulations of the chain of bones, 
the sound-conduction would be interfered with in greater or less degree ; espe- 
cially would this be the case if there were complete separation, for instance, 
in the incudo-stapedial articulation. In a case of this kind, now, the artificial 
membrane would operate to improve the hearing through pressure, by restor- 
ing continuity in the chain of bones and aiding sound-conduction. 
The above-cited observations of Toynbee, upon which he rests his theory of 
the mode of action of the artificial membrane permit of another solution to 
this question. If the membrana tympani is perforated, the deafness which 
follows depends, first, upon the hole in the membrane by which the surface 
for the reception of sound-waves is diminished, and consequently a less num- 
ber of sound-waves are conveyed to the chain of bones : particularly is this 
the case if the destruction of the membrane is in the neighborhood of the 
manubrium mallei; second, upon change in the conditions surrounding the 
ossicles, as by accumulation of secretion, or by loosening or fixation of theii’ 
articulations. Upon the latter changes depends the degree of deafness, as 
experience proves that in large perforations, where no considerable change has 
occurred in the condition of the chain of bones, there is, of course, a diminu- 
tion in the hearing, but yet the hearing will still often be sufficient for ordinary 
purposes, and the deafness never is in degree proportional to the extent of the 
defect in the membrane. This phenomenon, which is so striking, has its ex- 
planation in this, that in the large perforation, the sound-waves, without 
being received and conducted by the remnant of membrane, and malleus and 
incus, fall direct and full upon the foot-plate of the stapes and the membrane 
of the round window, and so reach the labyrinth in considerable numbers. 
The improvement in the hearing, in cases where the perforation is not exten- 
sive, which is effected through the closure of the opening by means of a drop 
of fluid, has its explanation in this fact, that, the continuity in the membrane 
being restored, the irregular nodes are removed which exist in every case 
where there is an opening existing in the membrane. 
Moos1 says:—According to the observations of Lucre, Politzer, and myself? 
it has been proven that, by the application of the artificial membrane, the 
intra-auricnlar pressure is increased. There is at the same time this advan- 
tage, that in some cases in which the ossicles are still preserved, but are loose 
in their articulation, which has resulted from an active, purulent inflammation 
of the middle ear, the artificial membrane, by pressure, restores them to n 
proper condition for the conduction of sound-waves. 
1 Ohrenkrankheiten, 1866, S. 275. Function .and utility of artificial drum-membrane. 
979 
Dalby gays;— The increased hearing may therefore be said to be produced 
b, approx,mat.ng the articulations of the ossicles, or supplying their place 
n these bones are partially wanting; which Dalby further states was' to 
substance the explanation offered by Dr Yearsley J GS HS U 
Roosa-says ,-The improvement to the hearing is probably due to the re- 
stoiation of the interrupted continuity of the ossicnla auditor tn f|IO r I 
ovalis and the labyrinth. y ossicnla auditus to the fenestra 
says :_The question whether the artificial membrane operates bv 
esneoifll v D°n r tympani, or by supporting the ossicnla and 
especially the stapes, is now decided in favor of the latter view 
euCby led" BatP§S? °BBi* 
Wr-tTtbeTbT °ffJhe f6neStra -tJu.dain acondihr: " 
Ke labyrinth M’ P of transmitting them to the nerve expansion 
In reaponae to inquiry I have obtained, relative to this question of 
conditions of the ear and function of the artificial membrane these for 
ther very interesting views. (I would state that I did not submit these 
questions to many whose views would be highly esteemed, for reasons 
winch have already been assigned, and regret it as detracting from the 
value and interest of this report. Three to whom the questions were 
submitted, made no reply.) 
f)r. Clarence J. Blake, of Boston, summarizes the conditions of the ear ’ 
Which the artificial membrane may be used, thus:—(l) Solution of continuit*1 
°f the membrana tympani, in which the artificial membrana tympani restores 
a surface for the reception of the sound-waves, or, by closing a small opening 
Prevents the simultaneous impact of the sound-waves upon the base of tim 
stapes and the remaining portion of the membrane, a condition which is shown 
experiments to result in interference;5 (3) Thickening of the mucous 
Membrane of the tympanic cavity, associated with perforation of the mem- 
*rana tympani, the increased pressure given by the artificial membrane re- 
selling in the readier conduction of short sound-waves; (3) Destruction of 
Ci)e membrana tympani, the artificial membrana tympani receiving the sound- 
waves on its outer surface, and conveying them directly by contact to the 
?cus or stapes; (4) Loss of the incus in suppurative otitis media, the artifi- 
Wtd membrane being made to press directly upon the-stapes, thereby restoring 
.he degree of tension of the membrane of the fenestra ovalis. (“I have seen 
lu Politzer’s clinic good results in such a case from the pressure induced by a 
S)hall cube of rubber-elastic, one millimetre in diameter, resting upon the 
sPipes and extending across the tympanic cavity.”) 
Id'. D. B. St. John Roosa, of New York, states that, accordingto his experi- 
the artificial membrana tympani may be used where there is a partial or 
Complete loss of the natural membrana tympani, with a moderate amount of 
shppuration, or no suppuration at all, and with one or more of the ossicles 
ln Mtu. If there be much suppuration, the irritation of a foreign body, such as 
ah artificial drum-head, will always be apt to increase it. In a few rare cases 
is useful, where the natural membrane is entire bat very much thinned by 
ations there is a great impairment of hearing, i.e,, inability to hear ordinary 
c°nversation. . . . The improvement in hearing is effected primarily by pres- 
a diseases and Injuries of the Ear, 1873, p. 127. 
Treatise on Diseases of the Ear, 1873, p. 380. 
Aural Surgery, 1874, p. 189. 
On Aural Catarrh and Curable Deafness, 1874, p. 370. 
.0. H. Burnett; Weber-Liel, Func. d. Memb. d. runden Fensters; Test with hi<di 
ll>sical notes, Moos, Archiv f. Ophth. und Otol,; High Musical Tones, C. J Ri.o-o 
kpi’ache und Ohr, 0. Wolf. ‘ Uke ” 980 
SPENCER, 
sure upon the stapes, re-establishing the proper relations of that bone to the 
fenestra ovalis, vestibule, and cochlea. 
Dr. O. D. Pomeroy, of New York, says :—Any condition in which the base 
of the stapes fails to exert the requisite pressure upon the oval window, and 
consequently upon the waters of the labyrinth. The lesions resulting in this 
condition are: (1) Perforation or loss of membrane; (2) Flaccidity of the 
membrane, either due to a cicatrix or to other causes whereby the membrane 
fails to close down firmly upon the ossicles ; (8) Loss of one or two of the 
ossicles, the stapes being in situ; (4) Separation from any cause of the ossi- 
cles from each other; (5) Partial luxation of the base of the stapes, or great 
relaxation of its annular ligament. The discharge from the ear must be 
moderate in quantity or absent. Polypi or granulations should be removed 
or destroyed. The ear must bear the pressure of the membrane without the 
production of either pain, tinnitus, vertigo, nausea, etc., increased discharge, 
or irritation of the chorda tympani. 
Dr. Arthur Mathewson, of Brooklyn, says :—Like the natural membrana 
tympani, the artificial serves to concentrate the force of the sound-waves 
through the ossicles on the nervous apparatus of the inner ear, focalizing these 
waves, as it were, as rays of light are brought to a focus on the retina by the 
refracting apparatus of the eye. In cases in which there is stiffening or anchy- 
losis of the joints of the ossicles, so that they cannot transmit the sound- 
waves, the artificial membrane only impairs the hearing. 
Dr. Albert H. Buck, of New York, says:—As I comprehend the matter, the 
artificial drum-membrane serves to intensify the sound-impulses. In the case 
of Hassenstein’s membrane, 1 can readily understand how the vibration com- 
municated to such a solid body, projecting as it does beyond the orifice of the 
meatus, may be transmitted to the hammer, and so on to the labyrinth, with 
a greater force or intensity than would have been the case had the same waves 
of sound reached the auditory nerve without the intermediation of such a solid 
body—the larger solid body offering a greater surface to the weaves of sound 
than does the hammer which is a smaller body. If there is a condition of 
anchylosis, an entire membrana tympani would, it seems to me, be a much less 
efficient intensifier of sound-impulses than would Hassenstein’s contrivance. 
Hence, where there is anchylosis, it is quite possible that the total absence of 
the membrana tympani may be rather a benefit than otherwise; for, in its 
absence, the sound-impulses can strike directly against the foot-plate of the 
stirrup (in other words, upon the fluid of the labyrinth) with greater force 
than they could via the chain of ossicles, the membrana tympani being intact. 
The temporary benefit of artificial perforation, in such cases (of anchylosis 
with entire membrane), may be explained in accordance with this view. 
Dr. C. H. Burnett, of Philadelphia, in reply to the question “ What is the 
office of the artificial membrane ; how is the improvement effected ?” says : 
This question is one not only of intense interest, but of the greatest impor- 
tance, for upon its answer depends, as it seems to me, the gist of the entire 
subject of application and usefulness of the false drum-head. Its office is 
emphatically to restore the proper isolation of the ossicles of hearing. 
will not perform their normal functions if they are too tightly locked, or B 
they are too loosely connected. Hence, in some cases, the false drum-head 
would have to be adjusted so as to gentfy overcome the indrawing of the 
malleus by the tensor tympani, while in other instances the benefit derived 
from the false drum-head would be entirely due to pressure inward, since it 
would thus overcome a too great relaxation of the joints of the ossicles, and 
thus enable them to swing with each delicate wave of sound. The latter is 
more easily accomplished, and perhaps is the more usual demand made on the 
false drum-head. But, now and then, the more the false drum-head is made to 
press on the remnants of the sound-conducting parts, the less the patient 
hears. In the cases of this kind which I have seen, the membrana tympani has 
been largely destroyed, but the ossicles have been present, and their attach- Function and utility of artificial drdm-memekane. 
981 
especially that of the tensor tyrapani to the malleus. Mani- 
estly, here the bones have been already too much drawn inward, and pressing 
down a pellet of cotton would but increase the defective isolation. If how“ 
e er, such eases the artificial membrane tympani be placed so as to gently 
freed i n mAvwmgof the malleus, the entire chain of ossicles may be 
heed and allowed once more to swing normally. This I have successfully 
Cr I’tl tllckl"g. t.le ul>per edge of the round or flattened pellet of cotton 
tfl l • 6Te llbrT; ,T r frmtyiL The latter would be only an addi- 
the ~tmW? n tT a,<klS °Utward force J“st enough to overcome 
the ret!action of the malleus The base of such a false drum-head should rest 
as nearly as possible along the line of insertion of the lower half of the mem- 
b ana tympana In doing this, should some of the lower portion of the artifi- 
c al membrane extend into the tympanum, as it almost surely will when the 
hlembrana tympam is largely destroyed at its lower border, no harm comes of 
, if there be no discharge from the ear when the artificial drum-membrane is 
serted, and if the ear be examined by a competent person from time to time 
order to learn the condition of the parts where the cotton pellet lies The 
great objects to be gained in such cases of undue retraction of the malleus and 
consequently of the entire chain of ossicles, are: (1) a good support for the 
case of the false membrana tympani; and (2) the adjustment of its upper edee 
behind the lower end of the manubrium. Of course, large perforations 
involving the lower half of the membrana tympani are supposed in what has 
Just been said. A small perforation does wot as a rule cause as much deafness 
ns a large one, and in any event the artificial membrane used in the former is 
to be laid over the perforation. 
Prof. Schwartze, of Halle, says:—The indication for employment of the 
ai'tificial membrane exists only in a partial or total defect of the membrana 
tympani, and it is contra-indicated by a subacute inflammation, or a profuse 
°torrhoea. 
Prof. A. Lucse, of Berlin, writes:—The artificial membrane should not be 
employed, and is of no value, in ancient perforations where the suppuration 
has ceased, and where the edges of the perforation have cicatrized. 
Prof. Politzer, in his communication to me, says:—lt is important for the 
action of the artificial membrane, as well the rubber disk as the pellet of cotton, 
*hat it should be fastened on a solid or elastic stem, by which a certain pres- 
Sl|,,e is exercised upon the deeper parts. The rubber disk or the cotton pellet 
which is fastened on a thread, will not produce so marked an effect, because 
Piis pressure from without is not then exerted. 
Prof. Weber-Liel,1 in a preliminary communication, states that according to 
11 s I‘esearches the band connecting the foot plate of the stapes with the edge 
the oval fenestra, described heretofore as the “ligaraentum orbiculare baseos 
sfopedis vestibulare,” should be considered rather as a circular membrane. It 
ls true that it appears on ordinary examination only as a very narrow band, 
Jet well prepared microscopic specimens, more than physical experiment on 
,lesh preparations, demonstrate that we have to deal with a relatively broad, 
vibrating, membranous band. On account of the peculiar posi- 
P°n and mode of union of the stapes witli the edge of the oval window (the 
Membrane generally going abruptly down to the edge of the stapes looking to- 
''Ul‘d the tympanum), it is only under certain conditions, that we obtain a 
cmnionstrative view. In well-prepared specimens, where the covering mucous 
of the tympanum has been previously removed, well-defined, radiating 
Jty-es can be observed in the circular membrane. The elastic-fibre layer of 
Piidinger,between the so-called “ligaraentum orbiculare baseos stapedis vesti- 
bulare” and the “ligaraentum baseos stapedis tympanicum,” constitutes the 
!e*l, very elastic attachment of the stapes-plate in the foramen ovale. Iu 
“lustration, there was presented, with this communication, a preparation of the 
1 Verhandlungen der phjsiologischen Gessellschaft zu Berlin. 3 tluni, 1876. 982 
SPENCER, 
human ear in which the wall of the vestibule opposite to the oval window had 
been opened, the edge of the opening having been filed and widened to admit a 
thin glass, which was made to close the opening hermetically, and through which 
the circular membrane could be closely observed, enlarged 15-40 times. In the 
external auditory canal there was loosely placed a glass tube, to which was 
attached a piece of India-rubber tubing, through which sound-waves could be 
introduced. At once, very low speaking, or singing high and low tones, into 
the tube, produced plainly visible excursions of the light reflexes on the cir- 
cular membrane, but none whatever on the stapes-plate. The light reflex ex- 
cursions were very marked with stronger and lower sounds, but only very loud 
singing into the tube produced the light reflex excursions on the stapes itself- 
The tensor tympani and stapedius muscles appeared to effect the changes of 
tension in the circular membrane. It was shown how, by pulling on the sta- 
pedius muscle, the vibrating faculty of the circular membrane was at certain 
points reduced or entirely checked. The counter-pressure of the labyrinth- 
fluid was replaced in the preparation by air, which could be compressed by 
means of a rubber balloon through a glass tube introduced into the closed 
vestibule, a piece of rubber tubing connecting the distal end with the air bag- 
I am indebted to this author for a personal communication, in which 
he applies this newly discovered anatomical relation to the question we 
are considering : “ The stapes, regulating the intra-lahyrinthine pressure, 
exercises also an influence upon the circular membrane through the ope- 
ration of the sound-waves and the tensor tympani and stapedius mus- 
cles. If the normal tension of the membrana tympani and chain ot 
bones and muscles be impaired, in consequence of defect in the mem- 
brana tympani, it is perhaps the pressure which is exercised by the 
artificial membrane on the stapes to which the improvement in the hear- 
ing can be referred. The intra-lahyrinthine pressure and the tension ot 
the circular membrane may by this means be brought nearer to a 
normal condition.” In connection with this interesting statement ot 
Prof. Weber-Liel’s, I may refer to the experiments performed by Mach 
and Kessel,1 conducted with a view to determining “ whether a traction 
upon the muscles of the tympanum will produce an alteration in the 
consonance of the auditory apparatus for notes of various pitch,” and as 
a result of which they state, “our conclusions are in unison with those 
of former investigators. All observers agree that contraction of the 
tensor tympani, whether produced artificially or by natural causes, will 
render high notes more audible than low ones.” This phenomenon has 
presented itself, I do not doubt, very many times to every gentleman 
present, in the course of treatment of suppurative and non-suppurative 
inflammations of the tympanum, there being at periods a marked im- 
provement in the hearing of high tones, with no increase, or a positive 
decrease, in the hearing of low tones. 
We may now consider the contra-indicating conditions to the use of 
the artificial membrane. After what has gone before, I shall consider 
that a mere statement here will be sufficient, and will not be controverted 
by any. In brief, then, the contra-indications to the employment of the 
artificial membrane are found (1) in a profuse suppuration; (2) in the 
presence of any adventitious growth in the tympanum or external audi- 
tory canal; (3) in acute disease ; (4) where there is pain, or where there are 
cerebral symptoms; (5) where the artificial membrane has been tried 
and found to produce irritation; and (6) in all cases where there does 
not exist a degree of intelligence sufficient for the self-introduction and 
1 Yersuche liber Accommodation des Ohres; Sitzb. der k. k. Akad. der Wiss., 1872.  AND UTILITY OF ARTIFICIAL DRUM-MEMBRANE. 
•Kf °?il 1 °-f !he ;'.rtiik'!al membrane, or for the formation of a judgment 
Zto the indications tor its continuance or discontinuance, and in cases 
ur young children. 
Tii e forms of membrane,and I shall enumerate only those which have 
some favor, and are in use among aurists to-day, are as follows 
I) Yearsley s cotton-wool (2) Toynbee’s' rubber disk. (3) Hassenstein’s 
tot Gotha) modihcation ot Yearsley’s membrane, made by attaching it to 
* pincette for its easier introduction and removal, and in order to supply 
ail increased pressure.. (4) Luc® s modification of Toynbee’s membrane 
oonsistini; in the removal of the metallic button and wire, and in the 
substitution of a hue rubber tube attached by a solution of gum to the 
outer surface of the disk ; the tube serves for its introduction by means 
M a probe, (o) Pol.tzer s artificial membrane, which is cut out of the 
'vail of a heavy India-rubber tube; it is from four to five lines long,and 
Should be one and a half or two lines thick; the upper end, through 
''lnch the wire of Toynbees membrane is passed, is somewhat broader 
than the lower. It is recommended in charity practice, for the readi- 
uess with which it is made, and its comparative cheapness of cost 
J- olitzerhas further modified Toynbee’s artificial membrane by fasten in 
40 the disk an artificial stirrup, to he used in cases where the head neck"5 
ar|d crura of the stapes have been destroyed, and only the foot-plate 
remains in the oval window. The foot-plate must be susceptible of its 
normal movements. (6) Gruber overcame the danger which is liable to 
occur in the use of Toynbee’s membrane, of the disk becoming separated 
from the stem and being left behind in its attempted removal, by at- 
taching a thread to the disk, and also to the ring which is formed in the 
outer end of the wire, for its extrication in the event of such an acci- 
dent. (7) Hartmann2 hits proposed an artificial membrane, to be made 
of whalebone, six to seven centimetres long and one to two millimetres 
broad, and as thin as possible. It is doubled upon itself to form a loop, 
after it has been wrapped with cotton. It is recommended for the elas- 
ticity of the pressure which it makes, for its easy introduction and re- 
moval, and as a means of treating the cavity.3 (8) Blake4 recommends 
the use of a disk of writing paper, to be employed only in a certain class 
°f cases; at the same time that it improves the hearing, the disk has its 
°bief value in its office as a therapeutic agent. 
The conditions of the ear presenting the indications for the employ- 
ment of the artificial membrane, which have been stated at such length, 
Occupying the greater part of the time allotted to this paper, with the 
miatornical peculiarities of the location, constitute the argument upon 
mliieh is based the preference for Yearsley’s cotton-wool. Ot all the 
forms of membrane which may be committed into the hands of the 
Patient—and it should be kept in mind that this is its fate—this 
form, in my experience, has proved to be the simplest of introduction, 
fbe easiest of adaptation in the cavity, and much the least likely to pro- 
duce irritation—which latter must be the constant tear of every intelli- 
gent wearer of such a contrivance. In its employment, it will not be 
forgotten that the artificial membrane (of whatever form) is a foreign 
body; and that, in those cases in which it will produce the greatest 
arnount of improvement in the hearing, it will be liable to defeat what 
1 For description, see page 975. 
2 Archiv fur Ohrenheilkunde, Band xi., Heft. 2. 
3 See pag’e 985. 4 &ee page 985. 984 
SPENCER, 
should he our first concern, the arrest of a process which endangers the 
health of an individual, if not his existence, and compared to which the 
improvement in the hearing is a matter of very secondary importance. 
The high degree of deafness which so frequently obtains in chronic non- 
suppurative inflammation of the middle ear, is comparatively of rare 
occurrence, associated with suppuration in the cavity ; and where B 
exists, we are apt to find more or less extensive destruction of the tym- 
panal machinery, with the destructive process continuing. These are 
the cases which when first presented necessarily excite some apprehen- 
sion in our minds, and which require a guarded prognosis. They are 
cases concerning which I have been led by sad- experience to feel an 
unusual solicitude; and when after a patient care of months, it may be, 
such an ear has been recovered from this state of danger to a compara- 
tively healthy condition, it is a question for the surgeon to decide, 
“Have I a right to hazard this result?” When the continued use of 
this mechanical aid to hearing has been determined upon—and circum- 
stances at times will warrant such a decision—the question arises, What 
form of membrane shall I employ ? And I care not what the degree of 
deafness, nor what the circumstances or condition of the patient making 
it desirable to have the functional relief, the conclusion cannot be influ- 
enced alone by the degree of improvement produced by this form of 
membrane or that, but the surgeon must also consider his responsibility 
in the case, and his duty to protect his patient, and he will put into his 
hands that engine which will be the least calculated to do him harm- 
If the rubber disk be used, it should be Lucre's, and never Toynbee s 
with its metallic button. 
I am further of the opinion that such a case should never pass entirely 
from under observation, but that the patient should report himself 
statedly for inspection to the aural surgeon. It is not without signifi- 
cance that some of those of enlarged experience and of honor among us, if 
they do not discountenance the use of the artificial membrane altogether, 
at least may be said to endorse its use, in any form, very qualifiedly* 
Among such are Lucre and Schwartze, of Continental-European aurists, 
and Buck, J. Orne Green, Knapp, Mathewson, and Prout, of those in 
our own country. 
Lucre says :—lt is well known that in a continuing, chronic suppui’ation, 
the artificial membrane improves the hearing in a high degree ; yet it irritates, 
and retards the cure of the otorrhoea, so that it would appear more rational 
to entirely abstain from its use, and principally to direct the attention to con- 
trolling the suppurative process. I have, therefore, in ray practice, restricted 
myself in the use of this appliance to those very rare cases in which it effects 
a marked improvement in the hearing, without at the same time producing 
any irritation whatever. 
Schwartze says:—As a general thing, I may state that, in ray experience, 
the artificial membrane is only in rare cases to be used as a means of improv- 
ing the hearing. In most instances, the improvement is not so considerable 
that the patient will bear the trouble and inconvenience which necessarily 
attend wearing it; and, continued for a little wdiile, it is soon thrown away. 
J. Orne Green says :—1 must say that my experience with them is not 
brilliant; occasionally, in very rare cases, they have improved the hearing, 
but even in these they are often not well borne. 
Knapp says:—My own experience with artificial drum-heads has been so 
unfavorable that I hardly ever try them again. Function and utility of artificial drum-membrane. 
985 
cc,TI-1i fu'lctl°nai ralue ?f the art!f>cial membrane has been sufficiently 
Ss «?8 T;- re,!rr,nB-“metl?inSt 0 be said it. therapeutical 
ness’ Tf 1 mChn? tLhefl°PJnl?n that tljis is i‘« office of greatest useful- 
ness. It serves, in the first place, fo protect the iuflamtd cavity from 
the pernicious influences of an unkindly atmosphere, and from particles 
«t dust and soot; and introduced to the depth of the meatus, in more 
or less profuse suppuration may absorb the vitiated secretion,■ and act 
bnL trntaut, where there remains a small perforation in the mem- 
biane with a subsidence of the middle-'ear trouble, to excite a further 
reproduction of membrane and thus close the cavity. In the second 
P ace, through this instrument, astringent solutions may be retained in 
application to the cavity, often with great advantage. It is proper, how- 
ever, to state here a precaution which may save others from an embar- 
rassment to which I have been subjected The cotton-wool should be 
Moistened merely, never saturated, with the solution ; as the continuous 
Presence in the cavity and meatus of so much fluid mioht lead to the 
development of a myringo-mycosis. Did time allow, I might' report a 
dumber of cases so treated. Prof. Pohtzer, in a letter, sinvests a differ 
>nt method of employing the cotton-wool with the mediated solution" 
r shall give it in the connection in which he states it, as the whole sub- 
ject is of interest. 
The most important modification, since the year 1864, is that of Dr Has 
senstein, of Gotha, who has contrived a pincette in which the cotton 
fastened. It possesses advantages over Toynbee’s artificial membrane in that 
(1) its introduction is less disagreeable to the patient; (2) In speaking and 
chewing, there is less often that disagreeable noise in the ear which accom- 
panies the use of Toynbee’s membrane; (3) It does not produce so much 
dotation ; (4) The cotton takes up the secretion of the cavity; (5) By means 
°f the cotton, which has been saturated in a concentrated solution of sulphate 
°* zinc, sugar of lead, nitrate of silver, or alum, and then dried, and moistened 
again when it is to be used, a medicament can at the same time be retained in 
c°ntact with the diseased mucous membrane of the middle ear. . . . In the 
Sanie manner Dr. Arthur Hartmann’s artificial membrane might be employed. 
. Dr. Clarence J. Blake informs me:—Lately, in cases of small perfora- 
tions of the membrana tympani, the middle-ear trouble having subsided, 
J- have covered the perforation with a small disk of writing paper, rnoist- 
eded; the sizing of the paper is sufficient to secure its adherence, and in 
some cases it has remained for several weeks ; the slight irritation caused 
l)y the paper favors closure of the perforation by cicatrization, and the 
Paper is then removed by the natural growth of the dermoid coat of the 
Membrana tympani. Dr. Blake kindly reports a case to illustrate the 
effeet of this disk of writing paper, taken from the Massachusetts Cha- 
ritable Eye and Ear Infirmary’s Record, occurring in his service:— 
Case 2024, Yof. Y.—Perforation of right membrana tympani from old otitis 
purulenta, discharge having ceased ; hearing for voice diminished, sound 
°* the voice being heard at six feet, but not understood readily on account of 
°Ss of softer consonant sounds. Perforation in anterior segment, a little 
than two millimetres in diameter. Disk of common note paper moistened 
and applied over the perforation. Yoice heard plainly, and conversation 
Understood at twelve feet (June 6, 1816). 
f 1 I have been in the habit of using, for making artificial membrane, a prepared cotton 
r°m which the vegetable oil has been extracted; this substance answers well for the pur- 
|'0se. and is also a better vehicle than ordinary cotton for conveying medicated solutions' 
0 the tympanum. 986 
SPENCER, 
July 1, 1876. Paper still in position, but has moved (by natural process of 
repair) one millimetre backward and downward. Perforation diminished in 
size. 
July 18. Paper having been moved from over perforation, is reapplied) 
with a repetition of the former favorable condition. 
Finally, it is not easy to determine in what percentage of cases tbe 
artificial membrane will prove of practical advantage, until it shall have 
been tried in every case of perforation of the membrane, including cases 
of one-sided deafness. We are ready to infer that the relative propor- 
tion to the whole number of chronic suppurations would be exceedingly 
small, where its use would be continued as a means of improving the 
hearing. Of 261 cases of ear disease presented during the last six months, 
O # O .1 
taken apart from clinical cases, as affording opportunity for more caretm 
observation, 84 have been cases of chronic suppuration of the middle ear 
—the right ear being affected 11 times, the left ear 8, both ears 15, Count- 
ing out all excepting the 15 cases of double-sided suppuration, for rea- 
sons that will appear manifest, but five of these have presented the war- 
rantable conditions for the employment of the artificial membrane, and 
only one has continued the use of the artificial membrane after being 
left with it for self-introduction. 
Dr. Blake has placed me under further obligations to him by furnish- 
ing these statistics;— 
The total number of eases of otitis media purulenta, treated at the Massa- 
chusetts Charitable Eye and Ear Infirmary from Jan. 1 to August 5, 1876, W»9 
267, divided as follows: Males 187, females 80; Right ear 95, Left 90; both 
ears 82. In several of these cases, artificial drum-membranes were tested, no 
record being made. I append notes of cases in which there was special record* 
Case 1928, Vol. V. Otitis media purulenta of both ears; destruction of 
membrana tympani, only a rim remaining; patient hears voice, except imme- 
diately, with difficulty; cotton applied in both cases with great improvement 
in hearing for voice. 
Case 1982, Vol. V, Otitis media purulenta; hearing for voice much dimin- 
ished ; wall clock (60 feet) not heard at 6 feet. After introduction of cotton 
dram, hearing for voice improved; wall clock heard plainly at 20 feet; noises 
in the street, unnoticed before, became very annoying. After remaining i’l 
place with continued improvement in hearing for four days, drum removed to 
allow of treatment of granular condition of tympanic mucous membrane. 
Case 208, Yol. VI, Destruction of left membrana tympani. Malleus drawn 
inward in contact with promontorium. Incudo-stapedial articulation visible* 
Voice understood with difficulty at 8 feet. Cotton drum introduced, being so 
moulded as to present a convex surface inward, pressing on the incudo-stape- 
dial articulation, and a plane surface outward. Voice understood readily 
6 feet. 
Conclusions. 
I. Of the various forms of artificial drum-membrane in use, the cot- 
ton pellet is preferable, for its greater simplicity and easier introduction) 
•for comparative safety in its employment, and for the greater uniformity 
of its effect. 
11. It lias an advantage over all other forms of artificial drum-mem- 
brane, in that, over and above the functional gain which rnay.be derived 
from it, there may be added its value as a means of treating the tym- 
panum; and this therapeutical use of the artificial membrane has a great 
future in otology. Function and utility of artificial drum-membrane. 
987 
111 The continued use of the artificial drum-membrane, as a means of 
improving the hearing, is indicated in rare conditions, which can only be 
determined by the aural surgeon. 
Discussion on Dr. Spencer’s Paper. 
After the reading of the preceding paper, Dr, Samuel J. Jones, of Chicago, 
Alter tue learn , haxve found the rubber disk of considerable service, 
|‘U ' I.nlS°lj iiaVe used the cotton pellet almost exclusively, occasionally 
bit latterly Even in some cases of active suppuration, if the 
f-“ SHCh cases’howevCT’ 
cotton behind the malleus when lm for the,.e are 
some cases of large 
m some cases than pressing deafneBß is 
the result of retraction of 
perforation in the di um- iea mapeus being retracted, the rest of the bones 
the malleus. In,slJchdouble is only increased if the artificial membrane pushes 
are pulled in, and the trouoie is ui .> 
the malleus inward. tliaJlk pr. Burnett for his suggestion; it may 
Dr. Spencer said:—l » failure of the cotton pellet in some cases, 
he the key to an explanation ot tne xaiui « 988 
MODIFICATIONS OF THE METHODS OF TREATING CHRONIC 
NON-SUPPURATIVE INFLAMMATION OF THE 
EUSTACHIAN TUBE AND MIDDLE EAR. 
BY 
SAMUEL J. JOUES, A.M., M.D., 
PROFESSOR OF OPHTHALMOLOGY AND OTOLOGY IN THE CHICAGO MEDICAL COLLEGE. 
The method of inflating the Eustachian tube and middle ear, intro- 
duced to the medical profession by Politzer, possesses so many advantage9 
for that special purpose as to have been almost universally adopted m 
the treatment of obstruction of the tubes, and of disease of the middle 
ear. Experience, however, has shown that violence may be done by the 
injudicious use of so large a rubber bag as that advised by Politzei’* 
More especially is this likely to occur when only one of the Eustachian 
tubes is affected. The other tube being normally free, a greater amount 
of force is exerted, on pressing the bag, by the air on the well ear, than can 
be employed with safety, even though that air should not be medicated. 
If, however, in those numerous cases where local stimulation, in addition? 
is needed, medicated air be used, still greater disadvantage may result* 
By this method of medication of the mucous membrane lining the air* 
passages, a greater impression will be made on the naso-pharyngeal part 
of it than on that portion lining the affected tube and middle ear? 
although the latter portion of the membrane needs it most. If the large 
bag be used, in connection with the Eustachian catheter, to introduce 
either pure or medicated air into the middle ear, the size of the bag 19 
an inconvenient one, and often makes the procedure painful. The 
amount of force usually employed with this large bag, in the treatment 
of children, frequently alarms them, even if pain be not produced, and 
renders it more difficult to treat them. 
If the nasal douche be used to remove the ’hardened secretions often 
found to be present in the naso-pharyngeal space, and obstructing the 
mouths of the tubes, it is open to the objection that the saline solution 
employed may be stronger than it would be safe to have enter the middle 
ear, through the Eustachian tube, as it is likely to do if either the reser- 
voir be placed too high, or the soft palate be removed from contact with 
the posterior wall of the pharynx during the operation. Acute inflam- 
mation of the middle ear, with occasional perforation of the membrana 
tympani, has thus been produced. If the soft palate remain in contact 
with the pharynx, that portion of its posterior aspect which is in contact, 
and which is very often granular and covered with altered secretion, 19 
prevented by its position from being washed by the current as the other 
parts of the membrane are, thus rendering the application only partial* 
In the use of the Eustachian catheter, if hard rubber be the substance 
of which that instrument is made, it necessitates a variety of shapes 01 
the catheter to meet the great variations found in nostrils. Unless the 
proper size and right curve of the instrument be obtained, pain will be 
produced, and failure to reach the tube will frequently result. Heating INFLAMMATION OF THE EUSTACHIAN TUBE, ETC. 
989 
the catheter to give it the required curve, delays the operation, to avoid 
'yhich it is necessary to have a number of different catheters. If alloyed 
sdver catheters be used, they are too firm to have their curve readily 
Ranged, and in consequence require the surgeon to keep on hand several 
°f them of different sizes and shapes. If Eustachian bougies be used to 
°pen the tubes, their introduction is generally painful and attended with 
s°me risk, whilst the results obtained are too often uncertain and unsatis- 
factory. 
. With a view to avoid objections incident to the use of these different 
I have been accustomed to substitute for the nasal douche a 
steam atomizer (Fig. 1), using the vapor of some alkaline solution, as 
Fig. 1. 
Steam atomizer. 
of the chlorate of potassium, or of borax, which the patient breathes in 
trough his mouth and expels through his nostrils—thus getting the 
effect "of the warmth, the moisture, and the alkali, to cleanse the mucous 
Membrane of its secretions, and to assist in removing the inflammation, 
•htavino- thus cleansed and prepared the mucous membrane for further 
dedication, a Eustachian catheter of pure silver (Fig. 2), readily adjust- 
to the curve required, is introduced. To this is ftttciched, bj nieuns 
°f a small hard-rubber tip and an elastic tube, a small rubber bag (Fig. 3), 
Figs. 2 and 3. 
Eustachian catheter and valve-bag. 
"•nil a valve such as is used in the local-anassthesia apparatus. The 
ordinary “ diagnostic tube” (“otoscope,” Toynbee) is then introduced into 
‘>>e external meatus of the patient, and into that of the surgeon Pres- 
?m-e on the valve-bag forces air through the catheter into the middle ear, 
,f the Eustachian tube be open, as is readily recognized by the sound 
Produced. This bag has the advantage ot always filling in one direction, 990 
JONES, 
thus avoiding the drawing of mucus into the catheter. If the tube be 
not open, a small hard-rubber syringe (Fig. 4), with its tip covered with 
Fig. 4. 
Hard-rubber syringe. 
a piece of rubber tubing to adjust it to the expansion of the catheter, lS 
tilled with a warm and slightly alkaline solution, with glycerine added, 
and is inserted into the catheter. With this, the solution is forced into 
the Eustachian tube, using the liquid as the mechanical meqnsof distend- 
ing the tube, instead of relying simply upon compressed air (as in tbe 
methods of Valsalva and Politzer), or of using bougies. 
Experience has shown that if the solution used be not of too irritating 
a character, and if its temperature be nearly that of the blood, no in]1)- 
rious effects follow its passage into the middle ear. On the contrary, 
assists, by dissolving them, in removing the secretions that have h’e' 
quently dried and remained accumulating in the middle ear and. mastoid 
cells. 
Having thus opened the tube, and dissolved the dried secretion, W 
impressed with iodine may be forced through the tube until the midcUe 
ear, and even the mastoid cells, may be impressed by it. This can be 
done by placing a few crystals of iodine between two pieces of sponge 
slightly moistened and inclosed in a hard-rubber bulb (Fig. 5), (such ns 
Fig. 5. 
Butties’s harcl-rubber bulb. 
Butties’s), attached to a catheter. Air is forced through the sponge by 
means of the valve-bag above described (Fig. 6). When the lining of tbe 
Fig. 6. 
Valve bag and hard-rubber bulb combined. 
tube and the middle ear have thus been sufficiently medicated, the catheter 
may be withdrawn, and a blunt nozzle attached to the bulb containing 
the iodine. If this nozzle be placed in one nostril, the other one having 
been closed by pressure, medicated air can be forced in, in the act ° 
swallowing water, as is pure air in Politzer’s method—impressing the 
whole membrane more thoroughly, by means of a smaller bag than tba 
used by Politzer, and with less attendant risk. 
By the method here pursued, the surface is readily cleansed, and the INFLAMMATION OF THE EUSTACHIAN TUBE, ETC. 
991 
Requisite amount of stimulation of the affected parts may be easily and 
painlessly obtained. Such cleansing and stimulation seem to be the basis 
°f the most successful treatment of this form of inflammation of the mid- 
dle ear, and thus better results may be obtained than are usually ex- 
pected in these cases. 
The modifications proposed consist, therefore : 
I. In the substitution of the steam atomizer for the nasal douche, to 
Remove secretions from the naso-pharyngeal space and from the openings 
°f the Eustachian tubes, and to reduce inflammation. 
11. In the substitution of pure silver catheters for those of alloyed sil- 
ver, or of hard rubber. 
111. In more frequent use of the Eustachian catheter as a means of 
dedicating the Eustachian tube and middle ear. 
IV. In the substitution of a warm, slightly alkaline solution, forcibly 
injected by means of a syringe through a catheter, to open the Eustachian 
tubes in certain cases, instead of condensed air or bougies, 
V. In the substitution of air, impressed with iodine, for irritating 
Squids, as a topical application to the mucous membrane lining the naso- 
pharyngeal space, the Eustachian tube, and the middle ear, this medi- 
cated air to be introduced through the Eustachian catheter. 
VI. In the substitution of a small rubber bag with a valve, designed to 
inflate the Eustachian tubes, for the larger bag recommended by Politzer 
for that purpose. 992 
ON THE BEST MODE OF TESTING THE HEARING OF SCHOOL 
CHILDREN, AND OF PROVIDING FOR THE INSTRUCTION 
OF PARTIALLY DEAF CHILDREN. 
BY 
CLARENCE J. BLAKE, M.D., 
INSTRUCTOR IN OTOLOGY IN HARVARD UNIVERSITY. 
One of the strongest arguments in evidence of the importance of the 
subject expressed in the title of this paper, is the fact that, except 
individual cases, or where the loss of hearing is so great as to lesu t 1 
deaf-mutism, no provision is made in our present school system for tn 
special instruction of those children whose infirmity, in this iespec ? 
gives them, if anything, a larger claim upon the efforts of those to whon 
is entrusted the laying of the foundation of that mental deyelopmen 
which is the basis of the prosperity of a people. To the attainment 
that proper degree of mental development which raises the man abov 
the animal, the sound mind in the sound body is necessary; and whet 
one of the channels for communication from without, is either whol y 
or partially closed, there devolves upon those who have the furtheranc 
of this development in charge, the duty of compensating in one way p 
another for the loss. How this may be best accomplished in the case i 
question, is for us to consider. _ i. 
In a work on the physical and mental education of deaf children, pu 
fished with the sanction and under the advice of Prof. Von Troltsch, 
author says :l The generally received opinion that diminution of hearnV 
in children, in consequence of disease of the ear, is rare, is a mistake1 
one; indeed, in some localities, the cases of disease of the ear exceed 1 
number the cases of disease of the eye, and moreover they are apparent O' 
on the increase; the steadily increasing demands upon the mental capaci 
accompanying the advances of the times, bring the defects of hearing nlot 
and more prominently forward, because they show themselves to be 
decided hindrance to the better education of the_ child. The results, 0 , 
its later mental development, of the loss or diminution of heating m 
child,are decided and permanent—affecting.the understanding, the cha ' 
acter, the self-confidence, and, at a later period, the ability of self-suppor - 
mental tools the possession of which is invaluable, and the want of win 
can never adequately be supplied. In this view, it is a matter of concer 
that more attention has not been directed to the educational develop 
ment of partially deaf children. _ _ -in 
An examination of a number of cases of partial deafness, occurring 
children under sixteen years of age, shows that, with the exception ot ‘ 
majority of those cases in which the disease of the ear ot < 
character, or of a degree of intensity, sufficient to so far impair t 
hearing as to bo followed, by deal-mutism, the diseases of the eai 
1 Franciska Schaeling. BDitrage zu einer richtigen,leiblichen, und geistigen Bizi 
gehorkranker Kinder. Thorn, 1872. HEARING OF SCHOOL CHILDREN. 
children are amenable to treatment, with more or less improvement in 
hearing, and that the impairment of hearing varies considerably in dif- 
ferent .cases, and is moreover subject, in any one case, to variation during 
the progress of the disease. In considering the subject of partial deaf- 
ness, therefore, we have to deal at the outset with a factor in our problem 
representing an unknown quantity ; each individual case of partial deaf- 
ness must be, as it were, a law to itself, as far as the compensatory advan- 
tages to be accorded to it are concerned. To facilitate investigation, 
however, two general divisions of the subject may be allowed. The first 
Will include those cases of partial deafness in which the loss of hearing 
W so great as to interfere with the acquirement of articulation, though 
not sufficient to permit the classification of the case under the head of 
deaf-mutism. This division will include those cases in which the dimi- 
nution of hearing is so decided as to interfere with the independent 
Requirement of information through the medium of the hearing, and will 
imply the necessity for special instruction. The second division will 
include a much wider range ot cases, from those in which the hearing is 
so slightly impaired as to permit of ordinary intercourse, downward 
through varying degrees of impairment of hearing until the degree 
belonging to the first division is reached. 
Those whose cases come under the first division, form fortunately but a 
small percentage of all the subjects of partial deafness among children; 
and a consideration of their needs may be deferred, as secondary to the 
subject immediately under consideration, and because moreover no pro- 
vision has been very generally made for their instruction. Tor the in- 
struction of those whose cases come under the second division,there is, as 
tar as I am aware, no provision made in out public schools, beyond the 
individual and independent efforts of the teachers. The childien who are 
subjects of partial deafness are, however, sufficiently numerous to warrant 
some special attention to the subject, with the view of determining the 
best means for living them equal educational with their 
tUore fortunate companions. To do this will require an examination into 
the nature of the cause of their disability, and the establishment of rules 
According to which the degree of impairment of healing may be deter- 
mined, that the character of the instruction may be varied accordingly. 
An examination into the etiology of partial deafness, shows that the 
diseases of the middle ear are its most frequent cause in children, and 
furthermore that a great many cases of partial deafness are due either to 
the subacute or chronic catarrhal inflammation of the middle ear, or to 
the purulent inflammation accompanied by perforation of the membrana 
tympani, which follows the simple acute inflammation, or occurs as one 
of the sequel® of the exanthematous diseases of childhood. 1 his general 
rule is subject to certain differences, in differing classes of society- 
among the wealthier classes, for instance, who perhaps merit our atten- 
tion less in this connection, because their children are educated more 
frequently in private than in public schools, the diseases of the ear 
accompanied by partial deafness and more or ess amenable to treatment, 
in children undei sixteen years of age, amount to but 7.8 per cent, of the 
whole number of oases of ear disease in children and adults taken 
together. Of this number, making the 7.8 per cent, of the whole, 76 per 
cent. are traceable to the exanthematous diseases of childhood, especially 
Scarlet fever, and in 56 per cent, there is found an existing purulent 
inflammation of the middle ear, requiring treatment, and causing a suf- 994 
BLAKE, 
ficient degree of deafness to interfere with the patient’s participation m 
the ordinary school exercises, on equal terms with other children. 
Among the middle and poorer classes, the proportion of diseases of 
the ear in children is largely increased, and it is these classes which 
have particularly to consider, since they more generally avail themselves 
of the advantages ottered by public instruction. Out of 8715 cases of 
disease of the ear, examined in patients of this category,1 2175, or 24.9j> 
per cent., occurred in children under fourteen years of age. Of tinß 
number, 2175 cases of disease of the ear accompanied by partial deafness, 
1085, or 49.8 per cent., are recorded as examples of purulent inflamma- 
tion of the middle ear; 113, or 10.5 per cent, of the cases of purulent 
inflammation, being due to scarlet fever. As many as 514 cases, or 23.6 
per cent, of the cases of disease of the ear in children, are recorded as 
examples of either acute or chronic catarrhal inflammation of the middle 
ear. This brief analysis is sufficient to show the much greater preva- 
lence of such diseases of the ear as are liable to induce partial deafness, 
in the children belonging to those classes in society which depend for 
their instruction on the advantages offered by our public schools. A 
more minute analysis of the material offered, which would hardly be h1 
place here, affords interesting information as to the general causes and 
the average course and results of diseases of the ear in children. It may 
be remarked, however, that, in the analysis given, only those cases ai’e 
included in which the deafness was not so decided as to interfere with 
the acquirement of articulation, or even with the use of the ear as & 
medium for instruction. The number of cases of positive deaf-mutism, 
and of cases in which, while there was a certain degree of hearing, it vva9 
so slight as to render instruction in articulation necessary, was 107, oh 
of all the cases in children examined, 4.9 per cent. The average age of 
all the children examined was about nine years. 
We see, therefore, that in a large majority of the cases of disease oi 
the ear occurring in children at an age when they should be profiting 
by school instruction, the disease is accompanied by partial deafness, and 
is moreover of a character to lead us to expect considerable variation 111 
the hearing during the progress of the disease, or during the ordinary 
term of school life. This point is one which should be especially con- 
sidered in coming to a conclusion as to the character of the instruction 
to be provided in these cases; we have to deal not only with a different 
factor, in the different degrees in which the hearing is diminished by 
■disease in different cases, but also with a possibly variable factor in any 
individual case. 
Admitting the necessity for making some provision for the wants oi 
children of this class in our public schools, and excluding, for the present? 
those cases in which the deafness is of so high a grade that special 
instruction is absolutely necessary, we have to consider the advisability. 
(!) of establishing separate classes in our schools for the instruction 01 
partially deaf children; or (2) of instituting such a system of inspection 
as shall lead to a determination of the wants of individual cases, and 
such a consideration thereof, on the part of the teacher, in addition to 
the ordinary course of instruction, as will permit of education in mixed 
classes, compensatory advantages being accorded in cases of partial deaf- 
ness. 
1 Aural Clinic, Massachusetts Charitable Eye and Ear Infirmary; Statistical Report 
Service of C. J. Blake. HEARING OF SCHOOL CHILDREN. 
995 
The objections to the former coarse would seem to be— 
(1) The encumbering of our school system with an additional depart- 
ment for which especial provision would have to be made. Against this 
objection it may be urged that initiatory steps have already been taken 
toward the establishment of separate public schools for the education of 
deaf-mutes, and the so-called semi-mutes, and that children suffering 
from partial deafness could be transferred to such schools, thus making 
Use of a department already in process of establishment, and avoiding 
the creation of another additional department for instruction of only 
partially deaf children. While the instruction of serai-mutes in the 
same school with deaf-mutes proper, has certain advantages which have 
been successfully illustrated in the public schools established for that 
purpose in Boston, and of which I shall speak hereafter, there are certain 
aguments against this disposal of the question, and in favor of a different 
provision for-the needs of those partially deaf children who do not at 
present, and, from what we know of the nature of the diseases which 
caused their deafness, are but little likely to, in the future, deserve classi- 
fication among semi-mutes. These arguments are included in the fur- 
ther objections to the establishment of separate classes for instruction, 
Which are— 
(2) The moral effect upon partially deaf children of making them, and 
recognizing them as, a class by themselves, and the exaggerated sense of 
their infirmity resulting from their being so set apart. The object of 
the public-school education is to fit the children for the best use of their 
mental powers in adult life, and to enable them to associate in the world 
Under circumstances which shall make their acquired knowledge best 
available for their own and the general good ; and this object would be 
in a measure defeated by the encouragement, in partially deaf children, of 
those feelings with regard to their infirmity which are one of the chief 
misfortunes°of the deaf-mute. To set them apart in the manner referred 
to, would be to permit an underestimate of their own powers, which, 
though every effort to counteract it should be made, wou 1 d necessarily 
carry its impress into adult life. 
(8) The loss of the beneficial association with hearing children, and of 
a proper spirit of emulation ; for since these children are to go out into 
the world, where they will be judged by the general standard of effort 
and success, it is best that they should associate in the beginning with 
those who are to be their companions or their opponents in the struggle 
for existence, and that they should be urged rather themselves to com- 
pensate for their defect than to expect compensation at the hands of 
others. More precisely, the association with hearing children helps 
toward the overcoming of certain faults which are common in children 
who are partially deaf? Partially deaf children are very apt to become 
heedless and inattentive; from not hearing occasionally, they get into 
the habit of not expecting to hear, and make less mental cftoit to com- 
bine such sounds of the voice, for instance, as they do hear, or to supply 
the deficiency of those which escape them. The ultimate effect of this 
habit, if uncorrected, on the mental development, is veij- decided; for, 
in these cases of partial deafness, nature does not seem to have made that 
effort at compensation which is so strikingly illustrated in the quickened 
perceptive powers of the deaf-mute. Again, many partially deaf children 
are almost morbidly sensitive on the subject of infirmity, and 
of their implied inferiority: a feeling which, if permitted or encour- 
aged, has a very unfortunate effect upon the child s efforts in its studies, 996 
BLAKE, 
and subsequently upon its efforts at the self-instruction and self-control 
of adult life. The association with hearing children, and that degree ot 
participation in class exercises which is possible under certain favoring 
conditions, tend to overcome the self-consciousness which is always more 
or less of a harrier in the way of advancement. 
(4) The final argument against consigning partially deaf children to a 
special class or school, lies in the fact, already mentioned, that the imper- 
fection of hearing is not a fixed factor in the problem. In the majority 
of the cases included in the analysis given, the hearing was susceptible 
of improvement, and in all of them was subject to temporary variation3 
during the progress of the disease or course of treatment. 
The best fulfilment of the second course under consideration, education 
in mixed classes, necessarily entails a determination of the degree of 
physical disability of the pupil, for which compensation is to be made. 
This may be accomplished in two ways, of which the best is by means of 
a competent professional examination of each case of supposed or evident 
deafness occurring in the pupils of, or those presented for admission to, 
a public school. This course offers the advantage of determining with 
accuracy, not only the degree of hearing, but also the character of the 
disease which causes the deafness, the amenability of the case to treat- 
ment, the probable course and duration of the disease, and its probable, 
ultimate effect upon the hearing; in very many cases, as may be judged 
from the statistics given, the need of treatment would be detected where 
otherwise it might have passed unnoticed. The establishment of the 
office of medical supervisor of public schools, the position to be filled by 
a qualified medical man wTho should devote his time to the duties of hi 3 
office, would cover this in addition to many more important needs h1 
connection with the hygiene of our public schools. 
In default of this more thorough method of examination, the object, 
as far as a determination of the degree of hearing is concerned, may be 
accomplished by the teacher, to whom may be committed the task ot 
classification according to certain simple rules for testing the hearing, 
applicable to all cases. The ordinary tests for the hearing, by means ot 
the watch and tuning-fork, or the use of other musical tones, are each ot 
precise value only when taken in connection with a competent examina- 
tion into the condition of the diseased organ, and a careful consideration 
of points of which only a professional observer is competent to judge- 
Careful tests of the hearing by means of the voice, however, in connection 
with one or other of the tests mentioned, would enable a competent 
teacher to determine whether a subject of partial deafness could be left 
to participate in the ordinary school-room exercises, in common wdth 
other children, or whether it would be necessary to give the child spe- 
cial attention. 
Following, for instance, the suggestions to be drawn from the obser- 
vations of Oscar Wolf on the musical value of the vowel and consonant 
sounds, and the effect which diseased conditions of the ear have upon 
the perception of consonant and vowrel sounds in combination, it is pos- 
sible to arrange a series of test-words which may be used by teachers as 
a standard test in schools. 
Each teacher may be provided with a form for tabulation of cases, 
which is to be preserved as a record of the degree of hearing power, ac- 
companied by instructions as to the method of conducting the examina- 
tion. These instructions should include a clear definition of the precau- 
tions to be taken in order to arrive at a correct estimate of the hearing, hearing of school children. 
997 
the personal opinion of the teacher being required only in remarks upon 
any other symptoms of disease of the ear, such as otorrhcea for instance, 
uch would seem to indicate the advisability of immediate treatment. 
Ie watch and the tuning-fork, or the tones of a musical instrument, may 
be employed as subsidiary tests, but the main reliance should be placed 
on tests with the voice for not only does the human voice, considered as 
a musical instrument, fulfil certain conditions as a test not otherwise 
attainable, but it is the voice of the teacher especially which the child 
is required to hear, and for the accurate hearing of which it is necessary 
that the child should be placed in such a position in the school-room as 
shall serve to compensate for its diminished hear in cr. As a rule there 
tore, the tests indicated should be repeated on the transference of a pupil 
from one room, or one teacher, to another, for every human voice has its 
peculiarities of pitch and quality, which give it, estimated as a test a 
hearing value of its own. These tests also may be repeated at intervals 
without proving a great addition to the labors of the teacher for the 
purpose of determining the average degree of hearing. 
. The hearing distance for the voice having been determined, the point 
ln the school-room at which all the test-words are distinctly heaVd should 
determine the position of the seat to be assigned to the pupil such prox- 
imity to the teacher as shall enable the particularly deaf pupil to hear 
the teacher’s voice as readily as a pupil with perfect hearing at the ex- 
treme limit of the room, being one of the compensatory advantages which 
his diminished hearing demands. Furthermore, the attention of the 
teacher should be directed to the necessity for giving such cases special 
attention, in such manner as to supply the loss of parts in class exercises 
which the pupil may have but imperfectly appreciated. A lack of 
knowledge on the part of teachers of the great obstacle which partial 
hiss of hearing may present to a proper appreciation of school exercises 
and the establishment of a fixed standard of instruction to which all the 
Pupils in a class are required to conform, results in added labor on the 
part of the partially deaf pupil, without the consideration which his 
imperfect ability in this respect should command. 
Passing from the consideration of those cases of partial deafness which 
biay be provided for in the manner above proposed, we have to consider 
fbe needs of that more unfortunate class whose hearing is so far impaired 
as. to render special instruction absolutely necessary. The objections 
Which were made to the separate instruction of the majority of partially 
deaf children, do not apply here. One of the earliest and most unfortu- 
nate consequences of extreme deafness, in children, is the impairment of 
speech ; with the loss of hearing is lost the medium through which the 
knowledge of speech is acquired, and the child gradually lapses into 
fbe use of gestures (to proclaim its wants) and the production of inar- 
tieulate sounds. To retain or to educate the power of speech, is, how- 
ever, but one of the objects to be attained by special instruction ; some 
means must be supplied which will compensate as far as possible for the 
loss of hearing, and prove another medium through which the child 
niay receive the same education as that afforded hearing children in the 
eoniraon school. The sense of sight may, in these cases, be called in aid 
aod the child may be taught to hear, as it were, with the eyes. 
Various systems for instruction in this so-called, visible speech, are in 
°peration, and their results, as far as I have been able to observe them 
are not merely encouraging, but eminently successful. Furthermore as 
every possible means of imparting instruction should be made available, 998 
BLAKE, 
in addition to education in lip-reading and articulation, such hearing 
as the child may possess should be utilized by the employment of arti- 
ficial means, if necessary, for the readier conveyance of sound to the ear- 
As a result of practical experience, and not merely upon theoretical 
grounds, the use of the hearing-trumpet, of one kind or another accord- 
ing to the requirements of the case, may he advised during school exer- 
cises ; indeed, in many cases, the use of such an instrument tends to 
improve the hearing not merely during the time of its use, but generally? 
the subjection of the ear to sound waves of larger amplitude either in- 
creasing the vibratory power of the sound-conducting apparatus of the 
middle ear, or acting as a stimulus to the auditory nerve. The proper 
application of these auxiliaries to instruction, necessitates therefore the 
formation of a separate class, for the benefit of which, as has been said, 
the public deaf-mute school, which now forms an important part of the 
Boston school system, and which must in time be engrafted upon the 
public school system of other large centres, may be made available. 
In the Boston school, the children are divided into two general classes, 
those who are total deaf-mutes, and those who are semi-mutes. Children 
in the latter class are instructed in articulation, for the purpose of over- 
coming faults which always exist where the hearing is imperfect, and in 
lip-reading, that they may learn to understand conversation from sight 
as a substitute for hearing. Such hearing as remains to them is also 
made useful in conveying ideas as to the formation of vocal compounds, 
by means of an ear-trumpet, if necessary, or by speaking directly into 
the ear. As the total deaf-mutes improve in articulation and lip-reading, 
they are advanced to the class consisting of semi-mutes, partly because 
the grade of instruction has become the same, and partly that they may 
profit by the example of those more fortunate companions who have had 
the advantage of having a little speech or a little hearing to start with* 
On this plan, the Boston schoql has now been in operation for five years, 
with increasing success and increasing evidence of its great value ; 
now provides for about sixty pupils, all of whom are instructed in lip' 
reading and articulation, the method employed being the system ot 
visible speech introduced in this country by A. Graham Bell. 
The conclusions drawn from a study of the subject of this paper, may 
be summed up as follows; 
I. The frequency of partial deafness in children, during the period ot 
school life, renders it advisable to make some definite provision in our 
public school system for compensatory instruction. 
11. Since partial deafness is a comparative terra, some provision should 
be made for a proper determination of the degree of disability. 
111. This may be best accomplished either by establishing a series of 
speech-tests, to be used by the teachers, or by instituting competent me- 
dical examination at the hands of a medical supervisor of schools; and 
the creation of such an office in connection with our public school system 
is strongly urged. 
IY. Partially deaf children, whose hearing is not so defective as to 
require special instruction in articulation and lip-reading, are better 
taught in mixed classes with those who hear well, compensatory advan- 
tages being allowed them according to their degree of disability. 
V. Partially deaf children, whose hearing is so defective as to interfere 
with the natural acquirement of articulation, and to render the ear ot 
little or no value as a medium for hearing, should be accorded the ad- HEARING OF SCHOOL CHILDREN. 
999 
Vantages of special instruction, of which education in articulation and 
Up-reading should form a part. 
Discussion on Dr. Blake’s Paper. 
After the reading of the preceding paper, Dr. Charles H. Burnett, of 
Philadelphia, said:—l would ask Dr. Blake if he has noticed, in the schools 
visited by him, whether adult mutes have been taught to talk? 
Dr. Blake said:—l have noticed, especially in the Northampton schools, 
that pupils who have reached the age of sixteen years, for instance, are taught 
to talk with very great difficulty. A deaf-mute taught in the sign language, 
learns to think in a language different from ours. One sign may convey two or 
three meanings, and its signification often depends upon the context. The 
deaf-mute’s arrangement of words in sentences resembles more closely that of 
the French, than that of the English, language. The success of deaf-mutes in 
the acquirement of articulation is sometimes very astonishing. The sound of 
the voice is at first harsh, and articulation is imperfect. But modulation of 
the voice is attained, in default of hearing, by the pupils learning to observe 
the sensations produced by speaking in the throat, by which means they soon 
learn to appreciate the difference between the rising and the falling inflection. 
There have been instances in which English deaf-mutes have been taught with 
such success that they have learned to speak French and German fluently, and 
1° 
sing harmoniously. 1000 
ON AURAL VERTIGO WITH VARIABLE HEARING. 
BY 
CHARLES H. BHRRETT, M.D., 
AURAL SURGEON TO THE PKESBYTERIAN HOSPITAL, PHILADELPHIA. 
Vertigo from disease of the semicircular canals has been fully recog- 
nized ever since the publication of Meniere’s papers on the subject. 
Guided by the description of his case, and, more recently, by the inves- 
tigations of Flourens and others respecting the physiology of the semi- 
circular canals, the tendency among medical men has been to ascribe all 
cases of acute aural vertigo, not directly traceable to some irritation in 
the external auditory canal, to disease in the labyrinth, preference being 
given to the semicircular canals as the seat of the direct lesion. 
Without entering into a discussion respecting the precise location of 
the lesion in labyrinthine vertigo, it can be comprehended why the deal- 
ness which is so marked a symptom of this disease, may be permanent. 
In fact, if the direct lesion be in the labyrinth, as it undoubtedly is, in 
true Meniere’s disease, one cannot understand how the deafness can fail 
to be permanent. In the affection known as Meniere’s disease, called also 
labyrinthine vertigo (Hinton), the chief symptoms are sudden tinnitus 
aurium, vertigo, reeling, falling without loss of consciousness, nausea, 
vomiting, and sudden, total, and permanent deafness in the affected ear. 
The other symptoms may occur in paroxysms for longer or shorter periods. 
Rut there are on record a few cases, and doubtless many others have 
occurred which have been recognized though not recorded in literature, 
in which all the above-named symptoms have existed, excepting the 
permanence of the deafness. Mr. Hinton records such cases,1 with the 
statement that the recovery of the hearing was perfect, and then raises 
the question “ were they not caused by muscular spasm ?” 
Especially noteworthy is that form of acute aural vertigo in which 
the hearing diminishes during the paroxysm, improves during the inter- 
val, and finally is restored when the paroxysms of tinnitus, vertigo, etc., 
cease to recur. In such cases, it is manifest that the direct lesion cannot 
be in the labyrinth, and the question might be asked, “ Are not such 
cases due to a spasmodic affection of the muscles of the tympanic cavity?’ 
Future investigations may show that such cases are caused by undue 
inward pressure of the stapes, which is brought about either by a tonic 
contraction of the tensor tympani, so powerful as to overcome the equi- 
librium normally existing between the latter and the stapedius, or by u 
relaxation of the latter muscle, which permits the normal tensor tynu- 
pani to act without the antagonistic counterbalance of the stapedius. A 9 
tending to answer in the affirmative the question which I have proposed, 
I would cite the following case:— 
Mr. X., aged 41, single, a stock broker, was brought to my door in a car- 
riage on May 8, 1875, apparently in collapse; upon approaching him, however, 
I found him conscious, but very pale and weak, and his surface cold and 
1 Questions of Aural Surgery, pp. 261-262. AURAL VERTIGO WITH VARIABLE HEARING. 
1001 
clammy. I was asked to accompany him immediately to his home, and while 
Wlg 80 Earned from him that he had been suddenly attacked about an hour 
ueiore, while attending a meeting of the Board of Brokers, with sudden and 
intense tmmtus annum and vertigo, with entire inability to stand, and that 
«e had finally vomited but that during all the time of this most disagreeable 
attach mind had been perfectly clear. I found his pulse about''75, but 
)eiy weak and he stated that there was still some vertigo, but that the buzzino- 
n the ear had given place to a stunned feeling” in the head, attended with a 
«on„g sensation winch seemed to start behind the auricle, and to extend inward 
jo the centre of the head. There was no complaint of altered hearing at this 
Jime biit I found that the hearing of the watch was reduced to A in. in the 
dnected ear. b 0 
The patient was put to bed, and, as his surface was very cold a little warm 
orandy and water were given, and warmth was applied to his feet In about 
an hour, the vertigo became much less, the' head was more comfortable and 
the face lost its intense pallor; pulse 80. The patient then stated that ’four 
°r five weeks before, he had noticed occasional attacks of slight tinnitus in the 
mft ear; this was brought on or increased by cold air blowing on the ear. A 
or two afterwards, he observed some dizziness with the noises in the ear 
and also some confusion in hearing, especially during the playing of the organ 
and the singing in church. The patient had had a good musical education 
and he stated that he heard all notes sharpened (heightened) in pitch in the 
left ear, which, of course, produced subjective discord with what he heard in 
the other ear. This was also true for the tuning-fork, small UA,” which seemed 
to him higher in pitch in the left or alfected ear. As the tinnitus passed off 
however, notes appeared once more to have their true pitch. 
With the cessation of the tinnitus, and with the return of the ability to hear 
notes in their true pitch, in the affected ear, the hearing also improved for the 
watch, rising from %% in., during the attacks, to in. as the paroxysms ceased. 
This variation in the to hear the watch occurred not only once but 
Repeatedly; and it was also observed that a mantel-clock, easily heard by the 
patient across the room in the affected ear, when unattacked by the paroxysms 
not heard during the latter. The left membrana tympani was more re- 
dacted than the right. The Eustachian tubes were easily inflatable; the fauces 
normal. There was a history of some stuffiness in the now affected ear, once 
after sleeping all night upon the ground, when in the army during the war. 
But beyond this, the patient knew of nothing out of the way in the ears. 
The patient remained in bed four days : On the first day, it was found that 
Rest in a reclining posture relieved the tinnitus and vertigo, but on the second 
day, a severe attack came on in bed, and lasted several hours. On the third 
an attempt to rise brought back all the symptoms, which were finally 
Relieved by vomiting. On the fourth day, another severe and long attack 
occurred. On the fifth daj', the patient observed that the “ stunned feeling” 
ffi the left side of the head, alternated with the tinnitus ; the latter invariably 
Preceded the attacks of vertigo, beginning as a low and distant singing or 
Ringing, and increasing to a loud roaring, which culminated in the vertigo and 
Oausea, On the sixth da\r, there was no attack. On the seventh, he felt very 
Rauch better until 11 A. M., when a severe paroxysm occurred; as a rule the 
attacks occurred in the afternoon or evening. On the eighth day, there was no 
attack, but on the ninth there was a light one. Again, on the tenth day, there 
no attack, but at midnight of the eleventh, there was a very severe parox- 
ysm of tinnitus and vertigo, which woke the patient up. Closing his eyes 
tad always aggravated the vertigo, and he now found that the darkness of his 
Room greatly increased the dizziness. Being entirely alone, and unable to help 
himself, he was obliged to call for a light in order to gain some relief from the 
terrible discomfort brought about by the vertigo. He felt as if his whole body 
being borne through space. Usually the apparent motion of surrounding 
objects, during the attacks, was around the patient from the right, over his 1002 
BURNETT, 
bead, to the left, under him and up again—that is, in a circle, the plane of 
which correspended pretty closely with that of the superior semicircular canal, 
and about at right angles with the antero-posterior diameter of the head. 
The severe attack of vertigo on the eleventh day, extended into the twelfth 
da}7, but there was no vomiting. On the thirteenth day, there were two attacks? 
but no vomiting. On the fourteenth day, there were again two attacks, but 
they were light, and there was no vomiting. On the fifteenth day, there was u° 
attack, but on the sixteenth day there was one very light and short paroxysm 
of tinnitus aurium and vertigo. On the seventeenth day, there was no attack, 
but on the eighteenth there was a very light one, which was the last the patient 
had. The hearing now became normal. 
Before these seizures.came on, the patient had been under intense mental ex- 
citement, and his general health had failed from the time of the financial panic of 
1873 to the date of his first attack of vertigo. He had also been, in this weak- 
ened and nervous condition, obliged by his business to endure the intense anti 
peculiar noise of the stock-brokers’ board, and also to strain his ears to heal’, 
and his vocal organs to perform his share of, the bidding which goes on ill 
such places. 
The treatment consisted in general support, with the administration of good 
food and some alcohol, together with large doses of bromide of potassium during 
the persistence of the paroxj-sms. As the latter diminished in severity, irou 
and quinine were given. On the sixth dajr of the disease, twenty grains of 
bromide of potassium were given every hour, and this was continued until the 
tenth day, when the patient took but ten grains every two hours. On the six- 
teenth day, the bromide was taken every three hours, and kept up in this way 
until the paroxysms had evidently ceased. 
The patient went to Europe, made a short tour, and returned to business m 
the autumn, about six months after his first attack of vertigo. There has been 
no severe return; this spring, when he was under considerable excitement once 
more, he had a slight return of the tinnitus, and a slight tendency to vertigo, 
but no sickness of stomach. A few days of rest, and from six to eight grain® 
of quinine daily, dissipated all these unpleasant warnings, and the patient has 
been able to continue his attention to business. 
This case of aural vertigo is especially interesting on account of the 
variable hearing which was so prominent a symptom during the disease, 
and also on account of the recovery of hearing which ensued when the 
paroxysms of tinnitus, vertigo, nausea, etc., ceased to recur. In fact, these 
features of the disease would tend to place it either in the list of those 
of infrequent occurrence, or among those the true nature of which fs 
not often recognized, and hence undescribed. It is well known that tbe 
prominent symptoms of aural vertigo, viz., sudden tinnitus, intense dizzi- 
ness, alteration in the hearing, nausea, vomiting, and falling, without 
loss of consciousness, may be caused by the irritation set up by the pres- 
ence of a foreign body in the external auditory canal. But here the 
cause is easily recognized and removed, and upon its removal the recovery 
is complete. The same general symptoms are notoriously characteristic 
of labyrinthine vertigo (Mdni&re’s disease), but there the deafness is sud- 
den, total, and permanent, though the paroxysms of vertigo may cease 
to recur. 
I have lately seen two cases of tumor in the brain (the one proven post 
mortem, the other diagnosed as such, but the patient still living), in 
which the new growths produced symptoms very much like those usually 
attending labyrinthine vertigo. Still, there were points of differential 
diagnosis in these cases. 
The subject of the first, a woman, suffered for many years with most of the 
distressing symptoms of Meniere’s disease, with the exception that she became AURAL VERTIGO WITH VARIABLE HEARING. 
1003 
flowly, entirely deaf, whereas the deafness in true, acute, labyrinthine vertigo 
ls sudden, intense, and permanent. In this case a post-mortem examination 
revealed the presence of two tumors,one on each auditory nerve; on the right 
side, the morbid growth, as large as a chestnut, seemed to have obliterated the 
herve, and extended into the porus acusticus interims,and apparently into the 
labyrinth. The microscopic examination of this growth has not yet been made. 
On the other side, the tumor, a smaller one, seemed to have simply grown in the 
auditory nerve, between the brain and the internal auditory canal. 
In the second case, that of a man, the presence of a tumor of the brain has been 
; the patient has some of the symptoms of aural vertigo, but there 
is permanent alteration of the gait, which is not characteristic of Meniere’s dis- 
ease, nor of any form of aural vertigo originating in the tympanum or external 
ear. Furthermore, the patient is not very hard of hearing (both ears are 
affected, as were in the first case), and, though he has constant tinnitus 
and paroxysms of vertigo, he can always relieve the giddiness by sitting down. 
While these cases may be classed under the head of aural vertigo, they are 
Manifestly not cases of primary labyrinthine disease. 
The case of Mr. X., given above, presented all the marked symptoms 
Which are found in aural vertigo of the labyrinthine variety, excepting 
the sudden, total, and permanent deafness; but this difference would 
exclude it entirely from aural vertigo due to primary labyrinthine dis- 
ease. The case certainly did not originate from irritation in the external 
auditory canal, and that it could have had its oiigin in cerebral tumor, 
is entirely out of the question, not only because such a supposition would 
be unwarranted bv the symptoms, but also because iecovei<y finally 
ensued. May it not be, however, classified as a case of aural vertigo of 
the tympanic variety, in which the primary lesion lay most probably in 
the muscular structures in the middle eai ? As tending to cause such a 
disturbance I would mention the intense strain on the vocal organs as 
Well as on the muscular accommodation of the tympanum, which neces- 
sarily occurs among those who frequent the biokers boaid, where bid- 
ding aloud and listening to bids go on. , . 
In conclusion, I would suggest that, in future invest,gallons of this 
most interesting and important disease, it would be well to make aural 
Vertigo” a general term; then four varieties of that disease could very 
easily be described, according to the anatomical situation of the cause, 
for there might be (1) Aural vertigo from external irritation (in the ex- 
ternal ear); '(2) Aural vertigo from tympanic disease (Mr. X. s case is an 
example); (3) Aural vertigo from labyrinthine disease (Mdmbre s disease); 
and (4) Aural vertigo from central irritation (cerebral tumors implicating 
the auditory nerve). Such careful distinctions in diagnosis are ex- 
tremely important, as aiding in prognosis—this being far more favorable 
in the first two than in the other varieties. 1004 
ON THE SEVERAL METHODS OF EDUCATING, AND ON TH$ 
SELECTION OF PROPER SCHOOLS FOR, THE 
DEAF AND DUMB. 
BY 
LAURENCE TURNBULL, M.D., 
TELLOW OF THE AMERICAN ASSOCIATION FOR THE ADVANCEMENT OF SCIENCE; AURAL SURGE01* 
TO JEFFERSON COLLEGE HOSPITAL; PHYSICIAN TO THE DEPARTMENT OF DISEASES 
OF THE EYE AND EAR, HOWARD HOSPITAL, PHILADELPHIA. 
The lot of the uneducated and ignorant deaf-mute is sad indeed; cut 
off from intercourse with his fellow-man by loss of speech, and unable to 
obtain instruction or amusement from such intercourse, or through books, 
he is left to “ Nature,” and is governed by naught but his animal passions 
and appetites. It is no wonder then that, when these latter are in full- 
development, he becomes allied to certain of the brute creation. From 
my own dissections of the brain of the deaf-mute, as from those of many 
careful observers, it is rendered probable that the deaf and dumb are 
capable of receiving and retaining as great an amount of intellectual 
knowledge as their hearing brothers or sisters, provided that adequate 
instruction be made available through the eye. 
As early as the fifteenth century, some effort was made to teach deaf- 
mutes, but it is to the sixteenth century that is due the great honor of 
having been the period of jubilee to the deaf and dumb ; and to the Abb 6 
de L’Fpde was given the great gift of teaching deaf-mutes by a symbolic 
language, so that they might know good from evil, have intercourse 
with a select few of their fellow-men, and above all acquire such aspi- 
rations after true knowledge as would fit them for a happy home here, 
and for a better world above. Another devoted man, the Abbe Sicard, 
who took up the clue already furnished by de L’Epde, adopted sign-lan- 
guage, and enlarged, improved, and reduced it to a system. The knowl- 
edge of this valuable method soon crossed the Atlantic, and its advocate, 
the Rev. Thomas H. Gallaudet, D.D., founded the American Asylum at 
Hartford, Conn. (1817), and, soon after (1820), M. Clerc (one of the favor- 
ite pupils of Sicard), who came over with Dr. Gallaudet, organized the 
Pennsylvania Institution for the Instruction of the Deaf and Dumb, in 
Philadelphia. This institution has sent out, since its organization, 1700 
pupils, well educated, and with a careful moral training which has been 
of inestimable advantage to them and to the community at large. Ger- 
many was not long after France in this philanthropic labor, for, in 1760, 
Samuel Heinicke, a Saxon by birth, developed the “ artificial method” 
of instruction for deaf-mutes. The principal aim of this good man was 
to improve the “French system,” and to endeavor to cultivate whatever 
might remain of speech, by developing the latent power which exists in 
all save a very few. In the early stage of this system, artificial signs 
are absolutely necessary; but when these have been acquired, they are to 
be employed only as a ladder to reach the higher department, where the 
finger-alphabet and other artificial signs are no longer required. When 
successfully taught by this system, pupils are enabled to think in the EDUCATION OF DEAF AND DUMB. 
1005 
1(lioms of the language of their country, to hold audible conversation, 
and so understand much that is spoken to them, being thus rendered 
practically less deaf, and actually less dumb. 
Another advance which has been made in the further improvement of 
the mode of instruction of the deaf-mute, comes from England, in the 
System known as “Bell’s Method of Visible Speech,” which, having re- 
vived but little attention in the country of its origin, was brought by its 
Author to the United States, where it has been received and adopted in 
seven of our forty-eight institutions, and with the most gratifying re- 
sults. I do not find fault with what has been done under the old me- 
thods, but rather rejoice that so many thousands of deaf-mutes have 
deceived the advantages of an education by means of the sign language, 
and of articulation taught by the German method. I would also state 
that the United States have a “ National College” at Washington, where 
tQore advanced studies can be pursued, and where young deaf-mutes are 
graduated with a standing and scholarship not inferior to that achieved 
by the graduates of ordinary colleges. This institution bears to others 
for the deaf and dumb, the same relation that colleges bear to schools 
and academies. Many of the graduates of this college have received 
appointments as teachers, while others are editors, authors, and writers, 
Or are found in the various government offices, in the exercise of duties 
Which they are quite capable of performing in an entirely satisfactory 
manner. In our Centennial Exhibition will be found some admirable 
pictures executed by deaf-mutes, as well as other products of their pencils 
and pens. They are also capable handicraftsmen, and are to be found in 
our shops and factories, as well as in the Industrial Homes founded in 
this city for their special benefit. _ 
Bell’s method or system of visible speech gives the pupil, by means of 
drawings etc. a knowledge of the concealed parts of the mouth and 
throat which ’are used in articulation, as also of the movements of the 
various parts, so that the pupil is thus better able to gain conscious con- 
trol over them This method of writing any sounds that the pupils may 
Utter serves to interest them in the practice of the elements and com- 
binations, thus giving them great power over their organs of speech, and 
obviating the necessity of informing them that a sound is wrong if it is 
not tlie one which the teacher wishes to obtain. It is the practice of 
those who teach this system to write all sounds m the visible speech- 
symbols, and especially those that are essential m English speech. The 
symbolizing of odd sounds also leads the pupil to think and study about 
the parts of the mouth that produce them. ~, ltn , . . , 
I shall now discuss the following questions: (1) What is the best me- 
thod of classifying deaf children, and is it advisable to place them in 
ordinary, or in splcial, schools? and (2) How many deaf-mutes are ca- 
pable of receiving Bell’s method of instruction, and should the attempt 
be made to instruct all deaf-mutes by articulation or by the sign language 
only ? Hot having heard Dr. Blake’s paper, I shall attempt to answer 
these questions from my own personal observations. 
If a child can hear sufficiently well to understand the teacher when 
near him, the ordinary school is, for him decidedly better than a special 
school. Children sometimes become deaf after having learned to talk 
and read; such children may profitably attend an ordinary school, pro- 
vided that the parents or teacher take time to explain the lessons; but 
if this be not done, the child will often recite in a parrot-like manner, 
Without understanding what he has learned, and will go over a great deal 1006 
TURNBULL, 
of ground with very little profit. This has been the experience 
teachers of deaf-mutes, even when the pupil has learned to read quit6 
well by observing the lips of the speaker. Congenital deaf-mutes, at- 
tending an ordinary school, may learn to write, or rather to copy, an(l 
may perhaps get some idea of numbers; but the teachers of such school3 
do not know how to reach their pupils’ minds, even if they have the tiro6 
to teach them. As a rule, such children might as well he at play, except 
that school occupies their time and their thoughts. Another advantage 
however, which is gained for the deaf-mute children, is in their mingling 
as much as possible with those who hear. 
If a child cannot profit by the instruction given in an ordinary school? 
let him if possible have a private teacher, but not necessarily in his oW1 
house, as he is not ahvays subject to the best government there. If be 
needs stimulating, it may be well to place him in a class with four or 
five others of a suitable degree of advancement; and if this cannot be 
done, he may be placed in a school or institution where the instruction 
is especially adapted to the deaf. 
If children are too deaf to profit by the common school, and yet have 
sufficient hearing to have acquired speech through the ear, instructors of 
the deaf are nearly or quite unanimous in the opinion that should 
he taught by articulation and lip-reading. The experience of the teachers 
would lead them to say, “ Let the attempt be made, if possible, to teach 
every deaf child in this way.” Of 116 pupils in the “Clark Institution 
for Deaf-Mutes,” three have been dismissed as incapable of learning arti- 
culation and lip-reading, and one because she required more individual 
instruction than could be given her. The latter, however, has since been 
taught, so that speech and lip-reading are her means of communication 
in her own home. Some of the remaining number of pupils (congenital 
mutes) speak imperfectly, but in every instance well enough to be under- 
stood in their own homes, while some of the indifferent speakers ar® 
fairly successful in lip-reading, an acquisition as valuable as that of 
speaking. Many congenital mutes speak so as to be understood by 
strangers, and will probably be able to make speech and lip-reading a 
successful means of communication throughout the world. Of the lib 
pupils at the above-named institution, one-third are semi-mutes or semi' 
deaf, although some of those so classed have not had hearing enough to 
learn to talk. 
My object in writing this brief paper has been : (1) To excite a greater 
degree of interest, in physicians, for the deaf-mute, with an endeavor on 
their part to prevent deafness, and so diminish the number of deaf-mutes ; 
(2) To induce a more conscientious study and treatment, by physicians, 
of the ears of their patients, when the latter are attacked by scarlet or 
typhoid fever, cerebro-spinal meningitis, or obstruction of the Eustachian 
tubes as the result of measles, diphtheria, tonsillitis, or syphilis; (3) To 
lead physicians to give the systems of instruction pursued in our various 
institutions for the deaf and dumb, a certain amount of study, so as to be 
able to recommend intelligently to patients, their relatives, or friends, the 
best method for each individual case; and (4) To induce physicians to 
recommend that there should be appointed by the governor of each State, 
a commissioner, to collect, examine, and classify the deaf and dumb, so 
that all who are found to possess any degree of hearing, or any remnant 
of speech, may be taught articulation by the method of Bell, and that 
those who are unable to profit by this system, may be taught the lan- 
guage of signs, natural or acquired. EDUCATION OF DEAF AND DUMB. 
1007 
To aid them in their arduous work, I have recommended to some of 
°nr teachers of deaf-mutes, that their pupils should use mechanical appli- 
ances for improving the hearing power. By speaking or singing differ- 
ent vowels into one of these aids to hearing (tubes or trumpets), we can 
determine how much hearing the pupil possesses, and, if he be able to 
distinguish one vowel from another, a continued use of this mechanical 
aid may ultimately enable him to utilize audition as an auxiliary to 
vision. I have known very deaf persons, by the aid of this means alone, 
to have had their hearing so much improved that they could distinguish 
all ordinary sounds, and, by some effort, enter into conversation. An- 
other important mechanical aid to persons who are deaf from diseases 
in which the tympanic membrane is lost, in part or in whole, but in which 
the inner small hone (the stapes) still remains, or in whose ears the bones 
have become stiff or anchylosed, is the pellet of cot:on, moistened and 
applied near to the bones, or against the stapes, so as to bring the parts 
in closer contact with external vibrations, and thus lause the sounds to 
be transmitted to the auditory nerve. 
In conclusion, I have added, chiefly from German authorities, the most 
recent views on the subject of phonation, knowing how much interest 
this subject is exciting in the minds of both physicians and teachers of 
the deaf and dumb, at the present day. Some writers have endeavored 
to prove that the brain molecules of the deaf and dumb differ from those 
of persons who hear 5 but, as I have already stated, the brain is rarely 
affected in those that are deaf, while, on the other hand, in many 
instances of extensive disease of the biain, not involving the auditory 
nerve, deafness has not resulted. Occasionally the spine is diseased, or 
the nerves which, coming from that great centie, give power to the 
tongue and larynx, thus rendering the deaf-mute unable to articulate, no 
matter how much instruction he may receive. Section of the spinal 
accessory, or of the inferior laryngeal nerve, entiiely destioys the voice, 
so that these may be termed the true vocal nerves. If, therefore, the 
centre of phonation is situated in the spinal coid, it is plain that it can- 
not be found in the brain; anencephalous children have been known 
to scream under the influence of external excitation 01 intei nal pain. 
The centre of the memory for words, appears to leside in the brain, and 
attempts have been made to fix its seat in the anteiior lobes, but the 
observations made on this subject are asjmt contradictoiy. Each centie 
is independent of the other, for a cry may be easily utteied when articu- 
lation is very difficult. Amnesia, or the loss of memory for words, there- 
fore, must be distinguished from ajihttsitt, or the loss of power to pionounce 
them; the patient "suffering from aphasia can still write his thoughts, 
While in amnesia he can only express himself by drawing a representa- 
tion of the object to which he wishes to refer. 1008 
ON BATHING, SWIMMING, AND DIVING, AS CAUSES OF 
AURAL DISEASE. 
BY 
LAURENCE TURNBULL, M.D., 
FELLOW OF THE AMERICAN ASSOCIATION FOR THE ADVANCEMENT OF SCIENCE ; AURAL SURGE0*1 
TO JEFFERSON COLLEGE HOSPITAL; PHYSICIAN TO THE DEPARTMENT OF DISEASES 
OF THE EYE AND EAR, HOWARD HOSPITAL, PHILADELPHIA. 
Swimming and diving in cold water seem to me to be important and 
frequent causes of disease of the external auditory canal and anterior 
surface of the membrana tympani, as also of the middle ear, though bath- 
ing in river or sea water is, when wisely and properly regulated, both 
healthful and pleasant. The evils attending bathing and swimming nj 
cold water are the entrance of this cold fluid, not only into the external 
meatus, but as far as the membrana tympani, causing inflammation ot 
the lower portion of the auditory canal, and of the anterior surface of the 
tympanic membrane. But a still greater evil is from sudden deglutition, 
during diving or swimming, by which—the mouth, nose, and pharynx 
being filled with cold water, and the mouths of the Eustachian tubes 
open—a portion of the water passes into the middle ear. This result 
rarely occurs in expert swimmers or divers, but is most common in begin- 
ners, who suddenly, from cold, or the shock of the contact of the water, 
breathe or swallow in a sobbing manner. I have, however, known it to 
occur in old and experienced swimmers while plunging headforemost, 
owing to the intense coldness of the water—the act of deglutition being 
entirely involuntary. 
If the water is not removed by placing the head to one side, and draw- 
ing the external ear forcibly outwards, shaking the head at the same 
time and opening the mouth, it is apt to cause inflammation, with the 
formation of pus, followed by perforation of the membrana tympani ; or 
the inflammation, if neglected, may pass inwards to the cochlea and 
labyrinth, and, implicating the brain, may terminate in death. 
It is a well-recognized maxim among those who devote special atten- 
tion to diseases of the ear, that no cold fluid should be allowed to enter 
even the external auditory canal; still this important fact is not suffi- 
ciently recognized by the profession at large. The entrance of warm water 
into the ear is less objectionable, but even this is not quite free from dan- 
ger, and has its disadvantages; and the water should in all cases contain 
a few grains of a saline ingredient, like borax, soda, or common salt, when 
employed in washing out the ear. The symptoms of water in the mid- 
dle ear are, in the first stage, an uncomfortable sensation, followed by 
earache or pain, which after a time becomes agonizing, and is accompa- 
nied with great tenderness behind the auricle. In proof that water in 
the ears is injurious, and causes deafness, I might cite a number of in- 
stances, and it is a well-known fact that dogs which are thrown into 
water become deaf. 
Many cases of this form of disease, in its chronic stage, come under 
treatment during all seasons, but acute cases, from swimming and diving, 
occur during the summer months, and chiefly in boys from eight to six- Bathing, swimming, etc., as causes of aural disease. 
1009 
teen years of age ; a much smaller number occurring in the fall and win- 
ter. If the acute form be promptly treated, entire recovery takes place; 
but should the case not be seen until after the chill, it is always followed 
by a discharge of shorter or longer duration. In cases not recognized, 
the symptoms of violent headache, furious delirium, and coma, give the 
physician the impression that disease of the brain is present, and the case 
thus improperly treated terminates in death. The morbid condition in the 
first stage consists in acute inflammation of the extremely delicate mucous 
membrane lining the middle ear. This inflammation is followed by effu- 
sion of fluid, and, after twenty-four hours, by the formation of pus; it is 
in every instance attended by fever, with swelling and inflammation of 
the nasopharyngeal space, and great 
by incision into the membrana tympani, followed by the use of the air 
douche, and injections of hot saline water, the patient recovers, and the 
ear is saved. The patient is apt to remain deaf for several weeks, and 
the local application of tincture of iodine, with or without some anodyne, 
brushed around the back of the auricle, facilitates the removal of the in- 
flammatory thickening. To diminish the discharge of pus, should it 
continue, we may employ a powder of salicylic acid and starch, blown 
into the meatus and after a time washed out, and reapplied twice a day, 
until the discharge shall have ceased and the perforation have become 
closed. 1011 
SECTION ON SANITARY SCIENCE 
PRESIDENT OF THE SECTION 
STEPHEN SMITH, M.D., 
VICE-PRESIDENT 
OP NEW VORK. 
JOHN S. BILLINGS, M.U., U. S. A 
OF WASHINGTON. 
SECRETARY. 
EZRA M. HUNT, M.D., 
OF METUCHEN, NEW JERSEY. 
the present condition of the evidence concerning 
“DISEASE-GERMS.” 
BY 
THOMAS E. SATTERTHWAITE, M.D., 
OP NEWYORK. 
The object of this paper is to give a sketch of the prominent theories 
Low held as to the nature of disease-poisons. It seems hardly necessarv 
for me to say that the short space of time at ray disposal will prevent me 
from attempting to furnish either a detailed account, or even a review, of 
the ample material that may be brought to bear upon these matters. I 
desire, however, to state this clearly at the outset, because I am sure 
that in the presence of the vast number of observations that have been 
Blade, especially during the past few years, nothing short of a very 
extended treatise could be made to fairly represent the whole subject. 
Fortunately, my task is limited by the title of my paper, but I find 
Biyself at the same time in the difficult position of one who is called 
upon to define the proper limits of the subject, or, in other words, to 
Biark out the debatable ground. 
In doing this, I have thought it desirable to direct the attention of 
the Section chiefly to a certain number of important topics bearing upon 
the subject, as in this way we can get a better idea of its present status 
and I have naturally included among the topics those with regard to 
Which I have had the most personal experience. 
It is a matter of regret that I shall be obliged to omit many facts of 
historical interest, as well as the names of well-known men, who, like 
Fasteur, Sanderson, Salisbury, and others, have enriched the field bv 
original research. I shall also have to run the risk of appearing doo-. 
Biatic, in assuming that certain questions have virtually been settled or 
that others do not concern us. I shall thus take it for granted that the 
niinute, vegetable organisms, called bacteria, exist pretty generally in 1012 
SATTERTHWAITE, 
nature, both in and out of the body ; and, following the acceptance of 
this idea, that the question of spontaneous generation need not be intro- 
duced into the present matter in hand. 
Almost any one, who for the first time follows the discussions on these 
subjects, encounters a little difficulty in the wrord germ, which is, per- 
haps, not a happy one to have come into use as expressing that from 
which a disease is derived. This, however, is its true meaning, and 
neither indicates a vegetable nor an animal character, nor even .that it is 
living, though this latter notion is held by Beale.1 For even should a 
disease-poison turn out to be a chemical substance, the term “germ” i 8 
equally applicable to it, according to the proper definition of the word. 
In fact, under this threefold character, we are called upon to study these 
active principles, for about these three possibilities, of a vegetable, an 
animal, or a chemical, character, are grouped the three prominent theories 
that have been framed to explain the origin of infective diseases. These 
theories, or hypotheses, as they might be more properly called, are (1) 
the vegetable-germ, (2) the bioplasm, and (8) the physico-chemical, 
theory. The infective diseases are such, in a general sense, as are either 
propagated by direct contact, or through the medium of the air, various 
gases, fluids, or common objects. Inquiries have mostly been directed 
to such of these as are called septic, viz., erysipelas, pyaemia, septicaemia, 
and puerperal fever, and to others known as contagious, miasmatic, and 
the like, such as smallpox and typhoid fever. 
I shall try to sketch these theories briefly:— 
I. The “ vegetable-germ theory” is the one that heretofore has 
attracted more attention and interest than any other. Though we 
have known it under this name for only a comparatively short time, it 
is not of recent origin, and has in reality been recognized from very 
early times in the history of medicine. It was at first, of course, merely 
a hypothesis of the flimsiest character, though it soon came to be re- 
garded as a possible one, when .the microscope showed that both animal 
and vegetable organisms, of exceedingly minute size, lived and grew in 
the interior of the body. 
More color was given to this theory by the labors of Sch-wann, Cag- 
niard de Latour, and Kutzing,2 who found that in fermenting matters 
there was a growth and multiplication of minute organisms, which they 
regarded as vegetable ; when at a later period Pasteur3 asserted that these 
particles were conditions essential to fermentation, then it came to be 
assumed that the phenomena of disease, which in many respects resem- 
bled them, might be due to an analogous cause. It was in this way that 
the doctrine of vegetable germs as the cause of disease came to be re- 
garded as having good d 'priori evidence in its favor. This belief was 
further strengthened by Schonlein, wdio, in 1838, published his account 
of the fungus plant found in Favus, which is now almost universally 
believed to be caused by the deposit and development of the plant in the 
diseased part. As. further investigations were made, the silk-worm dis- 
ease, and the potato-rot, or murrain, were also admitted to be caused by 
growths of a similar nature. 
More recently it has been held that a great many of the infective dis- 
1 Disease-Germs, p. 10. 
2 Schiitzenberger on Fermentations, pp. 36-7. 
3 Bastian; Lancet, April 10, 1875, p. 502. DISEASE-GERMS. 
1013 
eases have each a microphyte,1 or minute, microscopic plant, as its peculiar 
active principle. These latter alleged discoveries have, however, been 
received with marked opposition, many excellent authorities refusing to 
accept these matters as definitely proved. 
11. Other hypotheses had, therefore, to be brought forward, and promi- 
nent among them was that of Beale,2 who, admitting that particles of 
minute size may produce disease, and in fact laying stress upon this point, 
believes that the particles in question are degraded portions of the animal 
body. Such particles he tells us have been seen by him, when using a 
sufficiently powerful lens, and he assures us that they divide and sub- 
divide under suitable conditions, and “ as living matters alone divide.” 
Ross3 has a modification of the same idea, and Hutchinson4 states, 
with reference to certain diseases at least, such as gonorrhoea, purulent 
ophthalmia, erysipelas, and phagedtcna, that they are due to the conta- 
gion of living cell-material, such as is called protoplasm, or bioplasm. 
These tenets, with more or less modification, are sustained by those who 
believe in the “bioplasm theory.” 
111. Bastian deserves to rank as the ablest exponent of the remaining 
theory, the “physico-chemical,” ®r “physical.” It is called a modifica- 
tion of Liebig’s old theory, and, as now enunciated, holds that though 
minute organisms may act as ferments, they do so by virtue of chemical 
actions set up by them, while minute particles of the human body have 
almost an equal capacity for setting up diseased action under suitable 
circumstances. In either case, bacteria are apt to be engendered as cor- 
relative products.5 
It will be noticed that two of these theories are based upon the belief 
that the origin of disease is due to minute particles, and that this belief 
does not militate against the third theory, and is admitted as possible by 
its advocates. This simplifies the matter before us very considerably, 
and enables us to state at once that these poisons are particulate, or cer- 
tainly that they are apt to be bound up with particles.6 I will merely 
add here that, in my experience, it may be possible that this has always 
been the case; some of the particles or molecules, may, of course, be 
almost immeasurably small. 
We may get a good idea of the controversial points by considering 
first the arguments brought forward by those who support the vegetable- 
germ theory, and then the answers or explanations of its opponents. 
I have already stated that after the publication of I asteui s bril- 
liant experiments in relation to fermentation and putiefaction, they 
Were regarded as affording good, a priori evidence of the truth of the 
doctrine now under consideration. But it must be lemembeied that, 
thou°'h sustained by the observations of many others, these views were 
strenuously opposed by Willis, Stahl, Liebig, and others, chiefly of the 
German school.7 There is little doubt now that these latter were in a 
measure correct \ in fact, Pasteur3 has seen fit to modify some of his 
earlier statements, for he quite recently has said that both alcoholic fer- 
mentation and putrefaction may be initiated by the chemical processes 
1 Such as the diphtheria-micrococcus of Letzerich, the cholera-fungus of Hallier, and the 
measles-fungus of Salisbury. , T , 
Disease Germs, pp. 5 and 11. 3 British Medical Journal, May 27, 1876, p. 22. 
4 Ibid., April 24, 1875, p. 559. 5 Lancet, April 10, 18 u. . _ 
6 There is excellent evidence of this in all the diseases which are alluded to in this paper. 
7 Schiitzenberger, p. 40. 
8 Lancet, April 10, 1875, p. 508; and Tribune Medicale, Avnl 1, 18 <o, p. 321. 1014 
SATTERTHWAITE, 
taking place in the tissue-elements of certain fruits and vegetables, inde- 
pendently of the minute organisms supposed to be necessary to the pi’o' 
cess. Similar statements had previously been made by MM. Le Chartier 
and Bellamy, who found that, in modified forms of fermentation, inde- 
pendent organisms were generally absent at first, though they often made 
their appearance afterwards. Among the late contributors to this subject 
is Dougall,1 who tells us that he has produced putrefaction without bacteria, 
and has seen bacteria without putrefaction—in which latter statement 
he can doubtless find many to accord with him. 
Hiller2 has also made statements to the same effect, for, having injected 
fresh eggs with a fluid containing bacteria, but not putrid, the eggs 
remained unaffected, which showed that bacteria might be present with- 
out decomposition ensuing. These views have been further supported by 
Donnd and Beauchamp.3 They are interesting, as showing that there 
has been, and still is, a diversity of opinion among scientific men as to 
the r6le which organisms play in fermentation and putrefaction. I may 
here add, also, that, in regard to the question of the ferment or cause of 
the ammoniacal decomposition of the urine, or fermentation, as it has 
been called, Pasteur4 has stated definitejy that it has not yet been demon- 
strated mathematically that the little torula to which he called attention 
several years ago, is the cause of the change, though he asserts that 
whenever putrid urine is examined the little plant is found. 
(2) Another argument, commonly urged by those who believe in the 
vegetable-germ theory, is as follows; Almost all authorities admit that 
minute organisms may be the sole and sufficient cause of diseases such 
as scabies, favus, and the like, while many epidemic diseases among 
plants and animals are similarly produced, so that it is reasonable to 
suppose that vegetable organisms may be concerned in the production of 
infective diseases, the origin and propagation of which are thus explained 
with comparative ease. In reply, it is to be said that while no one 
may be willing to deny these facts, and while the silk-worm disease and 
potato-rot may be due to the vegetable particles that have been described; 
while various cereals may be affected with peculiar diseases, each exhibit- 
ing a peculiar plant; and while the pollen of many grasses may be the 
real cause of the hay-catarrh, or fever, as maintained by Blackley,5 yet, 
that, on the other hand, it is certain that close observation in certain 
other directions shows the number of diseases due to vegetable growths 
to be really smaller than wTas formerly supposed. One has but to compare 
the long series of skin-diseases which but a short time ago were put down 
as caused by microphytes, with the modest list of five possible and three 
probable organisms, which are mentioned by a recent authority in these 
matters.6 1 refer to the Achorion of Favus, the Tricophyton of Tinea, 
and the Microsporon of Pityriasis versicolor. 
The recent investigations of Lewis and Cunningham point in the same 
direction. They make it appear probable that in the Fungus-foot of 
India, the peculiar growth called Mycetoma is not necessary to the dis- 
ease, as in some instances it has not been found, though the examinations 
were doubtless conducted with skill and care.7 In the light of these and 
similar experiences, it would appear that while we are now and then dis- 
1 British Medical Journal, April 24, 1875, p. 557. 
2 Oentralblatt f. der med. Wiss., Dec. 1874. 
3 Schutzenberger, p. 225. 4 Loc. cit. 
5 Experimental Researches on Hay Fever, 1873. 6 Piffard, Diseases of the Skin. 
7 Lancet. January 22, 1876. DISEASE-GERMS. 
1015 
covering new plants or animals that act as disease-agents, we at the same 
time sometimes find that the number of such alleged causes of disease 
has been too large. 
(3) It is further said that, in a number of the infective diseases, such 
as smallpox, typhoid fever, etc., there is a constant ratio between the 
intensity (*f the disease, in a given part, and the presence of bacteria ; so 
that, where the disease is most active, bacteria are most numerous. This 
indeed, is just what we should expect, in support of the vegetable-germ 
theory, and it is a fact that few of its opponents are prepared to deny. 
But it has long ago been shown by Schwann and others,1 and more 
recently by Tyndall,2 that the air at times swarms with bacteria; and it 
is also true that bacteria occur in the body in health, the mucous mem- 
brane of the alimentary canal, from the mouth to the anus, having been 
found peopled by myriads of them in active, independent motion.3 "These 
facts have been so generally confirmed, that, as it may be remembered, I 
assumed them at the outset. Now bacteria are also found in the heart 
of the tissues, which is explained by the fact that they are taken up by 
the absorbents, and carried about, while they have, in a certain number 
of instances, been found in the blood of the lower animals, and some- 
times in human blood,4 hfow, as long as this remains true, it is for 
those who maintain this theory to show that there is a manifest differ- 
ence between the bacteria which they believe to be disease-agents, and 
those that we know are generally to be found in the tissues; for the 
mere fact that bacteria are found in extraordinary quantity at any one 
point, does not by any means indicate disease. In a large number of 
experiments, performed by Dr. Curtis and myself, it was found that, 
under certain circumstances not incompatible with ordinarily good 
health, vast collections of bacteria were to be found upon the tongue. 
Under these circumstances, it seems to me perfectly proper to believe 
that bacteria occur in the diseases just named as correlative products, 
and not as causes, of the disease. I may here venture to state that, as 
far as diphtheria is concerned, and upon this matter I have made some 
special study, I have never found any organisms connected with the 
disease that could in any way be distinguished from those found at other 
times in the body.5 Of these experiments, I shall say more presently. 
(4) Now, while it is further alleged that, in another class of diseases, 
such as erysipelas and pyaemia, septicaemia, puerperal fever, and hospital 
gangrene, there is always a numerical increase of bacteria at the points 
involved, we may be allowed to state, in this case also, that, the presence 
of bacteria in the body being allowed, their tendency to accumulate in 
diseased portions does not necessarily that they have any relation 
with the cause of the disease; and when the question is further asked, 
how may we distinguish the bacteria of such diseases from each other, 
or from those of putrid infusions, I think that the same difficulty will 
be found as in the case of the other infective diseases, before mentioned. 
(5) An important question is often asked, viz., Can any strictly chemical 
substance be a fever-producer, or do we know of any substance, whose 
chemical nature we can express by symbols, that can produce fever? 
This is a question usually put to those who advocate the physico-chemical 
1 Beale and Sanderson. _ Lancet, May 8, 1875. 
3 Bastian however, seems inclined to believe that these organisms do not come from the 
air> 4 Wagstaife and others. 
5’ See Report on the Pathology of Diphtheria, in Report of the Board of Health of the 
City of New York, for 1877. 1016 
SATTERTH WAITE, 
theory of disease. It may be impossible to answer it affirmatively, and 
yet this by no means settles the matter. The minute chemistry of animal 
poisons is far from being as yet in a satisfactory condition, but we can- 
not therefore say that such substances may not at some time be found. 
Weir Mitchell,1 of Philadelphia, in his most extensive researches on the 
poison of the rattlesnake, assures us that the poison is an albuminoid 
body (which he calls crotaline), which is not precipitated by boiling, but 
is by alcohol. Prince Bonaparte seems to have found, also, that the 
venom of the viper contains a similar, albuminoid substance, which he 
has called echidnine. Hiller2 also believes that, in glycerine, he has found 
a material that has the power of extracting certain chemical poisons in 
putrid and septic matters. We see, therefore, that a certain definiteness 
has been reached in our estimation of a few active principles, and it is 
possible that when this field has been more actively worked by the 
chemist, we may find those other matters which the microscope has 
failed to analyze, and which yet may react in a definite way, so as to 
show individual characteristics. It is also reasonable to suppose that 
chemical combinations of more or less complexity may be formed in the 
body, under the influence of peculiar processes, or of the presence of viru- 
lent matter, and then, in either case, may communicate like qualities to 
other ordinary matter of the body ; for the venom of serpents is certainly 
formed out of the normal tissue-elements. In the case of chemical com- 
pounds, they may increase to an indefinite amount when placed in suit- 
able liquids, where the proper constituents are present. 
(6) It is also maintained, by the vegetable-germ theorists, that the 
extraordinary capacity which disease-poisons have of retaining their 
vitality, is a strong argument in favor of their being bacteria, which 
resist various reagents, and exposure to extreme degrees of heat and 
cold, and which may remain dormant for long periods of time, without 
losing their capacity for reproduction. It is known, however, that the 
poison of the rattlesnake resists boiling, and is not rendered less virulent 
by alcohol; and Fayrer3 has asserted that this latter quality belongs to 
the poison of the cobra; but both boiling and alcohol prevent the multi- 
plication of bacteria, according to the testimony of so large a majority of 
observers that this point has seemed to me sufficiently settled. Whether 
or not minute particles of human tissue are capable of living long after 
separation from the body, is still a question before us, and not one that 
can just yet be summarily dismissed, as some would imply.4 But if it 
should prove true that the little particles of living matter soon lose their 
capacity for reproduction, it does not follow that they have lost their 
power of acting in such a way as to communicate qualities to, or set up 
actions in, other particles. This is advocated by one who believes in the 
physico-chemical theory. 
(7) Again, it is frequently urged by those who believe in the vege- 
table-germ theory, that the bacteria of certain diseases will induce like 
diseases in other persons or animals, when inoculated. This may be true 
in the case of individuals, though there is testimony against, as well as 
for, this assertion.5 
I may here state that the results of my experiments and of those of Hr. 
Curtis, in regard to diphtheria, have failed to show that the inoculation 
of the bacteria of diphtheritic membranes upon animals produce any 
1 Smithsonian Contribution, p. 46. 2 Centralblatt f. Chir., 14, 15, 1876. 
3 Edinburgh Medical Journal, 1868 et seq. 4 Sanderson. 
5 Compare the statements of Wolff, Kiissner, and others. DISEASE-GERMS. 
1017 
other lesions than those of bacteria artificially reared or obtained from 
our own months. Hiller1 proposed to himself the following questions; 
whether (1) bacteria had the property of exciting inflammation, when 
inoculated ? or (2) if in the blood did they produce fever? or (3)’multi- 
Pjy ?or (4) have the capacity of penetrating living organisms ? He expe- 
rimented on animals, using the bacteria taken from different kinds of 
decomposing substances. The temperature rose, but not above 2° Fahr.; 
°n the third day, the bacteria at the point of inoculation were shrivelled, 
pud on the eighth day they had disappeared. Even when introduced 
into the living blood, they soon ceased to be recognized, though in blood 
eXposed to the air they multiplied rapidly. In this connection, the expe- 
riment which Hiller made upon himself, the results of which he exhibited 
last year’s meeting of the German Surgical Society, deserves more than 
a passing notice.2 He allowed himself to be punctured in eight places 
With bacteria, which he had isolated by a method of his own. When 
these punctures were exhibited at the Congress, six days afterwards, they 
bad nearly healed, no traces of redness, inflammation, or pustule, remain- 
ing. He also showed another place where he had been subcutaneously 
inoculated three days before with a fluid containing bacteria. There had 
been local oedema, occurring six hours afterwards, but it had disappeared 
in forty-eight hours, and on the day in which he made his communica- 
tion to the Society his general condition was excellent, his appetite was 
good, and he had no fever. 
My own experiments on animals agree in a certain number of instances 
With those of Hiller. When the bacteria were filtered out of Cohn’s 
Nutrient fluid,3 in which they are known to grow with exceeding rapidity, 
and were inoculated in the thighs of rabbits, the organisms ceased to be 
visible after the fourteenth day, though there was usually a marked 
deposit of a pasty material at the point of inoculation. The same thing 
Was observed when inoculations were made with tongue-scrapings, or 
With diphtheritic membrane; the bacteria soon ceased to multiply, 
fbough the time at which the process stopped was variable ; they became 
bloated and distorted, so that it was hard to make them out; after three 
Weeks, they were rarely seen at all, though the focus of disease remained 
extensive, the animals quite often dying at a later date with symptoms 
°f constitutional infection. Still, in all of these experiments it is not 
probable that the bacteria were ever completely isolated, for even when 
Cohn’s fluid was used, where the only organic substance was the tar- 
trate, fermentation took place, and some of the products of fermentation, 
Perhaps in the form of minute particles, may have attached themselves 
to the bacteria which then may have been carriers of the poison 'itself a 
pbemical product. And yet I have, hi repeated instances, seen fluids 
inoculated upon rabbits, where the microscope showed bacteria in con- 
siderable numbers, though no trace of a lesion was observed. 
We have now to consider a topic of great importance to us, in further 
defining our subject, and this is the classification of the organisms that 
are now called bacteria, to which class the vegetable-germ theorists, 
almost without exception, refer the agency of disease. Their name does 
Hot by any means imply that they are all rod-shaped, though the word 
bacterium means a little rod, but rather that they belong to a class of which 
1 Allg. med. central Ztg., 1, 2, 1874. 2 Archiv f. Klin Chirargie, 1875. 
3 Tartrate of ammonium, 1 gramme; phosphate of potassium sulphate of magnesium, 
*ach, 5 decigrammes; phosphate of calcium, 5 centigrammes; distilled water, 100 cubic 
Ce utimetres. 1018 
SATTERTHWAITE, 
the rod-shaped bodies are common types. Various classifications hav® 
been given of them, those of Billroth and Cohn having met with specif 
favor, and each of these being tolerably complete. I will venture to sa}'? 
however, that no elaborate classification appears to be necessary for these 
bodies, judging at least from our present knowledge of them, so that 1 
shall describe them by common terras, which can be as well understood 
by those who are not familiar with these matters as by those who have 
carefully studied them. Simple as the classification will be, it is per' 
haps convenient rather than accurate, for while it seems to me to cover 
the whole ground, it may be questioned whether it does not do morel 
i. e., give a reality to some forms the existence of which is in doubt. 
First we have (a) the very minute, round bodies, varying in size frold 
those which are described as having a diameter so small that they cad 
barely be seen by the ordinary high powers of the microscope, up to those 
which have a diameter of about of an inch; these are the Micro- 
cocci of Cohn, and the Microbacteria of Billroth ; then we have (b) the 
little, oblong, or slightly oval, bodies that have a length of about one- 
third the diameter of a lymphoid corpuscle, and a breadth of about 
of an inch; they occur singly, or in chains of two or more elements I 
thirdly, there are (c) the little chains which often appear to be made iff 
of minute spheroids; fourthly ((d), the globular masses that appear to be 
made up of spherical bodies (Zoogloea of Cohn, Colonies of Hallier, Gib1' 
coccos of Billroth); and fifthly (e), the filamentous bodies which are so 
often seen to glide about with an undulating or serpentine movement 
across the field of the microscope (Spirilla of Cohn). 
I use the term bacteria for all these forms, and yet, as I have already 
said, objection may be made to this classification. It is held by sod10 
that the round particles known as micrococci, are nothing but either the 
rod-bacteria, seen end-wise, or merely particles of dead granular matter, 
or perhaps particles from the living protoplasm of cells. It is probably 
true that many mistakes of this kind have been made, and yet I should 
feel disinclined to believe that there are no round bacterial bodies, coming 
within the range already given, for it has seemed to me that the chain8 
just described are composed of minute spheroids. As for the filamentous 
bodies known as spirilla, they are also thought by some to be composed 
of spheres. These bodies when single, or in segments, have two states, 
one of activity and one of rest ; but mere absence of motion does not 
necessarily indicate that they have ceased to live, for under changed con- 
ditions they again resume their motions and multiply. All small sphe- 
roids have a motion within a limited area, but it is difficult, if not impoß' 
sible, to distinguish in them that motion which is called “ 
which is inherent in them as living particles, and is not caused by extern^1 
circumstances. It has long been known that the mere fact of motion,111 
such particles, does not indicate life ; for all particles are apt to show a 
kind of motion, which is greater in very fluid media, and less in dense 
media. These well-known facts, however, do not seem to be sufficiently 
prominent in the minds of some who have written on these subjects. 
Eeal motion in such bodies may be certainly recognized, Avhen they 
move against or across currents,'and do not merely show irregular rota- 
tion or vibration in a limited area. The rod-bacteria, chains, and long 
filaments, or spirilla, just described, have clearly this sort of motion? 
under certain conditions of life. The spirilla often dart across the field 
of the microscope, stop suddenly, and then dart back, or off in some neW 
direction. Various micro-chemical methods have been devised for assist- DISEASE-GERMS. 
}019 
mg the eye in detecting them. Among those that have claimed the 
most attention, are the methods of Letzerich, Eberth, and Hiller all of 
which are more or less useful. Letzerich1 employs a watery solution of 
mdine, which imparts to the rods and chains a deep-brown color • but 
Hiller has shown that this method is unreliable, from the fact’that 
granular iodine is deposited, and that there are no means, -probably, of dis- 
tinguishing the iodine particles from the so-called spherical bacteria or 
micrococci, etc., if such be present. The mere size of such atoms gives 
110 criterion for determining their character, for, according to Cohn", the 
distinguished botanist, they vary in size within exceedingly wide limits. 
My own experience in using this method has inclined me to coincide 
ontirely with Hiller. 
Eberth’s test consists in boiling the suspected bodies in alcohol or in 
caustic alkalies, by which process the rods, chains, etc., are unaffected • 
out this method is objectionable from the fact that if we wish to get rid’ 
of all the oil, which resists these reagents a long while, the suspected 
tissue is itself apt to be destroyed. 
The best method, in my experience, has been that of Hiller.2 I have 
found the following modification ot it to answer well; Make a ten per 
cent, watery solution of caustic potassa, in which the tissue to be ex- 
amined is then immersed for an hour and a half, then washed in distilled 
Water, and finally plunged into a mixture of tincture of iodine and dis- 
tilled water, 1-25; after remaining in this menstruum for fifteen minutes 
the substance assumes a brownish or deep-yellow color. The fatty 
matters are more or less dissolved, excepting, in some cases, the larger 
oil drops, but the bacteria retain the color more or less deeply. SuefTof 
the round, oily particles as remain after this treatment, can usually be 
distinguished from bacteria, by the fact that they refract the light 
strongly, while bacteria have a dull, lack-lustre appearance. 
Sometimes we are called upon to decide as to the character of the dark 
substances that exist in cells, to determine whether they are bacteria or 
uot. lat one time adopted a modification of this plan. In an instance 
where a rabbit had shown signs of constitutional disturbance after inocu- 
lation with putrid matter, I examined some of the blood on the second 
day after removal from the body, when bacteria were very plentiful, and 
when most of the white blood-corpuscles had disappeared, while those 
that remained were enlarged and granular. I added liquor sodfe in 
eXcess to a small amount of the blood, allowing it to act for one and a 
Half hours. At that time the white corpuscles had swollen and were 
generally dissolved, liberating a large number of granules. Ten of these 
Were kept in view, and moved about in all directions, turning and twist- 
mg; at one time they arranged themselves in a cluster, and then again 
separated, and formed a chain. During this time, the bacteria of rod- 
form had become more and more invisible; while these particular bodies, 
°n the other hand, had become brighter and brighter. During all this 
firne there was little or no change in a number of oil drops that were 
Scattered about the field. Here, then, we have an instance ot liquor sodse 
having afforded us a means of differential diagnosis, in an optical manner, 
between bacterial bodies and certain particles that took the chain-form, 
and that came from the interior ot white blood-corpuscles. 
One of the most important reasons tor putting little reliance on exact 
measurements as to the size and form of bacteria, is that these charac- 
1 Virchow’s Archiv, Ixii. 3, 1875. 
2 Virchow’s Archiv, Ixii., Jan. 1875. 1020 
SATTERTHWAITE, 
teristics are probably apt to change under varying conditions. Bastian 
tells us that if we take an ordinary organic infusion, and expose it to a 
warm temperature, it will show rod-bacteria. If we add a drop 04 
acetic acid, we will get bacteria of larger size; adding a few drops 
more, the changes take place less rapidly, and the organisms, instead 04 
multiplying as they did before, now grow continuously into filaments* 
This ground is said to be held by Trecul,1 of Paris, and is favored by 
Beale;2 my own experience is not sufficient to justify me in forming an 
opinion on this point. I may here add one point, viz., that I have seen 
no reason to believe that there is anything like a genetical relation be- 
tween bacteria and the mould or sugar fungus. 
I have already stated that my experience agrees with that of Chauvean 
and Sanderson, that the virulent principle is particulate, in certain in- 
stances at any rate. It is quite clear that very virulent fluids may be 
rendered quite harmless by passing them through a clay filter; this I 
have had repeated opportunities for observing, as far as relates to inocu- 
lation with putrid infusions, or with diphtheritic matter ; and yet when 
we come to the question, are these poisonous particles bacteria ? we kno'V 
that by successive filtrations, as through paper, where the bacteria 04 
distinctive forms are separated and removed, the fluid may still be poi- 
sonous. Granules are often observed in such fluids; are they sphericw 
bacteria, or the spores of these or others f 
We must remember, however, that rod- and chain-bacteria may be 
introduced in large numbers into the system without producing any 
lesion. When they appear to have been isolated, as in Cohn’s fluids 
this, as I have stated, is perhaps really not the case, but some organic 
compound may have attached itself to the vegetations, and thus have 
conveyed the septic influence. 
Various efforts have at times been made to determine whether or not 
the poisonous matter is albuminoid. Chauvean, Onimus,3 and Sanderson, 
have worked in this direction. Sanderson and Onimus tried dialysis 
and Chauvean diffusion. The former, in investigating the cause of the 
cattle plague, passed the virulent fluids through parchment-paper; the 
dialysate was wholly harmless, while the liquid that did not pass 
poisonous. As the question with Sanderson was whether the contagia 
were crystalline or colloid, he decided in favor of the latter possibility* 
Onimus concluded that the matters were albuminoid from experi- 
ments conducted in much the same method. But there were in both 
sets of experiments, possibilities of error, arising from the fact that B 
was not certain whether albuminoid substances did not actually pasS 
through the membranes, which it is now known that they will do, when 
certain quantities of the phosphates or carbonates happen to be present. 
It would, therefore, be erroneous to conclude that the poison remaining 
behind the filter was necessarily albuminoid, when it was uncertain 
whether the harmless filtrate did not also contain albumen. 
Chauveau appears to have shown, by his experiments, that it is ex- 
tremely unlikely that the poison in vaccine virus is due to a soluble, 
albuminoid substance. His method will be briefly noticed. He took 
vaccine lymph, collected from the arm, and placed it in a test-tube 
standing in an upright position. The introduction of the lymph into 
1 Lancet, May 15, 1875, p. 684. 2 Disease Germs, p. 37. 
3 London Medical Record, November 19, 1873. 
4 Twelfth Report of the Medical Officer of the Privy Council, 1869, p. 233. 
5 Graham, Proc. Royal Society, 1861, vol. ii. p. 243. I have not been able to refer to 
this paper. DISEASE-GERMS. 
}021 
the test-tube was effected with such care that the liquid did not touch 
the sides of the glass in the act of filling. Water, to the depth of a few 
In68’ Was then added Wlth Bimilar Precautions, and the whole was 
allowed to stand for twenty-four hours. Although no membrane was 
hsed, yet it is said that when proper care was exercised, the liquids did not 
hnx, except in the immediate neighborhood of the surface of junction 
All the soluble constituents of the vaccine matter passed upwards into 
the water. At the end of twenty-four hours, the most superficial layer 
"'as removed by dipping into it the end of a fine capillary tube. This 
supernatant liquid was then examined microscopically, and tested for 
albumen. Now albumen, though held to have the least diffusibility of 
chemical compounds, was found in the water, the inference beino- that 
Uo other soluble chemical matter had been left behind. This upper 
stratum was used upon heifers and children, but without success while 
tlle lower stratum produced the vaccine disease. Chauveau had pre- 
viously employed a method called subsidence, in which, by addins ten 
flumes of water, he had found that the leucocytes were separated 
did not produce the disease, but the stratum that produced infec- 
tton contained minute, microscopic granules, and it was therefore con- 
cluded that the disease was produced by them. Sanderson corroborated 
these conclusions in the great majority of his attempts, though he expe- 
rienced some difficulty in the required manipulations, which need a o-c,od 
"eal of delicacy. 
Colin1 asserts that he has been unable to “ diffuse,” as Chauveau claims 
to have done, and intimates that the method is faulty, and that no such 
rcal diffusion takes place; Chauveau, however, insists that the granules 
even when washed with immense quantities of water, retain their 
vh’ulent quality, and compares them in this respect to the spermatic 
dements of seminal fluid. The supernatant liquid which is not poison- 
ers, responds to the test for albumen by heat and nitric acid. In farcy, 
Chauveau finds that the granules are as poisonous as the pus itself! 
According to Panum’s2 experiments, the virulent substance of putrid 
I,Jfasions is not destroyed by boiling, and is soluble in water, but not in 
dcohol; which qualities make him surmise that it may arise from the 
recomposition of albumen, or may perhaps be secreted from the bacteria, 
though he feels uncertain as to what the nature of the poison really is. 
In prosecuting this line of inquiry, I have performed a number of 
experiments in co-operation with Dr. Edward Curtis, Professor of Materia 
Medica in the College of Physicans and Surgeons, New York, whose 
jjame I have previously mentioned in connection with other topics. The 
blowing questions were some of those that presented themselves for 
®°lution:—(l) Is the poisonous matter in putrid infusions destroyed by 
boiling and evaporation to dryness? (2) Is it soluble in alcohol, or not? 
p) Is it soluble in water, after boiling in water and in absolute alcohol ? 
A) If there are granules in the fluid which prove poisonous, will they 
oteed bacteria? 
. The liquid employed in these experiments was obtained from an infu- 
Sl°n of a calfs liver, that had been allowed to become putrid; the liquids 
solids used, were inserted into the muscular tissue of rabbits, and 
Examined at varying times thereafter.3 The following conclusions seemed 
111 ttiy opinion to be warranted:— 
1 La France Medicale, Fev. 26, 1876. 2 Yirchow’s Archiv, lx. 3 and 4,1874 
3 Many of these experiments have already been reported. In fact, this entire paper 
views which were published in 1875. Medical Record, Dec. 18 and 25, 1875. 1022 
SATTERTH WAITE, 
(1) Putrid matter, when introduced into the system, is capable of pi’0' 
ducing a well-marked train of symptoms, which are extraordinarily like 
those of ordinary sepsis. 
(2) The poisonous quality does not reside in the absolutely clear liquid, 
when entirely freed from granules. This was shown by porous clay- 
The apparatus used in these experiments was devised by Dr. Curtis, and 
consisted of a porous-clay cylinder or cup, over the bottom of which was 
drawn a bit of rubber tubing, which was thick, and made to grasp the 
cylinder firmly; in the opposite end of this tubing was fitted a cork, 
through which a glass tube passed, so as to connect the chamber beneath 
the cylinder with the interior of a small glass jar that could be exhausted 
of air by means of a common exhausting syringe. When the liquid to 
be filtered was placed in the porous cylinder, and the air was removed 
from the glass jar, the liquid passed through the cylinder, and stood in 
beads or drops on its bottom, from which it was collected in small quan- 
tity without much difficulty. 
(3) The poison is sometimes separated by coarse methods of filtration, 
such as by common filtering paper. When Cohn’s fluid was passed 
through the equivalent of 25 thicknesses of ordinary filtering paper, it 
produced no lesion, and yet Cohn’s fluid, unfiltered, and ordinary putrid 
infusions, produced about the same lesion. 
(4) Continued boiling and evaporation to dryness does not destroy the 
poison. 
(5) Continued boiling, and evaporation to dryness, and boiling with 
absolute alcohol, does not destroy the poison. 
(6) The dry alcoholic extract, freed from alcohol by evaporation with 
heat, is poisonous. 
(7) My experience with regard to the albuminoid character of the 
poison, has not made the matter clear to me, for while in these cases the 
dry alcoholic precipitate, after continued boiling, was poisonous (and it 
contained the albuminoid substances), yet the liquid alcoholic extract in 
one case produced a lesion, and in another did not. In my first account 
of these experiments,1 the results were stated as above, but in a subse- 
quent series of experiments, the liquid alcoholic extract produced exten- 
sive lesions in two cases in which it was tried. In other words, when 
the albuminoid deposit produced by both boiling and alcohol was separated, 
and water afterwards added, the virulent matter appeared to reside both 
in the precipitate and supernatant fluid. These experiments do not, 
therefore, decide anything as to the albuminoid character of the poison- 
(8) It further seemed to be shown of putrid matters which, after being 
filtered several times, were boiled to dryness, then boiled with absolute 
alcohol, and again dried and extracted with water, that the ordinary 
paper filtrate was poisonous. 
(9) On examining this watery liquid, it was found to contain granules, 
and yet, when these granules were placed in vacuum-tubes, they in several 
instances failed to show any development of bacteria under such circum- 
stances as favored the growth of bacteria. The suspected solution was 
put away in bent tubes, with suitable precautions, and while similarly 
arranged tubes that had been contaminated with the barest trace of bac- 
teria, were found turbid from the production of these bodies seventy-tw0 
hours afterwards, the suspected liquids were perfectly clear, with on® 
■exception, where there was a slight pellicle on the surface. It is true 
1 Loc. cit. DISEASE-GERMS. 
1023 
at, after a variable time, several tubes became contaminated, and yet 
°tners remained dear for months, and one for nearly a year, and as length 
°f nozzle and fineness of neck are necessary conditions for success in The 
experiment, and as those thus provided held out best, it is fair to suppose 
with the others some error was committed in carrying out the 
experiment, and that thus the bacteria of the air had in some way o-ained 
ar> entrance. That this is possible we have already seen. 
It is proper now to stop here, and note that the granules have been 
very frequently noticed in the poisons of infectious disease; they seem 
destined to play an important part in the discussions now pending on 
subject. There can be no question that in most of the diseases 
*hat are assumed to have a definite vegetable form as their immediate 
(for this is certainly the way in which the relation has been stated 
°ver and over again by the vegetable-germ theorists), authors have ofiven 
most conflicting accounts of the organisms, and we may fairly say 
that, with the exception of relapsing fever, not a single form has been 
a°cepted by any considerable number of germ-theorists as the agent, par 
cellence, of the disease. We have observed that, according to Chauveau 
Sanderson, and Beale, certain granules appear to be associated with the* 
of disease, and that this fact has been the point of departure of 
poth the vegetable-germ theorists and the bioplasm theorists, while it 
ls not incompatible with the physico-chemical theory. Let us examine 
points a little more closely. 
It is clear that if the vacuum-tube experiments be of value, they show 
the particles observed are not the spores of bacteria. What evi- 
dence is there that the matter in question is organic and pertaining to 
body? It is quite clear that, to the eye, using the ordinary powers 
°f the microscope, these particles cannot be distinguished from one 
Mother with certainty. Beale,1 however, assures us that by using 
Extremely high powers, such as the 2'5 or the g]s, he has seen them at 
dividing, and at others increasing in size, and that he has colored 
them with carmine. Some of these may, he says, be no more than 
Joeing °f an inch in diameter. In diseased conditions of the body, he 
Relieves that such particles may increase enormously. Belief in this 
doctrine is, of course, inconsistent with the old cell-doctrine, by which 
this body was regarded as the ultimate morphological element of the 
Astern ; and yet we may safely say that this old theory is not by any 
tdeaiis what Schleiden and Schwann once held. 
. It does not appear to be necessary that a cell should have an envelop- 
ldg wall, inclosing a softer material in which is a nucleus. Max Schultze 
showed that many important cells possessed no cell-wall, and that some 
Jdight not have a nucleus. Our notions, therefore, have been greatly modi- 
hed in these respects, and a living cell is now held to be merely a mass of 
Mutinous, viscid matter, which is endowed with peculiar qualities, called 
vhal, such as amoeboid motion, molecular motion, and the like. As to 
nature of this viscid substance, there is hardly much uniformity of 
°Pinion, as yet; some holding it to be formless and structureless, while 
believe that it consists of networks, and others again, as Beale, 
it is made up of minute spheres, closely packed together, and that 
hese spheres may in turn be made up ot other spheres. I hardly think, 
however, that microscopists are ready to agree upon any staining matter 
I'M is fitted to distinguish protoplasm or bioplasm in all cases, and these 
1 Disease Germs, p. 246. 1024 
SATTERTH WAITE, 
statements of Beale must, therefore, be accepted with caution. Even if 
the particles be large, it is not certain that carmine will differentiate 
them. It has, to be sure, a preference for animal tissues, and yet it will 
also stain various other substances, if they remain long enough in the 
staining fluids. While, therefore, it is conceivable that the ultimate 
living elements of the body reside in particles which go to make up cells* 
we have no sure means of recognizing them, and of deciding positively 
that they are animal, and not vegetable, or whether or not they belong 
to that ill-defined class called granular matter. If, however, we believe 
that such minute portions of the body are the agents of disease, then we 
have to assume that they have a capacity for life which is remarkable' 
that, in fact, they can be subjected to extremes of heat and cold, or to 
the action of various acids and alkalies, and that they can be separated 
for months, and perhaps years, from the body, without losing their active 
qualities—all of which does not comport with the opinions commonly 
held about living animal matter. 
The name “physico-chemical,” as applied to the theory which is thus 
designated, is objectionable, as it dates back to the old-fashioned notions 
of Liebig, when the ideas held on these and kindred subjects were quite 
different from those of the present day. Liebig1 held that the ferment 
was a portion of organic matter, which, itself unstable, was capable ot 
communicating molecular movement (chemical change) to certain sub' 
stances. Bastian, the exponent of the modified doctrine, holds, as already 
stated, that “ living organisms, though they may act as ferments, act iu 
this capacity merely by virtue of the chemical changes which the carry* 
ing away their growth necessitates, and that other chemical changes* 
taking place during the decay of organic matter, may make fragments 
of it (in the dead state) almost equally capable of initiating fermentative 
changes in suitable media.” 
This statement would appear to show that the friends of the theory are 
not altogether willing to deny to bacteria and allied forms, an influence iu 
the cause of disease, but that they regard them as perhaps remote factors* 
the important one being the chemical change exerted by the growth of 
the microphytes, while, at the same time, dead organic matter may have 
a similar power. This theory is, therefore, properly a chemical one, and 
admits of two possibilities; either, on the one hand, that the cause of 
disease operates through chemical changes under the influence of minute 
organisms, or on the other hand, that it so operates under the influence 
of dead portions of the body. The former hypothesis is unlikely, because 
the virulence of diseases can sometimes be shown to be independent of 
bacteria; the latter one, however, is by no means impossible, though 
we know but little in its favor. If we assume that there is a logicu'l 
connection between the processes of fermentation and disease, and decline 
to accept the hypothesis that minute organisms have that absolute rse 
that has been given them, we may believe, with Hiller and others, that 
the ferment is a chemical substance. This is the view held by Bert with 
relation to vaccine virus, which he subjected to conditions under which 
life appeared to be impossible. 
Under such an hypothesis, there is formed in the tissues, in certain dis- 
eases, a material which is able to resist various reagents (heat and cold, and 
the like), and which, when transferred to another organism, may occasion 
the formation of like compounds, just as the sulphate of sodium, instanced 
by Bastian, when placed in a liquid having the necessary ingredients f°r 
1 Lancet, April 10, 1875. DISE ASE-GEEMS. 
1025 
forming it, will increase in amount.1 How we actually know that the 
Poisons ot the cobra and of the rattlesnake, which are elaborated from 
Wealthy tissues, are capable of being subjected to conditions that are 
incompatible with life in its common acceptance. The poison of the 
Cobra may be diluted with water, ammonia, or alcohol, without bavins 
its deadly qualities affected, while, according to Weir Mitchell2 the no? 
son of the rattlesnake can be boiled or frozen, or subjected to the action 
°r strong sulphuric or muriatic acid, ammonia, chlorine water iodine 
soda or potassa, and yet, as far as the matter has not burned, its virulence 
oe unaffected. These qualities remind one strongly of the poison in 
Putrid matters, where, according to my own and Panum’s experiments 
neither ordinary boiling in water, nor in absolute alcohol, nor evaporation 
lo dryness, destroys its active qualities. 1 
Let us glance, in conclusion, at the leading opinions at present enter 
gained in regard to those of the infective diseases that have been most 
thoroughly studied with reference to the materies morbi. I shall refer 
Merely to cholera, vaccinia, the carbuncular diseases of man and ani 
jnals, typhoid and relapsing fevers, and diphtheria, in regard to which 
the most specific descriptions have been furnished of the (Organisms sun 
posed to be concerned in their production. ' 
The investigations which were occasioned by the cholera epidemic of 
1849, appear to have been the first in which attention was called to cer 
lain particles, alleged to be the cause of the disease. These particles were 
galled the cholera-fungus.3 In 1867, Hallier4 published a work in which 
ue described the supposed ferment, the cholera micrococcus, a granular 
Uiass that by cultivation underwent a great variety of changes in form 
Cohn5 and many others followed with descriptions of the fungus. It ig 
Bafe to say, however, that there has been no general agreement between 
the most prominent writers on this subject as to the specific form of the 
supposed contagium. In the Congressional report of the epidemic of 
1873 ,in the United States, we find it stated6 that no microscopic changes 
Peculiar to cholera were found in the discharges, though high powers of 
the microscope were used ; this being in agreement with the statement of 
Macnamara, who used a one-seventieth inch lens. Molecular matter was 
always seen by these observers, and it is stated in the report that from this 
tuolecular matter in the vibrionic stage of decomposition, and not from the 
vibriones themselves, the dejecta of cholera patients are capable of settino- 
Up a morbid action in the intestinal canal of those who receive them.7 ° 
Among the most recent and complete experiments on this point are 
those of Lewis and Cunningham.8 They injected 36 dogs, through the 
veius, with choleraic dejections. In 15 cases they obtained positive re- 
sults: that is, death was evidently due to the matter injected. In 17 of 
the cases this matter had been kept for ten minutes at a temperature of 
212° Fahr. In the remaining 19 cases it had not been exposed to heat, 
lu the 17 cases the mortality was 47 per cent.; in the 19 others it was 
°uly 36 per cent. It was thus found that a continued temperature of 
212° appeared to have no influence in abating the virulence of the mat- 
ter, for, when it was boiled, the mortality was even a little greater than 
T the other cases. These observers also believed that bacteria could not 
1 Bastian, loc. cit. 
3 Budd and others. 
5 Biologie der Fflanzen. 
7 Ibid., p. 43. 
2 Smithsonian Contribution, p. 4g. 
4 Das Cholera-Contagium. 
6 Report, etc., p. 36. 
8 Journal of Anatomy and Physiology 1026 
SATTERTH WAITE, 
be the cause of cholera, and in fact they found similar forms in the 
lesions produced hy inoculation of various other substances, such as so- 
lutions of ordinary faeces, or urine.1 
About ten years ago, it was noticed that vaccine virus contained minute 
spheroids, and they were described in 1867-1868.2 Cohn called them 
Microsphcerce vaccinias, and described them as small, colorless cells, some- 
times in rosary-like chains of eight or more links, and sometimes clustered 
together. Sanderson thought that they were “filamentous, not jointed, 
but branching, and giving off from their extremities microspheres or 
conidia, much after the fashion of the penicillium.” Having been favored 
by Hr. F. P. Foster, Director of the Vaccine Department of the HeW 
York Dispensary, with an opportunity of inoculating calves, I performed 
the following experiment in relation to this matter. Having prepared 
a solution of salicylic acid, with sodium phosphate as a solvent, I com- 
bined it with equal parts of vaccine virus taken immediately from fresh 
vesicles, and having allowed the two to remain in contact a minute, they 
were inoculated in my presence, on a calf, in the usual way. How this 
proportion of salicylic acid had been shown by previous experi- 
ment to be able to prevent the development of bacteria for from twelve to 
twenty-five days, and yet in this instance regular vesicles appeared at the 
proper time in nearly all the inoculated points. I cannot but think, 
therefore, that this experiment offers strong evidence against the theory 
that vegetable germs have to do with the cause of disease. 
The name Carbuncular Diseases, which the French employ synony- 
mously with the German word Anthrax, has proved to be a convenient 
form for a rather remarkable group of contagious diseases, which have 
a certain connection with one another, and which include malignant 
pustule, splenic fever, and the disease called “ mycosis intestinalis.” The 
post-mortem appearances in all these diseases are remarkably similar. 
Balls of rounded particles are said to be found in the affected parts, and 
rod-shaped bacteria in the circulating blood ; the spleen is enlarged ; there 
are hemorrhagic infarctions of the intestine, causing sloughing of the 
jnucous membrane, exudation and infiltration of serum, and enlargement 
•of the glands near the points involved. In such cases a pustule often 
appears, and hence the name Malignant Pustule; and yet it may not be 
necessary to the disease, which often proves fatal without it. How, in 
these diseases, Pollender and Davaine3 observed minute rods, which Da- 
vaine called bacteridia, and which he said were always motionless; and 
he has made such extensive studies of them that his opinions have be- 
come well known. He regarded them as necessary causes of the diseases 
in question, and as essentially different from what he called the bacteridia 
of decomposition, which were really what we know as the bacteria of 
putrid matters. His views have, however, not always met with accep- 
tance, and notably have been opposed by Bouley,4 Gaillard, and others, 
who assert that the blood may be infectious without the presence of rods. 
Bodinger, who is now regarded as one of the foremost German authori- 
ties, states that he also has produced the disease in question in a similar 
way, but that in such cases there have always been spherical bacteria 
present. We may justly ask, in view of what has already been cited, 
whether spherical bacteria were really present, and whether the particles 
he describes may not have been other solid particles ? 
1 Tribune Medicate, 369, 1875. 2 Virchow’s Archiv, 41, 42, 1867-8. 
3 Davaine in 1850, and Pollender several years previously. 
■* Cyclopaedia of Practical Medicine, vol. iii. p. 377. DISEASE-GERMS. 
1027 
Among the most recent and best recorded accounts of the vegetable 
organisms connected with typhoid fever, are those of Klein,1 of London. 
He declares that he has found peculiar bodies, in this disease, at or near 
■Peyer’s patches. These bodies were carried along the lymphatics or 
bloodvessels of the mucous membrane ; in color they were often yellowish- 
brown, and in size varied from one-fourth to three times the size of a 
human, red blood-corpuscle. It will be noted that if we accept these 
views, we are carried away from the subject of bacteria towards that of 
the other vegetable organisms, called torulae, which in my opinion have 
not been shown to have any genetical relation with bacteria. These 
views of Klein are comparatively new, and as yet I have failed to find 
any confirmation of them. 
In regard to relapsing fever, the microphytes are pictured with more 
vividness than in any other disease. In 1872, Obermeier, of Berlin, gave 
an account of certain bodies, long and filamentous in form, which were 
found in the blood during the rise ot the fever, disappearing with its 
fall, and reappearing during the relapse. These observations have been 
Very largely confirmed, but, on the other hand, Laptschinski made fre: 
quent searches for these bodies, but never found them, though he did 
observe an enormous increase in the number of the white blood-corpuscles, 
Which were unusually granular; when the fever decreased, the number 
of the white blood-corpuscles diminished. Recently, Heydenreich,2 of 
Moscow, examined the blood in sixty-four cases, and he asserts that he 
found the spirillum in every instance, and that it was the same as the 
Spirochtete plicabilis, of Ehrenberg, which this observer discovered in 
Water. In most cases these bacteria were found at the beginning of the 
febrile exacerbation, sometimes even preceding it. Before the fall of the 
temperature, the bacteria generally disappeared. On the other hand, we 
are told by Motschutkoffsky,3 of Odessa, that the blood of relapsing-fever 
patients was readily and successfully inoculated upon healthy human 
subjects, though not on animals. The blood was only poisonous when it 
Was taken during a febrile exacerbation, but it made no difference 
Whether it contained spirilla or not. 
In the matter of diphtheria, I may speak with more confidence, as my 
personal experience in this department of the subject is larger than in 
any other. The relation of bacteria to diphtheria has been made most 
prominent by the writings ot Oertel, Ilueter, and others; and, in con- 
junction with Dr. Edward Curtis, I have made some extended re- 
searches on the subject. Oertel, and others of the Oerman school, 
plainly ascribe to the micrococcus found in diphtheria, the cause of the 
disease; at least I can understand them to imply nothing else. _ In the 
first instance, it must be said that the real presence of bacteria in diph- 
theritic membrane is usually a matter of ready proof. They exist in 
collections on the surface of the membrane, and often in it, as well as in 
the secretions of the pharynx, trachea, nasal passages, etc. I hey are to 
he found in masses, or separate, and usually may be distinguished as rod- 
shaped. It is true that they often appear as spheres, but this appearance 
is apt to be deceptive, for, when they are accumulated together, they are 
often arranged in extremely regular order, and they then give this pecu- 
liar appearance. To show that in such cases they are rods, is not a 
matter of much difficulty: Press the cover against the slide, and the 
1 Report of the Medical Officer of the Privy Council, 1875. 
2 St. Petersburger med. Wochenschrift, 1, 1876. 
3 Centralblatt, and St. Louis Medical and Surgical Journal, May, 1876. 1028 
SATTEETHWAITE, DISEASE-GERMS. 
more prominent rods will be pressed down, showing their peculiar shape* 
Another source of deception is the fact that these bacteria are apt to 
move about with a gyratory motion, with extremity directed towards 
the observer. Watching such a particle carefully, it may sometimes be 
seen to turn and expose its side, and then we may see that it is nothing 
but the ordinary rod-bacterium. When we have to do with other parti- 
cles, then indeed it is well to give diagnostic points by which we may 
distinguish them from ordinary granular matter, such as fragments of 
tissue, minute oil particles, pigmentary matter, etc. I feel confident, 
however, from repeated examinations, that no particles have been de- 
scribed by Oertel as micrococci, that can be positively shown to be pre- 
sent in diphtheria alone. On the contrary, both Dr. Curtis and my sell 
have repeatedly examined the accumulations in our own mouths, and 
have there seen the forms which are described as belonging to diphtheria. 
And yet diphtheritic membrane is very poisonous, and fatal when 
inoculated in the muscles of rabbits, as I have had repeated opportunities 
of observing. I may here state that Oertel’s descriptions are the most 
elaborate and, perhaps, the most clearly given of any writer’s on the 
experimental pathology of diphtheria; as far, however, as my experience 
has gone, it has in most instances failed to verify them. In inoculating 
the cornese of rabbits, in a number of instances, no lesion followed, be- 
yond an ordinary keratitis, and none of the rabbits died ; in fact they all 
recovered quickly. The fresh diphtheritic membrane, when inoculated, 
was very fatal, the tendency to death being extremely common about 
the end of the second day. Of 27 rabbits inoculated with the solid mem- 
brane, or an aqueous infusion of it, 20 died, and 12 at about the end of 
the second day, or between the second and third. 
How the membrane when thoroughly boiled, was equally fatal in two 
cases, and yet boiling is said by most excellent authorities to destroy 
bacteria. In fact, this is a matter of general belief. Furthermore, bac- 
teria were shown to decrease rather than increase, when introduced into 
the system, so that certainly after two or three weeks they had either 
become distorted, so as to be hardly recognized, or they had altogether 
disappeared. When very strong solutions of salicylic acid, combined with 
phosphate of sodium as a solvent, were made up into a paste with diph- 
theritic membrane, and inoculated in the thighs of rabbits, they produced 
a fatal disease, though the lesions were not as extensive as when diph- 
theritic membrane alone was used ; and yet, in my experience, salicylic 
acid in the proportion of has, as before mentioned, prevented the 
development of bacteria for from twelve to twenty-five days. 
I believe that I have now given a tolerably fair account of the most 
prominent views entertained on the matter of disease-germs, and think 
that I am warranted in submitting the following conclusions with regard 
to the present status of the question : 
I. That, as far as inquiry has been made as to the nature of the active 
principles in infective diseases, it is probable that in a certain number 
the matter is particulate, or molecular in form. 
11. That in regard to the causes of septicaemia, pyaemia, puerperal 
fever, erysipelas, and hospital gangrene, and those of cholera, vaccine- 
disease, the carbuncular diseases of men and animals, typhoid and 
relapsing fevers, and diphtheria, there is not satisfactory proof that they 
are necessarily connected with minute vegetable organisms. 
111. That the real nature of these causes is still uncertain. 1029 
VITAL STATISTICS OF BUENOS AYRES. 
BY 
GL BAWBQHT, M.D., 
OF BUENOS AYRES. 
A brief review of the vital statistics of Buenos Ayres may perhaps 
awaken some interest in the International Medical Congress now assem- 
bled in Philadelphia, not only as adding to the data accumulated from 
day to day as elements ot Sanitary Science, but as presenting circum- 
stances peculiar to that Argentine city itself. 
Buenos Ayres, next to Rio de Janeiro the most populous city in South 
America, has grown with extreme rapidity, having tripled its population 
Within the last twenty-five years, mainly owing to the vast tide of 
emigration from European shores. But, even in.the event of a dimi- 
nution of the influx of immigrants, and a corresponding reduction of the 
rate of increase, it is almost certain that Buenos Ayres will, at the close 
of the present century, have upward of half a million inhabitants. Situ- 
ated in latitude 35° south, with a genial climate, it is exempt from the 
extremes of temperature so common in other localities; and, were it not 
for the modifying influences exercised upon its sanitary condition by the 
increase of population, and by the circumstances usually attending that 
increase—when not overruled by strict observance of the admonitions of 
science—it would be as healthy a city as its name {good air) would seem 
to imply. 
But the death-rate in Buenos Ayres attains proportions by no means 
satisfactory; and the recent epidemics, particularly the yellow-fever 
scouro-e of 1871, show that much has to be done before the city can 
regain that salubrity reasonably to be expected from its situation and 
soil, and from the prevailing winds and other climatic conditions with 
Which it is favored by Nature. Epidemics are warnings to mankind— 
Warnings all the louder in proportion to the severity of the visitation; 
and Buenos Ayres has learned from her recent sufferings the lesson to be 
desired. Works, both above and beneath the surface, are now in prose- 
cution for the sanitary improvement of the city, by means of a system 
of drainage and underground disinfection which will cost twenty mil- 
lions of dollars (eight millions have already been expended), and which, 
When completed, will be one of the most efficient in the world. 
Besides, the population of the city is, to a great extent, composed of 
foreign elements permanently incorporated therein and constantly in- 
creasing. In this respect Buenos Ayres bears a striking analogy to many 
cities in the United States, and, like these, presents a series of phenomena 
peculiar to this species of social evolution, as revealed in its vital statis- 
tics. The analogy here referred to I shall endeavor to point out in the 
course of the present essay. 
Population of Buenos Ayres.—lt is necessary, first of all, to determine 
the population of Buenos Ayres, and its component elements; but the 
accurate accomplishment of this is difficult, owing to the long intervals 
between the censuses, and the rapid increase of the number of inhabi- 1030 
RAWSON, 
tants. The mode of development in cities of the New World is 111 
general so irregular that, in measuring their growth, it will not suffie® 
merely to determine the difference between the numbers of births and 
deaths. The increase resulting from that tardy process is insignificant 
when compared with that derived from immigration, and with that 
which is due to the irresistible attraction which populous centres exercise 
at all times upon neighboring towns. This species of attraction is, from 
causes peculiar to the Argentine Republic, more powerful in Buenos 
Ayres than in other American cities of similar growth. In 1871, f^1’ 
example, the number of victims of the disastrous yellow-fever epidemic 
exceeded that of the births in the same year by 18,206; but the equi- 
librium of the population was more than re-established by the influx of 
emigrants from Europe, and from the surrounding provinces and repub- 
lics. By comparing the total number of births during the period from 
1858 to 1872 with the total number of deaths during the same period, in- 
cluding, of course, the victims of the cholera of 1867 and 1868 and those 
of the yellow fever of 1871, we observe an excess in the deaths, of 1778. 
Hence, if Buenos Ayres had depended solely upon its own resources f°r 
its growth, its population, instead of increasing, would have diminished- 
But the ravages of this frightful mortality were more than compensated 
for by immigration, and the remarkable growth of the city pursued its 
course without any apparent interruption. 
The progress becomes more and more marked, dating from 1852. 111 
the absence of official data, it is scarcely possible to estimate the popula- 
tion of Buenos Ayres in that year, which was marked by a political 
event of transcendent importance—the downfall of the dictatorship by 
which the nation had been oppressed and depopulated for the space ox 
twenty years. Numerous emigrants returning to their homes after a 
prolonged proscription; the establishment of liberty, political and civil; 
the opening the navigable rivers to the vessels of all nations; the dis- 
covery of riches susceptible of being developed advantageously in the 
Argentine Republic by the hand of man ; and the facilities offered by 
both the government and the people to foreigners desiring to take up 
their residence there, induced a stream of European immigrants, which 
continued uninterruptedly for a number of years. Dating from the be- 
ginning of the influx of foreigners, the rapid growth of the population 
became evident, and about that time the greatest increase took place- 
Nevertheless, no census of the city was taken until 1855, nor u 
second effected until 1869, the year of the general census of the republic- 
According to the terms of the constitution, the general census will m 
future be taken every ten years. 
The two censuses referred to are, therefore, the only available data on 
which to base my computations ; those for other years must, of necessity? 
be only approximate. In the census of 1855, the total population of the 
city was set down at 91,548, and in the general census of 1869, at 177,78/- 
Hence, the mean annual rate of increase during the period embraced be- 
tween these two extremes would be 4.8 per cent., always supposing the 
progression to have been uniform. Now, by applying the same system 
of reckoning to the previous years, that is to say, from 1852, and to the 
successive years down to 1875, the population of Buenos Ayres would be 
as in the annexed table in the years therein expressed:— 
1851, by calculation . . , 
76,000 inhabitants. 
1855, according to census . 
1869, “ “ ... 
. 91,548 
. 177,787 
1875, by calculation .... 
. 230,000 VITAL STATISTICS OF BUENOS AYEES. 
1031 
On reviewing the foregoing statement of the increase of the popula- 
tion, two objections are apparent, and I must now endeavor to explain 
them. They are: first, the epidemic of 1871, which would appear to 
have checked for the time being the numerical advancement of the 
population; and, second, the perceptibly decreased immigration in the 
last two years, 1874 and 1875. 
Buenos Ayres is not only the chief port, but also, by reason of its 
position, the natural centre of all movement in the republic. It is the 
point of disembarkraent for the immigrant on his arrival, and of re-ern- 
barkment for those who return to Europe. Passengers, whether immi- 
grants or not, coming from Montevideo, likewise land at Buenos Ayres; 
and there they go on shipboard again when leaving to go back. There, 
too, is the rendezvous of all craft navigating the tributary streams of 
the Rio de la Plata. Hence, the movement of passengers throughout 
the year may at all times be readily ascertained, and the balance to the 
credit or debit of Buenos Ayres accurately determined by comparison of 
the arrivals and departures. The communications by land are extremely 
limited, and confined to the rural districts of Buenos Ayres and the 
neighboring provinces. It is generally admitted that more than two- 
thirds of all immigrants to the republic, come whence they may, remain 
in Buenos Ayres city, the remainder being distributed through the sur- 
rounding country. The following table shows the movement of passen- 
gers for the port of Buenos Ayres in the years 1864-72: 
Tears. 
1864 . 
Arrivals. 
. 29,307 
Departures. 
16.745 
Balance 
remaining. 
12,562 
1865 . 
. 30,556 
24.434 
6,132 
1866 . 
. 40,132 
20,658 
19,474 
1867 . 
. 42,729 
21,154 
21.575 
1868 . 
. 56,354 
25,342 
31,012 
1869 . 
. 73,045 
29,990 
43,055 
1870 . 
. 81.166 
33,450 
47,716 
1871 . 
. 49,741 
28,468 
21,273 
1872 . 
. 70,991 
36,756 
34,235 
As seen in the foregoing table, in 1870, the year immediately follow- 
ing the general census, the balance in favor of the population reached 
the highest point so far known, as far as the arrival and departure of 
passengers were concerned. That yeai was an auspicious one for the 
city. Immediately after the termination of the Paraguayan war, a vast 
accumulation of capital was effected, credit facilities were opened up, en- 
couragement was offered to such as desired to embark in new industrial 
enterprises, and important public works were undertaken', such, for in- 
stance, as city railroad lines; and the result of all these favorable cir- 
cumstances was the attraction to, and permanent establishment in, Buenos 
Ayres, of a vast number of people from foreign countries and from the 
other provinces of the republic. The influx of strangers at that time 
amounted to two-thirds of the balance of 47,716 mentioned in the table, 
that is to say, over 30,000 new inhabitants, which is equivalent to three 
and one-fourth times the usual rate of increase. Such at] excessive aug- 
mentation of numbers, at a time when the city was not suitably prepared 
to receive them or to afford them necessary accommodation, gave rise 
to an accumulation altogether incompatible with the general good health, 
and contributed, beyond all doubt, to the awful seveiity of the epidemic 
of 1871, by which more than 12,000 foreigners were carried off. 
The yellow fever committed its ravages in the midst of an overcrowded 
city. But, notwithstanding the great mortality, there still remained, 1032 
RAWSON, 
with a surplus for the following year, a mass of inhabitants greater than 
would have been obtained by calculation, adopting the established an- 
nual rate of increase, and to which should be added the number of the 
immigrants of 1871 who settled in the city. These remarks may serve 
to meet the first objection above alluded to. 
As for the second, suffice it to state that, in 1872, the tide of immi- 
gration again began to flow, and foreigners arrived in such numbers as 
to leave a balance of 34,235 ; and that in 1873 immigration reached the 
highest figure ever attained in South America, leaving a balance much 
more favorable still than that of the year immediately preceding; I 
deeply regret that I have not at hand the official returns to offer in sup- 
port of this statement. In 1874 and 1875, by local causes easily ex- 
plained, and others of a general character which have produced and still 
produce such grave perturbation in commercial and industrial circles 
throughout the world, immigration to Buenos Ayres was considerably 
diminished, while emigration was increased in a proportionate degree. 
There has, nevertheless, been no instance as yet, even at the worst, ot 
the departures having exceeded, or even equalled, the arrivals ; a balance, 
however small, still exists in favor of the latter. Now, taking into con- 
sideration the excessive accumulation which occurred in the two years 
immediately preceding the crisis, the same reasoning may apply to 187-1 
and 1875 as we have already applied to 1871, with the favorable differ- 
ence in the case of the two former years that they were marked by no 
such catastrophe as the epidemic of the latter, to exercise a depressing 
influence upon the population. Hence, the adoption here of the mean 
annual rate which served us in estimating the number of inhabitants 
for the earlier periods, would seem perfectly justifiable; and we may, 
without any fear of exaggeration, set down the population of Buenos 
Ayres in 1875 at 230,000. 
This population is spread over an area of 1620 hectares (or 6 square 
miles approximately), or a mean of 70 square metres (= 83f square yards) 
to each individual. Of course, the distribution is not always uniform. 
There are many districts much more densely populated than others, and 
the tenement-houses, though disseminated through all the districts, are 
in themselves centres of accumulation, pernicious alike to the physical 
and moral well-being of the community. The streets are for the most 
part narrow, barely eleven metres in width ; and the public squares are 
few and of inconsiderable dimensions. Within the last few years, a vast 
system of horse-railways has been introduced, with an aggregate length 
of seventy miles, by means of which cheap mode of conveyance a certain 
degree of expansion is afforded to the inhabitants. It may here be ob- 
served that, with the exception of Philadelphia, Buenos Ayres has, in 
proportion to its population, a greater extent of horse-car lines than any 
other city in the world. 
Prom this short history of the development of the population of Buenos 
Ayres, it may be presumed that it is largely composed of foreign ele- 
ments. Indeed, the census of 1869 shows that, in that year, foreigners 
constituted almost one-half of the total number of inhabitants. 
Total population 
. 177,787 
Argentines 
. 89,666 
Foreigners 
. 88,121 
177,787 
Doubtless the proportion of foreigners has increased in a marked degree 
since that time, and, in the absence of precise data, I calculate that their 
number in 1875 exceeded that of the natives as follows: VITAL STATISTICS OF BUENOS AYRES. 
1033 
Total population 
. 230,000 
Argentines 
. 105,000 
Foreigners 
. 125,000 
230,000 
But, in order to give an idea of this foreign mixture, and commence 
the study of the vital statistics upon a more solid basis, I shall here tran- 
scribe a page from the census returns of 1869, with all the details and 
particulars to which we may have occasion to refer. 
Table showing the Population of the City of Buenos Ayres, in 1869, 
Arranged according to Nationality, Age, and Sex. 
To 1 year 
2 to 5 
6 to 10 
11 to 15 
16 to 20 
21 to 30 
Nationality. 
M. 
E. 
M. 
F. 
M. 
F. 
M. 
F. 
M. 
F. 
M. 
F. 
Independent America:— 
3,704 
3,565 
6,672 
7,136 
7,070 
7,668 
5,568 
6,858 
3,022 
5.811 
3 
4,262 
26 
8,240 
1 
2 
1 
1 
9 
13 
3 
1 
15 
26 
32 
25 
34 
24 
54 
46 
123 
60 
1 
1 
5 
4 
9 
13 
46 
30 
96 
32 
1 
2 
6 
7 
6 
15 
8 
47 
13 
239 
20 
48 
25 
150 
129 
266 
221 
414 
325 
620 
449 
1,093 
770 
1 
2 
15 
11 
43 
37 
68 
25 
64 
17 
117 
33 
Peruvians . 
2 
• 4 
3 
4 
2 
2 
i 
1 
3 
2 
4 
15 
15 
Europe:— 
2 
3 
1 
3 
4 
46 
2 
241 
17 
2 
1 
21 
17 
29 
27 
27 
32 
88 
72 
596 
234 
2 
1 
3 
4 
2 
4 
8 
38 
16 
15 
16 
87 
90 
161 
158 
471 
305 
1,604 
496 
3,706 
2,810 
1,035 
26 
12 
97 
109 
168 
172 
302 
242 
919 
585 
1,524 
9 
2 
28 
20 
45 
46 
71 
67 
192 
132 
809 
368 
82 
75 
559 
524 
954 
818 
1,881 
1,026 
2.670 
1,629 
9,490 
4,063 
1 
1 
2 
5 
4 
6 
3 
39 
4 
274 
20 
2 
5 
11 
11 
20 
13 
35 
29 
23 
112 
60 
417 
114 
From other European countries 
2 
2 
2 
7 
6 
5 
7 
190 
38 
538 
63 
>.. 
1 
2 
1 
4 
4 
3 
9 
5 
48 
13 
2 
i 
2 
1 
2 
8 
3 
6 
3,896 
3,711 
7,666 
8,094 
8,812 
9,209 
8,949 
8,971 
9,753 
9,407 
24,870 16,652 
31 to 40 
41 to 50 
51 to 60 
61 to 70 
71 to 80 
81 to 90 
Nationality. 
M. 
F. 
M. 
F. 
M. 
F. 
M. 
F. 
M. 
F. 
M. 
F. 
Independent America:— 
Argentines 
2,909 
11 
5,543 
2 
2,043 
4 
3,712 
1,343 
8 
2,089 
612 
1 
987 
3 
223 
425 
2 
43 
110 
Brazilians 
Chilians 
93 
65 
37 
23 
54 
51 
23 
21 
32 
21 
21 
94 
12 
15 
14 
13 
11 
SI 
2 
3 
3 
2 
4 
9 
1 
2 
3 
2 
North Americans 
Uruguayans 
128 
423 
78 
361 
11 
164 
32 
225 
7 
142 
10 
49 
3 
66 
3 
3 
1 
14 
4 
25 
3 
7 
Peruvians 
From other parts of America.. 
7 
6 
7 
4 
9 
7 
4 
2 
2 
1 
1 
2 
Europe:— 
109 
11 
44 
i 
ii 
3 
7 
2 
2 
Germans 
431 
160 
175 
17 
1,237 
79 
4 
53 
2S 
2 
33 
4 
19 
5 
4 
1 
Belgians 
2,478 
2,229 
453 
718 
410 
496 
179 
167 
76 
113 
31 
230 
59 
25 
27 
12 
4 
1,051 
1,320 
671 
490 
251 
193 
60 
9 
6 
166 
257 
125 
101 
59 
64 
458 
38 
13 
23 
127 
14 
7 
1 
3 
15 
7,428 
2,612 
3,852 
1,387 
1,343 
636 
56 
29 
141 
11 
105 
10 
SO 
7 
3 
5 
262 
72 
118 
36 
33 
12 
2 
2 
i 
From other European countries 
298 
62 
146 
26 
46 
29 
13 
6 
9 
4 
2 
34 
14 
39 
24 
40 
39 
27 
45 
31 
40 
20 
24 
Asiatics 
2 
4 
3 
2 
1 
1 
1 
1 
1 
3 
1 
17,635 
10,892 
9,727 
6,781 
4,241 
3,522 
1,719 
1,590 
588 
624 
128 
177 RAWSON, 
91 to 100 
101 and 
upward 
Age unknown 
Eecapitulation 
Nationality. 
M. 
F. 
M. 
F. 
M. 
F. 
M. 
F. 
Total- 
Independent America:— 
10 
29 
3 
2 
2 
37,486 
60 
52 175 
89,661 
87 
’ 27 
455 
262 
717 
i 
312 
144 
456 
526 
77 
603 
2 
i 
i 
3 249 
2 738 
5,987 
437 
] 56 
593 
43 
25 
68 
47 
38 
83 
Europe:— 
33 
499 
43 
512 
1 461 
578 
2,039 
116 
47 
163 
2 
i 
i 
10,486 
8,625 
2,034 
3 512 
13,998 
13,402 
2 
14 
4 777 
] 
1 
1,027 
13,074 
67 
350 
3,081 
4 
2 
i 
5 
1 
28,883 
711 
41,937 
778 
1 
1 
1,030 
1,315 
263 
1,380 
From other European countries 
2 
2 
33 
347 
1,662 
2 
7 
3 
3 
219 
482 
12 
9 
21 
1 
21 
4 
25 
Totals 
21 
41 
14 
6 
75 
16 
98,091 
79,696 
177.787 
Attention is at once attracted by the numerical relation of the pre- 
dominant elements in the native and foreign populations respectively* 
It should be borne in mind that, among immigrants to Buenos Ayres, the 
male element is far in excess of the female, and that for reasons as obvious 
as they are natural. The pioneers of emigration are always robust men 
in the prime of life ; and not until prolonged experience has proved the 
certainty of happy results, do the women and families set out to share 
the fortunes of the fathers and brothers wdio have left their native homes. 
Immigration to the United States has now assumed a character of perma- 
nency and stability induced by satisfactory experiments extending over 
more than half a century; nor is it to be wondered at that immigrants arrive 
on the shores of the Union in a state of almost complete family organiza- 
tion, or, at least, that 45 per cent, of them are females of all ages. And it 
is a noteworthy fact that the distribution of female immigrants through- 
out the country is, according to the census of 1870, in direct ratio to the 
age of the States. In Maine, New York, and Massachusetts, for instance, 
the female foreign population is equal to, or often in excess of, the male; 
while in the new States and in the Territories, the number of females iu 
the foreign population is small as compared to that of the males, save i>l 
the single Territory of Utah, where, for well-known reasons, the reverse 
is the rule. 
The population of Buenos Ayres in 1869 comprised:— 
Males of all ages and nationalities 
. 98,091 
Females “ “ “ ... 
. 79,696 
Total 
. 177,787 
The Argentine branch of the population, of all ages, comprised, in the 
same year: males, 37,486 ; females, 52,175 ;or an excess of 14,689 females. 
In the foreign branch, including all ages and nationalities, there were: 
males, 60,605 ; females, 27,521 ; or an excess of 38,084 males, which 
not only compensated for the deficiency of males in the Argentine popu- 
lation, but constituted an excess of 18,395 males in the total number ot 
inhabitants. VITAL STATISTICS OF BUENOS AYEES. 
1035 
9ooa fegard t0 age’ chlldren under five years numbered 23,367, of whom 
had been born m foreign countries. In Hew York, the number of 
children of that age, so interesting in the study of vital statistics is equal 
to 11.8 per cent, of the whole population, while in Buenos Ayres it con 
statutes only 13.1 per cent. From the age of five to fifteen, the proportion 
ot foreign-born children gradually increases, which is likewise observed 
to be the case in Hew York, as shown by the report of the Commissioners 
ot Emigration for 1875, in which children not over twelve years of ao-e 
Represented 21 per cent, of the 84,000 immigrants who arrived at tliat 
port in the year mentioned. The period ranging from sixteen to sixty 
years, is that in which the numerical superiority of the foreign popula- 
tion is most marked in Buenos Ayres; and the same phenomenon is* 
observed in Hew York, though without the strange proportions charac- 
teristic of the former city. This is the period of life in which full physi- 
cal and moral development are attained—plenitude of power for labor for 
reproduction, and even for organic resistance of the permanent influences 
which menace health and existence. In this triple point of view the 
foreign population is certainly superior wherever it presents, as it does in 
-Buenos Ayres, such an evident majority of individuals in the a«’e of vmor 
and strength. & & 
Marriages.—The following table shows the number of marriages that 
took place in each of the seven years from 1867 to 1873. I have taken 
care to compare the numbers with the population in the respective years 
calculating the latter according to the established rate of increase' in 
order to ascertain the number of persons per thousand married in each 
year:— 
Years. 
Marriages. 
Number of 
persons married 
per 1000. 
1867 
. 
. 1530 
19.0 
1868 
. 1703 
20.2 
1869 
. 1858 
20.9 
1870 
. 1916 
20.5 
1871 
. 1896 
19.4 
1872 
. 2193 
21.4 
1873 
. 2291 
21.3 
Mean 
number of persons married per 1000 during 7 years 
. 20.39 
From this table it appears that the number of marriages increased 
gradually, save in the year 1871, in which there was a decrease of 20 as 
compared with the figures of the year immediately preceding, due to the 
perturbation caused by the great epidemic. In the succeeding years the 
increase was again visible, as was also that of the population. It is like- 
wise to be observed that the proportion per thousand varied very little 
and may be set down at an average of 20, though the mean for the seven 
years was 20.39. Figures in statistics assume greater importance when 
compared with others of like nature. Here, as in other branches of the 
present report, I prefer to make the comparison with the city of Hew 
York, not only because I have ready access to the official documents 
relating to the vital statistics of that populous city, but also on account 
of a certain analogy which I find it to bear to Buenos Ayres in the 
department which now engages my attention. The number of marriages 
in Hew York in each of the same seven years, as given in the 
vital statistics published by the Board of Health, and for which I am 
indebted to the courtesy of Hr. Hagle, will be seen in the subjoined 
table. I should add that, in computing the rate per 1000 of persons who 1036 
RAWSON, 
married, I have estimated the population before and after the census of 
1870, according to the rate of increase—say 2.1 per cent.—adopted by 
the official authorities ; 
Years. 
1867 
Marriages. 
. 7144 
Persons married 
per 1000. 
16.14 
1868 
. 6926 
15.33 
1869 
. 8695 
18.44 
1870 
. 7985 
14.71 
1871 
. 8646 
18.07 
1872 
. 9008 
18.52 
1873 
• 
• 
. 8887 
17.72 
Average . 
16.99 
This mean annual rate may be regarded as somewhat below the truth 
for New York, inasmuch as the Registrar-General, in the course of his 
reports, complains of the culpable negligence of some of the persons 
required by law to have marriages registered in the proper office. At all 
events, the data I have adopted as the basis of my calculations are of 
official origin, and they show the increase in the number of marriages 
to be not uniform, as likewise the proportion per 1000. This variability 
or lack of uniformity I am at a loss to account for, nor am I aware to 
what causes, social or economical, it should be attributed. I shall add, 
by way of comparison, a list of the marriages in nine American cities in 
the year 1872, observing that the population of the city of New York 
has been increased in the proportion corresponding to two years after the 
census. 
Cities. 
New York 
1872. 
Marriages. 
. 9008 
Number per 
1000 of persons 
married. 
18.52 
Boston . 
. 3762 
28.38 
Philadelphia . 
. 6496 
19.28 
Richmond 
. 567 
18.90 
Providence 
. 943 
26.46 
Pittsburg 
. 1143 
26.56 
Albany 
. 613 
16.14 
Newark , 
. 1241 
23.62 
Jersey City 
677 
15.74 
Buenos Ayres 
2193 
21.04 
In view of the heterogenous composition of the population, it is im- 
portant in a statistical point of view to inquire into the nationality of 
the consorts. The results of observation in this respect are, in Buenos 
res, as follows: 
Marriages according to the Nationality of the Consorts. 
Argentines. 
Foreigners. 
1 Q£Q 
[ Males . . 
... 444 
Males 
. 1414 
| Females . 
... 719 
Females .... 
. 1139 
1163 
2553 
f Males . . 
... 519 
Males 
. 1397 
\ Females . 
. . . 770 
Females .... 
. 1146 
1289 
2543 
1 0*71 
f Males . . 
... 478 
Males 
. 1418 
[ Females . 
. . . 737 
Females . . . . , 
. 1159 
1215 
2577 VITAL STATISTICS OF BUENOS AYEES 
1037 
1872- 
f Males . . . 
. . 483 
Males . . 
• . . 1708 
[ Females . . 
. . 722 
1207 
Females . . 
• • . 1471 
3179 
1873 -j 
\ Males . . . 
[ Females . . 
. . 418 
. . 758 
1176 
Males ... 
Females . , 
• • • 1873 
• ■ . 1533 
3406 
In these five years, the number of foreigners who married is seen to 
exceed by far that of the Argentines. And if, for the sake of greater 
accuracy, we take the year 1869, bearing in mind that the foreign and 
the Argentine elements were then almost equal, the different nationalitv 
°r the persons who married can only be explained by special comparison 
°f the foreign element in relation to age and sex. Thus, the number of 
Argentines who contracted marriage in the year referred to was 1163 
and that of the foreigners of both sexes, 2553—that is to say about 2 19’ 
°f the latter to lof the former. It will also be noticed that the number 
G Argentine males was in still greater disproportion to that of the 
foreign males, namely 444 to 1414, or as Ito 3.18. Still another com 
Parison with one of the foreign nationalities: The Italian population G 
sct down in the census at 41,957, against 89,661 Argentines. Aow the 
Number of Italians who married in the course of that year reached 1304 
aNd that of the Argentines 1163, of both sexes, while the Italian males’ 
to 704, and the Argentines to only 444. A similar dispropor- 
tion is noticed in Yew York in a series of years. Let us tnk-A f™ 
example, the year 1873‘ ’ 01 
Natives. 
Foreigners. 
Males . . . . 
. 2688 
Males ... 
. 6,183 
Females .... 
. 3530 
Females .... 
. 5,341 
6218 
11,524 
Here the natives stand in the proportion of 1 to 1.8 of both sexes the 
Proportion of native males being even smaller—l to 2.3. The same 
observation may be made in Yew York with reference to the German 
Nationality, as that I have just made with respect to the Italians in 
Buenos Ayres. The German population, according to the census 
amounted to 151,216, the native having been 523,198. Meantime, while 
out 6218 native Americans of both sexes contracted matrimony, the 
Number of Germans who married was 6340. And, in order to render 
Ibe analogy still more marked, let us mention that the American males 
entered into wedlock numbered only 2688, and the Germans 3416. 
Births.—The same uniformity of progression appears in the births. It 
N»ay also be stated with certainty that the number of births follows the 
focrease of the population, preserving with it a uniform proportion, which 
Proves that the registration has been carefully attended to, and that my 
Estimate of the population before and after the census is neither exces- 
sive nor deficient. Although I have the registers from 1855 down to 
1873, I only adopt in the following table those relating to the five years 
commencing with that of the census, and consequently including the 
Nnhappy year 1871:— 
Years. 
Population. 
Births. 
Rate per 1000. 
1869 
177,787 
6944 
39.3 
1870 
186,320 
7561 
40.5 
1871 
195,262 
7549 
38.6 
1872 
204,634 
8078 
39.4 
1873 
214,456 
8559 
39.9 
Mean annual rate per 1000 
• • • 
. 39.5 1038 
RAWSON, 
Continuing the comparison with the vital movement in Hew York, I 
transcribe from the official documents the number of births during the 
same five years, in relation to the population calculated according to 
annual growth;— 
Years. 
Births. 
Bate per 1000. 
1869 
. 13,947 
15.17 
1870 
. 14,524 
15.41 
1871 
. 20,821 
21.64 
1872 
. 22,068 
22.45 
1873 
. 22,683 
22.61 
Mean annual rate per 1000 . 
. 19.45 
The different rates in the first two years as compared to the others 
may perhaps, in the absence of a visible specific cause, be attributed to 
a defective system for the registry of births. But, even taking the 
proportion of 22.61 per 1000, which is the maximum, it is far from the 
mean annual rate in Buenos Ayres. The accompanying table will show 
the proportion of births in a few cities of Europe and America, and will 
serve to demonstrate how- variable that proportion is in different nations, 
though not on account of difference of race, but from other and complex 
causes which must, sooner or later, come within the range of sanitary 
science:— 
Cities. 
Brussels .... 
Births in 1873. 
6.200 
Bate per 1000. 
33.51 
London .... 
. 121,100 
36.05 
Bordeaux .... 
5,036 
25.95 
Berlin .... 
. 36,281 
38.19 
Dublin .... 
9,031 
28.70 
Milan .... 
9,091 
33.52 
Mexico .... 
9,273 
41.21 
Boston .... 
9,688 
35.07 
Brooklyn .... 
5,027 
11.54 
Philadelphia 
“ (1874) . 
. 17,811 
23.74 
. 19,387 
24.07 
Chicago .... 
. 
9,718 
24.29 
In some American cities the proportion of births is so low, as observed 
by the Board of Health of Philadelphia in its reports, as only to be ac- 
counted for by defective registration. If such be the case, the necessity 
of reform is evident in this very important department of statistics. 
The matrimonial statistics with respect to the nationality of the con- 
sorts, would seem to promise a like proportion in the births with respect 
to the nationality of the parents. I shall confine my examples, in the fol- 
lowing tables to births of children whose parents were either both Argen- 
tines or both foreigners, omitting cases of parents of mixed nationalities, 
and cases without any specification. 
Births. 
Parents both 
Parents both 
Years. 
Argentines. 
foreigners. 
Proportion. 
1869 
. 1512 
3314 
1 to 2.0 
1870 
. 1403 
3881 
1 “ 2.7 
1871 
. 1564 
4019 
1 “ 2.4 
1872 
. 1580 
4451 
1 “ 2.8 
1873 
. 1543 
4738 
1 “ 3.0 
The proportion of children of foreign parents to children of Argentine 
parents, increased from 2 to 1 in 1869 to 8 to 1 in 1878, it being worthy 
of remark that the augmentation coincided with the most extensive 
immigration. Here, again, I meet the same analogies as before between 
Buenos Ayres and Hew York, as set forth in the subjoined table, in which VITAL STATISTICS OF BUENOS AYRES. 
1039 
Jre included only births of children of American parents and children of 
foreign parents. 
Births. 
Years. 
American parents. 
Foreign parents. 
Proportion. 
1869 . 
. 2457 
9,080 
1 to 3.7 
1870 . 
. 2553 
9,282 
1 “ 3 6 
1871 . 
. 2631 
14,144 
1 “ 3 8 
1872 . 
. 3721 
14,829 
1 “ 3 9 
1873 . 
. 3827 
15,353 
1 “ 4.0 
In New York, the excess of births of children of foreign parents as 
pom pared with those of children of American parents, is more remarkable 
foasrauch as it reached the proportion of 4tol in 1873. This extraordi- 
nary proportion is far in excess of that suggested by the number of 
Carriages according to nationalities, and indicates that the fecundity 
nf these different classes of persons is affected by other causes as proved 
V the two following facts : (1) That the predominance of males over 
females is greater among children of foreign than among those of Ameri- 
pan parents, and (2) That, according to the curious observations contained 
m the tables of statistics published by the Yew York Board of Health 
from 1870 to 1873, among American mothers whose children were reVis- 
fered in those years, 
35 had had up to that time 
17 
9 “ “ “ “ 
5 
2 
1 
• ■ 12 children each. 
. 13 
. 14 
. .. 15 
. 16 
. 18 
69 
And among foreign mothers there were counted 
215 with 
12 children each. 
119 “ 
13 
57 “ 
14 
(( u 
17 “ 
15 
“ “ 
12 “ 
16 
(( (6 
11 “ 
17 
a U 
4 “ 
18 
a u 
1 “ 
19 
a it 
436 
foaking a total of 436 fecund foreign mothers, and only 69 American, 
the fecundity of the latter appearing, too, in a less degree than that of 
the former. 
Mortality.—l have now reached the most painful portion of my review. 
In regard to the sanitary condition of Buenos Ayres, I must state facts 
plainly as I apprehend them to exist, not merely because science should 
he in possession of the whole truth, but also because the truth may serve 
a useful end in stimulating the praiseworthy efforts now being made to 
remedy the evils which menace the public health in that city. 
Annual reports of the vital statistics of Buenos Ayres have only been 
Published within the last few years, and always so late as to have lost 
Uiuch of their interest when they have reached the eyes of the few per- 
sons who consult them. The public is for the most part ignorant of the 
number of deaths that have occurred during the year, and is altoo-ether 
Unaware of the proportion existing between the mortality and thepopu- 
lation, so that the belief still prevails that the city is very healthy. From 
time to time such epidemics have appeared as smallpox, scarlatina or 1040 
RAWSON, 
measles, often carrying away large numbers of people; but such visita- 
tions have been regarded as temporary exacerbations of mortality, which, 
once past, would give place to returning health and all its attendant bless- 
ings. In 1858, a yellow-fever epidemic, confined within the narrow limit 9 
of a single ward of the city, killed from three to four hundred victims. 
As the same disease had raged to a fearful extent the previous year at 
the neighboring city of Montevideo, its appearance in Buenos Ayres pro- 
duced a profound impression of terror, and caused a large number of the 
inhabitants to flee to the rural districts ; but the epidemic having proved 
of short duration, and its effects somewhat limited, it was believed that 
the sanitary condition of the city was so perfect as to prevent the spread- 
ing of the horrible malady, and a general complaint arose against the 
quarantine department for want of vigilance in allowing the introduction 
of an exotic disease. In spite of the frequent returns of smallpox, scarla- 
tina, and typhoid fever, and the mortality caused by the tetanus infantum 
(popularly called the “ seven days’ sickness”), and other diseases common 
among children, the idea of the salubrity of the city still prevailed in the 
public mind. 
In 1867, Asiatic cholera made its first appearance, and the following 
year it returned, extending its ravages through the surrounding country 
and most of the provinces of the interior. Much greater, indeed, would 
have been the alarm in Buenos Ayres, if timely publicity had been given 
to the disastrous effects of the warnings from Nature, who in no instance 
allows any violation of her laws to p>ass with impunity. Much greater, 
I say, would have been the alarm, for the people would then have been 
made aware that the number of deaths in 1867 had reached 8029, or 49.9 
per 1000 of the entire population, and 38.9 per 1000 in 1868. As it was, 
however, the evil was productive of some good results: works were under- 
taken for supplying the city with running water, and the cleaning of the 
streets, and other sanitary details coming within the province of the 
municipal police, were more regularly and efficiently performed. 
The year 1869 was a peculiarly favorable one for determining the real 
sanitary condition of the city, there being no epidemic just then in 
Buenos Ayres, and the general health being, to all appearance, perfectly 
satisfactory. The census of the population was taken in the year just 
mentioned, and that was the juncture fixed upon for inquiring into the 
real nature of the city as a habitable centre, and examining the status of 
its account current between life and death, always bearing in mind that, 
after the disappearance of severe epidemics, the relative death-rate de- 
creases in a sensible degree. Now, had a report of the vital statistics 
then been drawn up and pmblished, it would have exhibited a mortality 
of 5982 for the year last referred to, or 33 per 1000 of the inhabitants who 
had just been numbered, and would have shown that, with such a usual 
rate, Buenos Ayres could not ap>pear to advantage beside other civilized 
cities, in which latter—even including the most populous of Europe and 
America—the mean annual death-rate is, with very few and marked 
exceptions, much lower. Then would the existence have become evident 
of permanent causes, the removal of which was indispensable in order to 
the improvement of the public health. It would also have been dis- 
covered that those causes tended to heighten the severity of epidemics, 
and that something more was necessary than merely defending the 
entrance to the city against the invasion of pestilence (even could such 
defence, which is rarely the case, be rendered efficacious), namely, the 
purification of the city itself, in order to render it salubrious under all VITAL STATISTICS OF BUENOS AYRES, 
1041 
circumstances, and to weaken the virulence of disease in the event of 
cxtraordinary visitations. 
In 1870, peace and prosperity reigned undisturbed in the city the 
general health seemed good, immigrants, in hitherto unprecedented 
’lumbers, were flocking in, labor was abundant and well remunerated 
and capital easily obtained, and commerce and industry were more active 
than ever before. Buenos Ayres was all contentment, and looked with 
evident satisfaction upon its visible growth ; and the very possibility of 
another epidemic was forgotten by the people, who supposed the entrance 
to their city well guarded by vigilant sentinels. Indeed, the death-rate 
tor that year was 1.5 per 1000 lower than that of the year immediately 
preceding, though still far above the usual rate in other cities between 
tvhich and Buenos Ayres comparison was allowable. The situation 
remained unchanged until the early days of 1871, when some cases of 
yellow fever were reported in the southern extremity of the town How 
uad the enemy entered, and who was to blame for the neHect? Investi- 
gation was idle; the yellow fever, the terrible yellow fever was in their 
tuidst, and the frightened inhabitants anxiously occupied themselves 
Until the thought: what is likely to be the severity, and what the 
extent, of the visitation ? All, families and individuals, who could do so 
left the city in search of a refuge from death that stared them in the 
face. The pestilence, in the mean time, spread apace, and gained in 
intensity as it spread. It attained its maximum severity in April and 
thenceforward gradually subsided until the end of May or beo-innino- of 
June, when the last cases occurred. The epidemic had extended through- 
put the entire city. Its ravages were truly awful; 106.5 of every 1000 
inhabitants died in that year, including in the population those who 
Were saved by withdrawing to the rural districts—some 60,000 persons 
Such mortality was beyond all imagination: one out of every nine in- 
habitants is a death-rate unprecedented in the civilized world in the 
nineteenth century; nor is it possible to describe the feelings of ano-uish 
and terror which it left in the breasts of the survivors. It then became 
deplorably evident that the hygienic condition of Buenos Ayres was 
Unfavorable in the extreme, and that the prompt investigation and 
removal of the causes of the evil, at any sacrifice, were matters of the 
utmost urgency. Under the promptings and counsel of science and 
experience, works of sanitary improvement were at once commenced 
and on their completion we shall be in possession of that salubrity which 
is so much to be desired, and which is always the reward of man’s efforts 
to secure it. The lesson has been a severe one. 
It is only within the past few years that the beneficial results of 
Sanitary Sciences have been experienced, even in Europe itself. To know 
that many diseases are avoidable, inasmuch as their determining causes 
are known and may be suppressed, is the first step, and comes within the 
province of science. The will and the means necessary for the removal 
of those causes are to be applied by the people, through their municipal 
or political organization. The world has been very tardy in learning to 
know itself in this respect, and is still slow in reaching the ultimate 
consequences. It is not, therefore, to be wondered at that Buenos Ayres 
should have been so ignorant, and still more neglectful than ignorant of 
the interests of the public health. Its very rapid growth warrants the 
presumption that its sociological evolution may possibly partake of a 
somewhat tumultuous character. Political agitations on the one hand' 
apt on occasions to assume convulsive forms; inward satisfaction at 
66 1042 
RAWS ON, 
conscious advancement on the other, with the accumulation of stinim1 
developed in a feverish and progressive society, and the complete con- 
centration of power, individual and collective, in pursuit of the more 
material and tangible ends of human energy, have been so many i*l' 
fluences tending to divert, and which have in reality diverted, the minds 
of men from those other interests, more radical and enduring if we will’ 
hut less peremptory than the first, because their sphere is not measured 
by common vision, and because a catastrophe is at times required to 
bring them to the public attention. 
Although the foregoing reflections do not strictly form a part of the 
principal object of the present review, they bear so close a relation to it 
that I cannot forbear including them, they having been suggested to nW 
in the course of my statistical inquiries. It also appears to me proper 
to mention, in this place, the chief causes of the increased mortality? 
though they differ in no respect from those which—in all cities where 
the laws of hygiene are imperfectly observed—contribute to augment 
the number of deaths. 
In Buenos Ayres, as in all Spanish towns, the streets are narrow, and 
they present, together with the few, small,public squares, an area of very 
inconsiderable extent. It is to be remembered that the proportion of 
the municipal area to each inhabitant, as mentioned in a preceding page 
•—7O metres—is the average proportion, there being many parts of the 
city sparsely populated ; and it is likewise to be borne in mind that in 
most houses considerable space is devoted to extensive court-yards, etc. 
As the population increases, these relative advantages grow less, and 
they will become altogether null at no far distant day, unless prudent 
forethought lead to the enlarging of the squares, and the converting 
them into health-giving parks, and the widening some of the streets into 
vast and spacious avenues. 
In the course of the past twenty-four years, about two-thirds of the city 
have been rebuilt, but without any attempt having been made to improve 
that opportunity by adopting a methodical system of widening, save only 
in the new streets of the suburbs. A grave error was committed in 
using the filth of the town for the purpose of filling up and levelling some 
of the streets, which were immediately paved over. The filth thus em- 
ployed consisted of a heterogeneous mass principally made up of the 
refuse from the dwellings, that is to say, animal and vegetable matter 
united with dust and other substances, comprising house and street 
sweepings. Such a sediment is destined to be decomposed by putrid 
fermentation, and gives place to the generation of mephitic gases, which 
escape through the porous surface stratum, and, mingling with the air 
breathed by the inhabitants, constitute an inexhaustible source of poison 
for the atmosphere. Indeed, it has been observed that the people dwell- 
ing in the wards here described, have been relatively the principal suf- 
ferers during epidemics, and that some portions of these districts are 
rarely exempt from typhoid fever, especially in the spring and summer 
seasons. 
The water formerly used in Buenos Ayres, both for drinking and gene- 
ral household purposes, was derived from three sources ; the rich had 
rain-water, preserved in impermeable tanks or cisterns, and the remain- 
der of the population took well-water and the river-water sold in the 
streets, which was commonly brought from the portion of the river La 
Plata contiguous to the town, and was certainly contaminated by the VITAL STATISTICS OF BUENOS AYRES. 
1043 
fluvial population of the port, and by the liquid animal matter flowing 
flown from the slaughter-houses situated on the borders of the Riachuelo, 
Borue two miles south of the centre of the city. With the exception of 
the cistern water, for the most part good, the water chiefly used was 
Necessarily bad, as may be presumed from the nature of the sources from 
Which it was derived. Since 1868, steps have been taken for supplying 
the town with running water proceeding from a more suitable portion of 
the river, towards the north of the city; but the supply thus obtained is 
extremely limited, nor is the source from which it is taken altogether 
free from objection yet. The extensive works at present in process of 
Gxecution will accomplish a radical improvement in this respect. 
The system of privies was primitive in the extreme. The receptacles 
°f the excrementitious matters were common cesspools, usually sunk 
below the level of the subterranean water. In the soil, eminently porous 
hi that region, a deposit of putrescible matter was maintained for years, 
flissolved more and more by the subterranean water, whose level has a 
Uiean alternate rise and fall ot about six feet from the dry to the wet 
season. Hence, the process of absorption was rapid; and not only the 
gases generated by fermentation, but the liquids in which the decomposed 
°i’ganic matter was held in solution impregnated the soil, vitiated the 
Water of the wells, and sent to the surface mephitic emanations incompa- 
tible with the good health of the people who breathed an atmosphere 
thus poisoned. Hn 1868 a new system of impermeable privies was insti- 
tuted ; but it has not yet become sufficiently general in its application, 
and since 1871 the plan has been put into practice of emptying and 
cleaning the privies by a pneumatic mechanism similar to that so suc- 
cessfully applied in France. The works of drainage and sewerage, so 
actively prosecuted at the present time, are destined to radically remove 
this infection, which experience has demonstrated to be one of the most 
fruitful causes of disease and death. 
Before closing this tedious enumeration, I must add that there existed 
two other foci of infection in Buenos Ayres. One of these was an immense 
heap of refuse, made up of animal and vegetable matter in full course ot 
decomposition, which was accumulated some three miles southwest from 
the centre of the city, and from which the noxious gases were carried to 
the town by the atmospheric currents, and mainly by the wind called el 
pumpero, blowing in that direction from the pampas, and reputed as the 
Uiost healthful in the region. The quantity of filth gathered in that 
place was enormous; in 1873, three hundred tons of the pestiferous mix- 
ture were carried oft" daily, and in 1875, three hundred and ninety tons. 
Since 1873, the evil effects of the accumulation have been sensibly modi- 
fied by the simple and most efficient means adopted ot burning the 
Unclean matter. 
Two miles southward from the centre of the town runs the Riachuelo, 
which empties into the Rio de la Plata. Here the loading and unloading 
ot the coasting and other light craft are mainly effected , and on the 
banks of the Riachuelo stood lor many years the slaughter-houses and 
fat-boiling establishments, which represented the two principal industries 
of the province, and in which as many as half a million ot cattle were 
slaughtered annually, and more than two millions of sheep and mares, and 
the various parts of their carcasses were prepared for commerce. All the 
liquid and much ot the solid refuse matter proceeding fiom these estab- 
lishments were thrown into the Riachuelo. The mass of intection thus 1044 
RAWSON, 
collected may easily be imagined, as may the consequent contamination 
of the waters by the fermentation of the organic matter, from which arose 
stifling gases to corrupt the air shortly to be breathed by the inhabitants 
of the town. So extensive were the interests connected with the ancient 
and remunerative industry allowed by our legislators to be carried on 
the manner described, that, notwithstanding oft-repeated warnings ot 
the grave objections ottered by the nuisance, all the terror and desolation 
of 1871 were necessary to bring about its abrupt suppression. Many 
proprietors, no doubt, suffered materially by the measure; but the bene- 
ficial results to the public health were incalculable. The diminution ot 
the typhoid fever since the removal of the saladeros', etc., affords an 
evident proof of the wisdom of the step. 
Is it, then, astonishing that, under so many unfavorable circumstances, 
mortality should have been so great in Buenos Ayres? If the peopl6 
had been informed of the number of deaths from year to year, and the 
relation between that number and the number of inhabitants, they would 
have seen that, during the years 1854-1872, the death-rate was never 
less than 31 per 1000, without counting the great epidemics ; they would 
have understood that the severity of the cholera and yellow fever which 
decimated their ranks was intimately connected with causes within 
their midst, calculated to encourage the development of contagious 
maladies; and they would have investigated the nature of those causes, 
would have found them where all modern societies have found them, and 
would have energetically set about their removal. They would thus have 
avoided much grief and many losses of greater moment than the expendi- 
ture would have involved. There is no doubt that, if the public health 
be persistently and intelligently cared for, and past and future experience 
in this respect be profited by, the rate of mortality will in a few years 
descend to the level of that of London, the metropolis of the world, as 
it is called on account of its gigantic proportions. The climate ot 
London is not better than that of Buenos Ayres; nor are the wTaters of 
the Lea or the Thames comparable, either for purity or abundance, to 
the sweet and crystalline streams of the Parana and Uruguay, which 
unite to form the Plata; nor is the food used in England more healthy 
or nutritious than that used in the Platine city ; nor is the soil of the 
former more extensive or more fertile than that which the latter can 
offer to the present and to future generations. If, in our endeavors to 
improve our own condition, we use the same enlightened determination 
which England uses, and which secures for her the respect and admira- 
tion of all beholders, we shall accomplish what she has accomplished, 
namely, the reduction of the death-rate in her large cities from 50 per 
1000, near the close of the last century, to 22 per 1000, which has been 
the mean rate during the last few years. 
Let us now see what statistics say in their austere language. Taking 
a series of fourteen years, from 1861 to 1875, exclusive of 1874, for which 
I have as yet no returns, but inclusive of 1867 and 1868 with their 
great cholera epidemic, and 1871 with its yellow fever, the mean annual 
mortality is found to be 38.9 per 1000. If we leave out the years 
marked by epidemics, the mean annual rate of the eleven remaining 
years will be 31.3. But I prefer to present these data in tabular form, 
for the sake of clearness, and in order that the maximum and minimum 
mortality in the years referred to may be readily perceived. VITAL STATISTICS OF BUENOS AYRES. 
1045 
Years. 
Estimated 
population 
Mortality. 
Rate per 
10G0. 
1861 
. 121,280 
3.410 
28.1 
1862 
. 127,101 
4.313 
33.8 
1863 
. 133,200 
4,539 
34.0 
1864 . 
. 139,593 
4,378 
31.3 
1865 
. 146,292 
5,857' 
40.0 
1866 
. 153,313 
5,111 
33.3 
1867 . 
. 160,671 
8,029 
49.9 
1868 
. 168.382 
6.564 
38.9 
1869 . 
. 177.787 
5,982 
33.6 
1870 . 
. 186,320 
5.886 
31.5 
1871 
* 
. 195,262 
20.748 
106.2 
1872 
. 204,634 
5,671 
27.7 
1873 . 
. 214.453 
5,891 
27.4 
1875 
. 230,000 
6,751 
29.3 
Mean annual rate 
38.9 
31.3 
Mean annual rate, 
leaving 
out the years marked by epidemics' 
In the foregoing table are included three years of dreadful epidemics 
It is beyond doubt that, although the importation of contagious maladies 
18 almost always accidental, the extent to which they spread and the 
severity of their character are always to be imputed to the sanitary con- 
dition of the population, and to the same account is the increased mor- 
ality to be charged. The year 1865 likewise figures in the table with a 
death-rate of 40 per 1000, owing to the fact that the soldiers wounded 
)n the first battles of the Paraguayan war, fought on Argentine territory 
invaded by the enemy, were brought to Buenos Ayres, and considerably 
increased the number of deaths registered in the city. Deaths occa- 
sioned by war should also appear in vital statistics: they are losses of life • 
and, sooth to say, the cause to which they are due is araoiu the most 
easily avoidable. With these observations, the mean annual rate for the 
period we have chosen may readily be estimated. If we leave out the 
epidemic years and the first year of the Paraguayan war, the mean 
annual rate of the ten remaining years will be 3i per 1000. 
Let us see the state of things in New York during the same period. 
As will be observed in the subjoined table, I have adopted the figures of 
Ibe census returns of 1860 and 1870, and computed the population of the 
intervening years by applying the mean annual rate of increase corres- 
ponding to 1.5 per centum. For the years following 1870, I have, for 
reasons already hinted in this paper, adopted 2.1 per cent., the mean 
annual rate of increase admitted by the Board of Health. The State 
census of 1865 has always been regarded as too low ; and such must be 
the case, for, by comparing the population as set down in that census 
With the mortality for that year, the death-rate would be 3.5,4, which is 
inadmissible, as being out of proportion with the rates of the previous 
and succeeding years. 
1 Commencement of the Paraguayan war. 1046 
RAWSON, 
Years. 
Population. 
Deaths. 
Rate per 
1000. 
1861 . 
. 825,873 
24,525 
28.4 
1862 . 
. 838,260 
23,150 
27.6 
1863 . 
. 850,833 
26,617 
31.2 
1864 . 
. 863,625 
25,792 
29.9 
1865 . 
. 876,579 
25,767 
29.3 
1866 . 
. 889,726 
26.815 
30.1 
1867 . 
. 903,071 
23,159 
25.6 
1868 , 
. 916,641 
24,889 
27.1 
1869 . 
. 930.337 
25.167 
27.0 
1870 . 
. 942.292 
27,175 
28.8 
1871 . 
. 962,079 
26.976. 
28.0 
1872 . 
. 982,282 
32,647 
33.2 
1873 . 
. 1,002,909 
29,084 
28.9 
1874 . 
. 1,023,969 
28,727 
28.0 
1875 . 
. 1,045,467 
30,709 
29.3 
Mean annual rate of mortality per 1000 . 
. 28.8 
In comparing the two tables, I have only to observe that the death' 
rate for the years 1872 and 1873, in Buenos Ayres, is lower than that fqr 
the same years and the year 1874 in Yew York, while that for 1875 
precisely the same in both cities; that the number of still-born infants is 
included in the total of deaths in Buenos Ayres, but not in that of the 
deaths in Yew York, according to the usual custom in the United States 
and England; and finally, that, of the total number of deaths figuring 
opposite the year 1875 in the Buenos Ayres table, 1041 were caused by 
smallpox. 
Comparative Table of the Rate of Mortality in some American and 
European Cities in the Year 1873. 
Cities. 
Rate. 
Cities. 
Rate. 
New York 
. . . . 28.9 
London .... 
. 22.8 
Philadelphia 
. . . . 19.6 
Liverpool .... 
. 25.8 
Chicago 
. . . . 23.8 
Edinburgh . . . 
. 21.9 
Boston . . 
. . . . 28.4 
Paris 
. 23.0 
Cincinnati 
. . . . 22.8 
Bordeaux .... 
. 26.7 
Buffalo. . 
. . . . 13.7 
Berlin 
. 27.8 
St. Louis . 
. . . . 19.4 
Vienna 
New Orleans 
. . . . 37.5 
Valparaiso . . . 
. 50.0 
Cleveland , 
. . . . 19.2 
Buenos Ayres . . 
. 27.4 
The statistics of mortality in Buenos Ayres are taken with commen- 
dable numerical accuracy; but that alone is not sufficient when those 
statistics are to form a part of the general vital statistics, for in the 
tables of these a methodical and scientific classification is required. The 
classification in Buenos Ayres is defective. The deaths are registered 
according to the medical certificates, in which is expressed the cause ot 
death ; but the diagnosis is not submitted to the criterion of any compe- 
tent authority; nor are any fixed rules observed in the preparation of 
the tables. The municipal employes, in their turn, but so long afterdate 
as to preclude the possibility of adequate revision and correction, copy 
down in alphabetical order the diseases mentioned in the physicians’ 
certificates ; so that statistics thus compiled leave much to be wished foiq 
in a scientific point of view. The establishment of a uniform system ot 
classification for all countries would be desirable, as much enhancing the 
advantages to be derived from comparative statistical studies. The classi- 
fication proposed by Dr. Farr, and approved by the International Statis- 
tical Congress in Paris, in 1855, is the one commonly followed in the 
United States and England; but'it has not been adopted in France and VITAL STATISTICS OF BUENOS AYRES. 
1047 
J?any other nations, nor is it uniformly observed even in the United 
states. In the reports of the Chicago Board of Health, which I have 
before me, I find the diseases arranged in alphabetical order, without anv 
regard to their special character. 
The publication of the complete statistics of Buenos Ayres would 
therefore, be of no practical interest; and so I shall select the latest of a 
series of reports in my possession—that for 1875—and transcribe there- 
tj-om such portions as are necessary. Of the 6751 deaths registered during 
that year, the prevailing causes were as follows: ° 
Smallpox ........ 
. 1041 
Phthisis 
858 
Tetanus infantum ...... 
445 
Typhoid fever 
140 
Meningitis 
355 
Pneumonia 
382 
Organic affections of the circulatory system 
389 
Diphtheria 
101 
Diarrhoea . 
296 
The mortality according to sexes was as follows:— 
Males 
- 3841 
Females 
. 2889 
Not specified 
21 
Total 
. 6751 
According: to ages: — 
Up to 5 years (including 189 still-born) .... 
. 3521 
Up to 100 years 
. 3072 
Not specified 
. 158 
Total 
. 6751 
According to nationalities:— 
Argentines 
. 5102 
Foreigners 
. 1649 
Total 
Smallpox stands for 15.4 per cent, of the mortality of the year. Few 
cities present so large a number; and this is precisely the disease the 
ravages of which may be most effectually prevented. If vaccination 
Were made obligatory in all cases and by all means, and due care taken 
to be sure of the efficacy of the virus by frequent renewal, the deaths 
from smallpox might be reduced to one-tenth of the number figuring in 
the table; particularly when the hygienic condition of the city should have 
been improved by the overground and underground sanitary works now 
in progress. The appearance of smallpox is no longer an accident, but 
an event of ordinary occurrence ; the extent of its ravages is variable, 
but the disease never fails to come, as proved by the following table:— 
In 1869 
the number 
of deaths by smallpox was . 
. 183 
“ 1870 
tt 
tt tt tt 
. 195 
“ 1871 
tt 
tt tt tt 
. 1656 
“ 1872 
it 
it tt tt 
. 836 
“ 1873 
tt 
tt tt tt 
76 
“ 1874 
it 
It tt tt 
. 525 
“ 1875 
tt 
tt it it 
. 1041 
Total . 
. 
. 4512 
Giving a mean annual rate of 644 during the seven years mentioned. 
Such figures as these need no comment, nor even comparison with those 
of American and European cities or regions. 1048 
RAWSON, 
The next item of importance is that of 858 deaths from pulmonary 
consumption, representing 12.7 per cent, of the total mortality. The 
death-rate caused by phthisis has sensibly augmented in six years, 
will be seen in the following table:— 
Years. 
1869 . 
Deaths 
from 
phthisis. 
. 370 
Kate per cent, of 
the total 
mortality. 
6.1 
1870 . 
. 274 
4.6 
1871 . 
. 495 
2.4' 
1872 . 
. 597 
10.5 
1878 . 
. 755 
12.8 
1875 . 
. 858 
12.7 
This progressive increase of tuberculosis, at a time when cases of zymotic 
disease are tending to diminish in number, save only smallpox, which Is 
due to a specific cause, can only be accounted for by an increase of damp- 
ness in the soil underlying the city, in combination with the other causes 
of insalubrity already mentioned, and which have as yet been but slightly 
modified. Dr. Buchanan observed the effects of the drainage-works in 
twenty-five cities in England, and reported that in all of them the gene- 
ral mortality had decreased, particularly that determined by typhoid fever 
and diarrhoea; but that in those which had been supplied with thorough 
sewerage, without an equally effective system of underground drainage, 
neither pulmonary consumption nor catarrhal affections had undergone 
any diminution. The immediate effect of subterranean drainage is to 
dry the ground, thus allowing the air to penetrate into the latter and 
take the place of the water throughout the thickness of dried earth, and 
there hasten the oxygenation of the infectious substances held in solu- 
tion, and thereby establish a healthy condition of the sod. Besides, this 
drying process exercises a powerful influence upon the atmospheric strata 
immediately contiguous to the ground and forming the air breathed by 
the inhabitants. It has been observed as an invariable rule, easily ex- 
plained by physical laws, that fogs disappear or are diminished in a re- 
markable degree in cities and elsewhere where the ground has been dried 
by drainage. From the two foregoing facts it may be deduced that the 
increase of tuberculosis corresponds to the increase of underground hu- 
midity in conjunction with other depressing influences; and that if we 
desire to put a limit to this grave malady, all the more to be feared from 
its hereditary character, it is necessary that a most perfect system of 
underground drainage should form a part of the works now in process 
of execution, not only to prevent the invasion of new masses of water, 
but to dry up that now contained in the ground, and so remove the 
existing infection. 
Buenos Ayres is not, indeed, the city which offers the greatest mor- 
tality from pulmonary consumption. This disease has always been pro- 
portionately more destructive in Hew York. The statistics of fifty-five 
years demonstrate that, down to 1853, it caused from 16 to 21 per cent, 
of the total mortality of that city ; but that since that time it has 
diminished, in severity, as may he seen by the subjoined table, corre- 
sponding to that above given for Buenos Ayres : 
1 The year of the great yellow-fever epidemic. VITAL STATISTICS OF BCEXOS AYRES, 
T ears. 
Deaths 
Rate per cent, of 
from 
the total 
1869 
1870 
1871 
1872 
1873 
1874 
phthisis. 
mortality. 
. 3364 
• 4030 
13.37 
14.82 
. 4186 
. 4274 
15.52 
13.09 
. 4134 
. 4034 
14.21 
14.04 
1875 
. 4172 
13.78 
Aor is Yew York the least favored city in this respect in the United 
States or Europe, as may be seen from the following table: 
Cities. 
Rate per cent, 
of deaths 
Rate per cent. 
Boston . . 
from phthisis. 
St. Louis . 
from phthisis. 
. . 8.78 
. . 14 55 
Philadelphia . 
. . 14.28 
Baltimore . 
Portland . 
. . 25.03 
London 
• . 11.70 
• • 18.90 
. . 11.00 
• . 15.24 
Cincinnati . . 
. . 11.64 
Paris 
Cleveland . . 
. . 7.76 
Rome . 
Chicago . . 
. . 6.68 
Naples . . 
Yext in order of numerical importance, on our list of causes of mortal it - 
stands tetanus infantum or trismus nascentium, the number of victims to 
which was 445 in the year referred to, or 6.5 per cent, of the total mor 
tality. The peculiar tendency of the soil of Buenos Ayres to determine 
such a considerable number of cases of tetanus infantum, vulgarly called 
the “seven days’ sickness,” and in England the “ nine days’ sickness ” is a 
circumstance deserving experimental and scientific inquiry. This sneei 
of tetanus is regarded as traumatic, and as proceeding from the section 
of the umbilical cord: it may set in during the process of cicatrization 
That this is not the only determining cause, is proved by the existence 
of the disease in the endemic form in the city and province of Buenos 
Ayres, and, to a certain degree, in the other littoral provinces. That it 
is dependent upon the impurity of the surrounding atmosphere and the 
want of care bestowed upon new-born infants, is demonstrated by its 
almost total disappearance among families comfortably situated in clean 
and well-ventilated houses; while the chief ravages of the affection 
occur among the poor, particularly in houses overcrowded with people 
who either know not how, or are unable, to give their infants that care 
which is required by their tender years. At all events, the mortality 
from tetanus infantum has been on the decrease for a number of years 
owing to the improved condition of the general hygienic police, for I 
have no doubt of the existence of a zymotic element in the production 
of the disease. 
Deaths from 
Date per cent. 
Years. 
tetanus 
of the total 
infantum. 
mortality. 
1869 . 
10.5 
1870 . 
. 689 
11.7 
1871 . 
. 470 
2.21 
1872 . 
. 558 
9.8 
1873 . 
. 620 
10.5 
1875 . 
. 445 
6.5 
It is not here possible to establish a comparison with other cities the 
tetanus of new-born infants either not being mentioned at all in their 
statistical reports, or only figuring therein for an extremely small pro- 
portion of the total mortality. One exception I should, however, make' 
1 Year of the yellow fever. 1050 
RAWSON, 
the city of Havana, where 388 of the 8390 deaths which occurred in 
1875, were caused by tetanus infantum, being 4.6 per cent, of the whole 
mortality. 
Typhoid fever was represented in 1875 by 128 deaths. The number 
of deaths by this disease was 600 in 1869 ; but it has been gradually 
decreasing since the suppression of the saladeros in 1871, and the de- 
struction of the filth in 1872 and 1873. This, like the other zymotic 
diseases, is subordinate to the infection of the soil and air, and will pre- 
vail in inverse ratio to the progress of the sanitary works now in course 
of execution. 
I shall devote no special remarks to the other causes of death enume- 
rated in the table, partly because they are common diseases, and again 
because the sanitary improvements will exercise a certain influence upon 
them. After a brief examination of the subject of mortality among 
children in Buenos Ayres, I shall proceed to consider the relation in 
which the various nationalities appear before the law of death. 
The number of children under five years of age who died in 1875, was 
3521, including still-born infants, or 52.1 per cent, of the total mortality 
for the twelvemonth. More than one-half of the deaths in Buenos Ayres 
are of children under the age of five, which proportion is at once extremely 
large and afflicting, especially as it seems to increase from year to year, 
as set forth in the annexed table :—- 
Years. 
1869 . 
No. of deaths 
among children. 
2534 
Kate per cent, of the 
total mortality. 
42.2 
1870 . 
2690 
45.7 
1871 . 
3591 
17.3 
1872 . 
2649 
45.7 
1873 . 
2891 
49.0 
1875 . 
3521 
52.1 
Let us compare this table with the following one for Hew York during 
the same number of years:— 
Years. 
No. of deaths 
among children. 
Rate per cent, of the 
total mortality. 
1870 . 
12,971 
48.0 
1871 . 
13,333 
49.0 
1872 . 
16,188 
49.5 
1873 . 
14,182 
48.7 
1874 . 
13,956 
48.9 
1875 . 
14,839 
48.3 
From the comparison it would appear that the relative mortality 
among children was greater in Hew York than in Buenos Ayres. But 
in both cities it is very much greater than in localities the hygienic 
condition of which is more favorable to general health ; while, on the 
contrary, wherever that general condition is less favorable, infant mor- 
tality represents a still higher proportion. 
Where a full-grown adult may be able to brave morbific influences 
with impunity, a tender infant will succumb. The mephitism of cities, 
resulting at once from accumulation, imperfect circulation of air, defec- 
tive’light, and the gases from decayed organic matter which pervade 
the atmosphere, menaces the health of all; notwithstanding which, the 
great majority of adults survives, thanks to fully developed vigor and a 
confirmed habit of organism, inured, as it were, to these adverse circum- 
stances. But the infant, just emerged from the maternal cloister, igno- 
rant of the circumstances in the midst of which it lives, unaccustomed 
to the straggle, breathing that impure air from twenty-six to thirty VITAL STATISTICS OF BUENOS AYRES. 
1051 
times each minute, with extremely permeable membranes, and the rapid 
processes of assimilation required by the progressive development of its 
oro-ans • the infant, in a word, feeble, inert, and defencelessly exposed to 
the poisonous air, without knowledge of the evil, and even helpless to 
avail itself of its locomotory mechanism to enable it to avoid danger 
under the guidance of instinct, droops, and is prostrated by disease 
and death. And all this without taking into account the baleful effects 
of hereditary transmission, by which those tender organisms are unfitted 
for life poisoned as they are before birth by virulent infections, which at 
best doom to a miserable existence the beings who receive them with 
the blood of their progenitors . , 
These simple reflections, dictated by common sense, serve to illustrate 
the incontestable fact that, under whatever hygienic conditions,, even 
the most satisfactory, life is surrounded by most dangers when in its 
dawn and that deaths will be more numerous during that period than 
at any other time with which it may be compared ; but the same reflec- 
tions serve also to illustrate another phenomenon less generally known, 
thjlt ;n proportion to the development of toxic influences in a 
comm unit not only will the general mortality be enhanced, but the 
iXTSuty0 among children will be increased in a still higher 
degree This unchanging fact, proved by statistics and never contra- 
j-Lh hv experience, points to the conclusion that the proportion ot the 
dieted by' ®Xv to thi total mortality in each community may be taken 
as neorometer, and That from it may be deduced the 
saidtary condition of that community, even without an absolute knowl- 
edge of the population at asucceed i„ reducing its 
S°PK“-'SI f “ 1000 „ it was in 1875, to the London rate of 21 
peTIOW (whichfit seems tome, would be perfectly attainable in a few 
the aggregate nior , 14 839 would not only be reduced, in pro- 
fant mortality, which (the rate per cent., instead of 48.3, 
portion to the total, to 10 bO4 But t S|ealthy citieß) would not 
being only 40, as it is PP mol.e\han six thousand children annually 
rise above 8781, there y S circumstances under which they are 
who are novv sacrifice ytl same reckoning were applied to 
born to await death. Aim, u have been 4830, instead of 
Buenos Ayres, the mor a i y mortality would have reached but 
6751, and the corresponding infant 
1932, and 1589 infant ( Ayres show that, of 6751 who died in 
The, vital statistics ofot Qf the total 
that city in 18/5, 51 - exception of 1871, in which year the 
number who perishe . J wft tpan that of natives, the latter 
number of foreigner from 70 to 75 per cent. Indeed, the exeep- 
stand in the fof^ 
persons, almost 
tion mentioned is to e exf refuse in the rural districts, while 
exclusively Argentines fled and took-mn, remained for th’e most 
the foreigners (workingmou with tteu 
part, in the mfeote sabjoined table, in which are set forth the 
sake ot clearness, L .nffl and foreigners, and the death-rate of the 
formeHn SfnVthe total mortality in the city during a period of 
six years:— 1052 
RAWSON, 
Years. 
1869 
Argentines. 
. 4203 
' Foreigners. 
1,779 
Percentage of 
Argentine deaths 
70.2 
1870 
. 4587 
1,299 
77.9 
1871 
, 8082 
12,660 
38.9 
1872 
. 4121 
1,550 
72.6 
1873 
. 4319 
1,572 
73.3 
1875 
. 5102 
1,649 
75.5 
If we examine the figures corresponding to 1869, which, taken as they 
are from the census-returns of that year, present the advantage of being 
accurate, and bear in mind that the native and foreign elements were 
then almost equal (89,661 Argentines, 88,126 foreigners), we shall observe 
that the mortality among the former was at the rate of 46.9 per 1000, 
and that among the latter 20.1, And, if we take into consideration that 
the proportion of the foreign to the native element has increased from 
year to year, the marked inequality in the relative proportions of mor- 
tality in the two groups will become at once perceptible. The gravity 
of such an alarming state of affairs as shown by statistics is somewhat 
attenuated by the fact that, among the number of deaths of Argentines, 
is included the total mortality of children up to five years of age. 
Deducting the latter from the death-returns of the same year,. 1869, 
which, as has been seen, is likewise the least unfavorable for the Argen- 
tines, and counting as adults (in as far as probabilities of life are con- 
cerned) all individuals of upward of five years of age, we shall have:— 
Argentines .... 
4203 
Children 
. 2534 
. 1669 
Foreigners .... 
1779 
that is is to say, a slightly greater mortality among foreign adults. It 
is, however, to be observed that, of the 28,367 children (up to 5 years) 
shown by the census, 2290 were born out of the republic. The portion 
of these among the children who died in that year, and who were natu- 
rally registered acording to their respective nationalities, forms a part of 
the 1779 foreigners of the death-returns, and hence cannot be deducted 
from the total of the Argentine infant mortality. If 9.8 per cent. o± 
the infant population, up to live years, is made up of foreign children, 
it is fair to suppose that at least 9 per cent, of the infant mortality 
belonged to that category, in whicn case the approximate result would 
he; 
Total of deaths among children 
. 2534 
Nine per cent, of foreign children . . 
. 228 
Number of Argentine children 
. 2306 
which deducted from the total Argentine mortality, would leave, instead 
of 1669, a remainder of 1897, a number much higher than that of the 
deaths among foreigners. 
Before proceeding any further with the review of the sad details sug- 
gested b}r the foregoing results, let us compare these with those of the 
corresponding table for New York, as follows: 
Years. 
Mortality. 
.A. 
Percentage of 
Americans. Foreigners. 
Americans. 
1868 . 
. 16,805 
8,084 
67.5 
1870 . 
. 17,471 
9,714 
64.2 
1871 . 
. 17.470 
9,566 
64.7 
1872 . 
. 21.448 
11.199 
65.6 
1873 . 
. 19,135 
9,949 
65.7 VITAL STATISTICS OF BUENOS AYRES. 
Taking the year of the census, in which the population was composed 
of 528 198 Americans and 419,091 foreigners, the mortality among the 
former was 33.3 per 1000, and among the latter 23.1 per 1000. If the 
children be also deducted, for the same reason as in the case of Buenos 
Ayres the balance of the adult mortality is in favor of the native popu- 
lation’ in the proportion of 4671 deaths of adult Americans and 9714 of 
foreigners regarding as adults, as usual in my calculations, all the in- 
habitants of more than live years of age. It is necessary here to make two 
observations concerning these comparative results. The first has refer- 
ence to the difference as regards ages, between Buenos Ayres and Yew 
York whence it appears that the inhabitants under live years of age 
constitute, in the first city, 13.1 per cent, of the total population as may 
be seen by the census returns, while in the second they represent but 11.8 
percent and consequently, that the mass of inhabitants among whom 
de-ith makes ’its most abundant harvest is relatively larger in Buenos 
Avres The second is contained in the following words of Dr. Elisha 
Harris recorder of vital statistics of York Board of Health: 
u Wp next notice that more than half of the total population which is 
over five vears of age is of foreign birth, and> that families, the heads of 
which are of foreign birth, constitute the chief portion of the tenement 
population, as shown by the returns of census-takers in the different 
wards” “Vigorous as the better portion of foreign residents 
are 'the rate’ of mortality in their children is excessive.” These state- 
ments ox) to show that the mortality among foreigners of over five years 
of ao-e who live under such depressing circumstances, as also among their 
voting children, must be greater than that among the native population, 
by whom other advantages are enjoyed. . 
“ There is in all this something more radical and seiious than mere 
'numbers In order to attenuate the gravity of the vital statistics, the 
argument of the mortality among children is at all times adduced, and 
tlmir number deducted from that of the deaths among natives, thereby 
Itrovinv that from the age of five years upward the vital energy to 
■esis disease and death is no greater in foreigners than in natives. Xdo 
not wish to discuss this point, respecting which much might be said m 
view'of the lessons of history and of the biologica sciences ; but 1 must 
sly something upon the subject of the element with which it ,s asserted 
tSt the balancebgainst the native population is c osed Considered in 
its relation to social mechanics, a child is assuredly not a powei, but a 
resistance • not a force, but a burden ; and, according to this incomplete 
ami fallacious theory, the death of a child would only be a loss in the 
breasts of those who Mourned him, and not for the producing capacity ot 
uieasts ot tnoso lace(i pv a vigorous adult, come whence he might. 
Sulh 'a doctrhm condemned by our natural feelings by justice, and by 
buch a doctr » opposition to the dictates of sound reason and 
philanthropy, is also moppositio and the ho of the 
statistics. Socially, the cm let is "/A",.. , nt_ ti,p pitHpn who 
farnilv • uolitically, he is the citizen of the futuie. ibe citizen who has 
bee born and grows up in the land of his fathers, not only assimilates 
the materials of his organism in the continued process of:rapu renova- 
tinn but takes in in that atmosphere, the constituent elements ot his 
disnosition and thus becomes by progressive education, by the contem- 
p ation of vicissitudes and of the struggles of manhood, and by the innate 
fove of all belonging to him, the surest guaranty ot the farmness of the 
institutions under whose influence and in whose mould he has I,ecu 
formed It is then, the duty of well-constituted societies to bestow 1054 
RAWS ON, 
attention upon their children in view of the double interest just referred 
to, and, if for nothing else, for the purpose of preserving the largest 
number possible for the battles of collective life. 
If the mortality among Argentines in Buenos Ayres, and among 
Americans in New York, should become enhanced, or even retain its 
present proportions, it would be difficult to foretell how far the respec- 
tive nationalities may become weakened as a ruling power in society, 
and how, little by little, that loss of influence may be felt in the customs 
of the people and the integrity of the institutions. In my opinion this 
danger is neither imaginary nor remote, and the only means I can dis- 
cover by which it may be averted (and I have long studied the subject) 
is, by the energetic improvement of the sanitary conditions of states, 
cities, and towns ; the reduction of mortality to its lowest possible ex- 
pression (18 per 1000, for instance); and the perfecting of the systems 
of education, popular, moral, and physical. From what we have already 
seen concerning the susceptibility of favorable or adverse influences m 
infancy, if mortality be lessened, those most benefited thereby will be 
the children; while society, by the preservation of a larger numbei o 
these, will secure the organic advantages which I have mentioned. 
Statistics have also a voice in the question. The city of New York, 
during the seven years ending in 1873, had a mean annual death-iate 
of 29"per 1000, while the rate of births for that period was very low. 
Taking the figures as they stand in the register, the number of deaths 
and births was as follows:— 
Deaths during the seven years ... 
Births “ “ “ “ 
. 189,385 
. 119,226 
Difference against the population . 
. 70,159 
which is equivalent to a loss of more than 10,000 per annum. So that 
if such losses were not compensated, and even exceeded, by immigration, 
the population would go on gradually decreasing. I should here mention 
that, according to official reports, the registry of births is so defective 
as to warrant the assumption that not more than 75 per cent, of the real 
number is recorded. Even accepting this hypothetical suggestion, and 
supposing no omissions to have occurred in the death-registers, we should 
have:— 
Deaths .... 
. 189,385 
Births .... 
158,968 
30,417 
which would still leave a considerable loss for the population. And, in 
order to avail ourselves of these figures, let us suppose the mortality in 
New York to be reduced to 21 per 1000; in which case we should have 
the following results;— 
Deaths .... 
. 140,692 
Births .... 
158,968 
18,276 
leaving a balance of 18,276 in favor of the population, in place of a real 
loss, as it has been sustaining ; and this without taking into account the 
positive fact, based on experience, that the number of births increases 
with the improvement of the sanitary condition of the city. _ It is like- 
wise to be borne in mind, respecting children, that mortality among 
them decreases much more rapidly with an improved healthy condition VITAL STATISTICS OF BUENOS AYRES. 
1055 
of the city than among adults ; so that, if, of the hypothetical number 
of deaths (140,692), 40 per cent, had been of children, the mortality of 
the latter would have been 56,276, instead of the 93,677 who died during 
the seven years, thereby constituting an economy of 87,401 infant lives, 
or as many fathers or mothers of families in the course of a few years. 
Durino- the same seven years, Buenos Ayres had 51,207 births and 
58,771 deaths, including the three epidemics (1867, 1868, and 1871), or a 
loss of 7564 inhabitants. By reducing the annual death-rate to 21 per 
1000 the mortality would have been 27,455 in the seven years, and the 
difference in favor of the population 23,752. lam not examining chi- 
meras but realities; death and life are recorded in official statistics, and 
the improvements which I hold as possible are graven in imperishable 
monuments in the form of sanitary works, in those American and 
European communities which have struggled gloriously with death, and 
have conquered it. ... x . .. , . , , 
Wherever there is death there is sickness. It is generally admitted,. 
and to a certain extent proved by statistics, that the sickness-rate of a 
city or town is approximately two sick persons throughout the year to 
each death per annum. Hence, to ascertain the number of days of sick- 
ness suffered by the population, taken collectively, the permanent factor 
7SfliVi v 21 is multiplied by the number of deaths during the year: so 
that when the mortality is considerable, the number of sick persons is 
also considerable in like proportion—which is perfectly reasonable, inas- 
much as sickness and death proceed from the same causes acting, in a 
given locality, upon each and all of the inhabitants. In 1875 the mor- 
tality of New York was 30,709; and, if, as has been admitted, there 
were two sick persons for each death constantly throughout every day- 
in the year, the number above given should be multiplied by 780 and 
thp rimd nef 22 417 590, would be the number of days ot sickness suffered 
by the population collectively, which is equal to 21.4 days tor each 
Onedav of sickness signifies one day’s labor lost for those at an age 
for workfmr and producing. The number of these is easily computed 
kLw thiraccordlngtothe census of 1870h there were. the 
citv 350 556 nersons engaged in all occupations, that is to sa}, 37.1 pci 
total popultioii; and by applying thi. percentage to the 
population in 1875, we ascertain that as many asi 387 
,vo,ki',g,-- i"yl/i'i-mhh'hk.A Ae i- 
and individual capacity, it is not easy to adopt a unitoim staudaid , so 
I shall take the lowest rate said, by Commissioners < 
to have prevailed in 1875 for persons working b} the day, namely, to 
8150 preferring the first, in order to avoid all appearance of exagge- 
ration P The value of the labor lost would amount, at the rate of $1 per 
day to $8 298 566 The expenses occasioned by sickness are incident to 
the whole population ; and the number of days’sickness, for population 
lie whole popu a » was 22 417,590. The approximate amount 
inay be ascertained by means of the data furnished by 
the8 hospitals, and according to which each mt.ent coats about $2 per 
dav, Now reducing those expenses by one-half (-ay to $ 1 instead of 
$2) and including therein the outlay for professional attendance, medi- 
cines reAmen and nursing, for the inhabitants of all classes, the aggre- 
gate’cist would be $22,417,590, corresponding to the number of days ot 
sickness. 1056 
EAWSON, 
I shall not present in the pecuniary form the depressing influence 
which morbific causes exercise upon the capacity, physical and moral, of 
those individuals who, by reason of their vital energy, can resist the 
effects of such causes and preserve their health. To eliminate and 
prevail over a pathological agent, implies a waste of organic force in the 
process, and so much less force in the physical and moral aptness applied 
to production. Mens Sana in corpore sano. It is enough to mention this 
last branch of the subject, the pecuniary value of which cannot be esti- 
mated. 
Those who die during the working age have an independent value as 
capital irrecoverably lost. Not only the days of sickness, or the days of 
the year, are here lost, but the very instrument of production itself for 
the future. In the United States, an adult immigrant is estimated as 
representing a capital of $lOOO incorporated in the national wealth: now 
8580 adults, approximately, died in 1875, in the city of New York, 
.figuring consequently for an aggregate of $8,580,000. 
With these numbers, every figure of which I have carefully calculated 
according to data, either official or of acknowledged scientific authority, 
the losses in the account of the public health for 1875 may be posted in 
the ledger of the city of New York, as follows; 
Work lost 
. $8,298,566 
Loss, expenses incurred by sickness 
. 22,417,590 
Loss, adult lives 
. 8,580,000 
$39,296,156 
These losses cannot be avoided, but they may be considerably dimin- 
ished, If the mortality had been 21 per 1000, instead of 29 per 1000, 
each of the items of the account would have been reduced in the same 
proportion ; the aggregate would only have been $28,452,216, and there 
would have been an economy of $10,838,840. 
That amount of money saved would be equal to the interest of a capi- 
tal of $150,000,000 at seven per cent. And let it be asked of the dis- 
tinguished Dr. Chandler, President of the Board of Health, or of the most 
skilled and experienced Sanitary Engineers, either of this country or 
of Europe, if that capital, or one-half thereof, intelligently invested in 
sanitary improvements in the city of New York, would not be sufficient 
to place that city on the level of London in point of salubrity. lam as 
certain that the reply would be in the affirmative as I am that never 
could money be invested in a more remunerative speculation. 
As for the causes of the evil, and its remedy, there is a set of books 
which contains their explanation, and which is worth a whole library. 
The Reports of the New York Board of Health enumerate those causes, 
accompanied by eloquent suggestions of remedies, from year to year, 
supported by the authority of science and study. If the reading of those 
Reports were rendered popular, the influences which make an imperial 
metropolis an unhealthy city, in the eyes of the laws of hygiene, would 
be recognized; people would then know in what mortiferous conditions 
live one-half of the population, and how those conditions may be mate- 
rially improved, and what are the existing defects in the system of 
drainage and sewerage, and the danger of those defects being enhanced, 
to the still greater detriment of the public health ; the relations of 
meteorological phenomena to the mortality of the city would be discov- 
ered ; and for each and every one of those evil influences would be found 
a certain remedy, suggested by experience both at home and abroad, or VITAL STATISTICS OF BUENOS AYRES. 
1057 
the means of attenuating such influences as were not immediately depend- 
ent upon the hand of man. The recommendations of the board of health, 
once put into action, with the amplifications required by successive 
developments, would be sufficient to reduce, within the space of five 
years, the mortality of New York from 29 per 1000 to 21 per 1000, and 
thus secure all the"benefits, physical and moral, to be gained by such a 
U lUs for the interest of all, both poor and rich, natives and foreigners, 
to aid in the realization'of sanitary improvements, which are peremp- 
torily urgent for the present and necessary for coming generations And it 
must be remembered that the cost of their execution is enhanced by every 
day’s delay. One of those omnipotent movements ot opinion which in 
a strong-minded people are commonly attended by prodigious results, 
would lead to the immediate and complete solution of the grand problem 
Nor does this subject concern alone Buenos Ayres in that far-distant 
region of America, nor New York, in tins part of the continent: it is a 
subject which affects the interests of whole nationalities New York 
in 1790 had 33,000 inhabitants; eighty years later, with a million o 
souls, it' is the third city of the Christian wor d, and is marching onward 
to become the first, at the close of the second centennial of the United 
States. Philadelphia competes with Berlin and Vienna ; on the banks 
of the Mississippi is rising up St. Louis another city which would 
monopolize the admiration of all who beheld it were it not that on he 
margin of Lake Michigan, Chicago rears her head in pride before the 
astonished gaze of natives and fore.gners-Ch.cago, the new born city, 
which now contains half a million ot human beings What, in the course 
of time, will become of these grand centres of civilization, and of many 
others as yet without a name? The problem of their destiny is m then- 
own hands, and Sanitary Science should he the chief light to guide them. 
The tendency to centralization, witlnts advantages and inconveniences, 
is inherent in human nature, and not to be controlled. In 1860, there 
were in the United States 18 per cent, of the 
of 8000 inhabitants and upwards; and in 
of the cities of 8000 And 
of the total popu a i > interests which should tend to dissemi- 
over the entire length and breadth of the land; spite 
of the S and lakes, canals and railways tbe aggregate length o which 
would reach three times round the 
facilities for cheap and rapid transit forpeopie_and 1 
Wln'th^AreenrineBEepublieThifiietinetiTe force of centralization is still 
more marked than in the ®iqiTy SfCm. 
?orll townsls prop.rtionately much more rapid than that of the towns in 
toral towns is prt tfaat of Buenos Ayres, where the agglo- 
the interior, *nd 1 incommensurate with that observed elsewhere in 
meration is f“ time to inquire into the sociological 
’,d M ccm sequences of this natural inequality ; but, n treating of 
tl lifp of pities and of the statistics of Buenos Ayres, to the latter are 
rl wi «!h considerations as that species of agroupment may suggest. 
Tffor the causes of the excessive mortality of Buenos Ayres, they have 
mvt been briefly enumerated, as have also the measures undertaken for 
their removal. 1058 
RAWSON, VITAL STATISTICS OF BUENOS AYRES. 
For the rest, in the sanitary condition of cities, whatever be their 
population, it is incumbent, not only upon them, in as far as their cir- 
cumscribed capacity may extend, to assume the responsibility of the 
present evil and of its future aggravation, but upon each and all of the 
inhabitants; all have to take part in the continued struggle in defence 
of life, as well individually as in municipalities, legislatures, and con- 
gresses. I know not whether the illustrious Cobden and Peel concerned 
themselves little or much with matters of public hygiene, but I do know 
that the liberal commercial legislation established by them in England, 
has served to improve the condition of the poor of that nation, by ren- 
dering their existence less burdensome through the lower prices of 
articles of food, and has contributed effectually to lessen the number of 
deaths and of those diseases which are induced by want. 
In closing this paper, 1 feel it my duty to apologize for the liberty 
which I have taken of instituting comparisons with the vital movement 
of Hew York, without the authority of prolonged personal 
On one hand, I should say that the Argentines ever look to this part ot 
the world for example and stimulus; and on the other, that I have 
noticed such close anthropological analogies between what I have seen 
during my short stay in Hew York and that which has long been the 
object of ray study in Buenos Ayres, that I have not been able to resist 
the desire of establishing a few comparisons, even at the risk of arriving 
at defective or inaccurate conclusions. 1059 
THE GENERAL SUBJECT OF QUARANTINE WITH 
PARTICULAR REFERENCE TO CHOLERA 
AND YELLOW FEVER. 
BY 
JOHN M. WOODWORTH, A.M., M.D., 
SUPERVISING SURGEON-GENERAL, UNITED STATES MERCANTILE MARINE-HOSPITAL SERVICE.1 
The earliest recorded measures instituted to prevent the spread of 
disease were adopted by Moses, who made regulations concerning the 
leprosy, in which he not only provided for the isolation of the infected 
people, but held the suspected for observation and cleansing. In the 
fourteenth century, certain restrictions were placed upon vessels arriving 
at Venice and Genoa, in Italy, to prevent the introduction of the plague’ 
but it was not until the fifteenth century that quarantine was vonprall J 
established. & y 
The early system of quarantine was not based upon scientific facts or 
experience, but appears to have been an outgrowth of that peculiar 
period (noted for ignorance and superstition) known as the “ dark ages' ” 
The name “ quarantine” fairly indicates the hypothetical extravagance 
which held sway at its birth. As out of the forty days’ fast in the wilder- 
ness grew Lent, the period of abstinence instituted for the purification of 
the soul, so the process of purifying ships and passengers from so called 
contagion was made to cover forty days, and this process was termed 
quarantine.1 In the measures blindly enforced to protect seaports from 
infection, not only was commerce crippled, and property needlessly sacri- 
ficed, but the comforts and rights of the suspected were entirely ignored. 
They were not only compelled to undergo a tedious, and worse than 
useless, period of observation, but, by the very process of sequestration 
they were exposed to tenfold greater danger from fornites that mio-ht 
chance to be in the ship. Many of the senseless and inhuman practices 
which grew up under the name of quarantine, have by degrees, and from 
time to time, been discontinued, and yet—so hard is it to cut loose from 
the influence of tradition—not a little of the fog and delusion associated 
with the term “quarantine” in the past continues to the present day, espe- 
cially in the countries where quarantine was first established. 
As the visits of the plague became less frequent and less severe, yellow 
fever and cholera commenced their migrations. These diseases gave a 
new interest to quarantine, which had previously been confined in its 
operations to the old world, but by these diseases was extended to the 
new. To the quarantine of ships, and of those who travelled by them 
was added the “ cordon sanitaire” against cholera, in the hope of prevent- 
ing its march by land. This last measure has been enforced in Europe 
with the utmost rigor, and, though utterly futile in its results, appears 
1 Charles Caldwell, M.D., on Quarantine, 1837. 1060 
WOODWORTH, 
not to have been entirely abandoned in some localities even during the 
prevalence of the last recorded epidemic of this destroyer.1 
In America, quarantine was first established in 1708, at Hew TOl ? 
against yellow fever. Though I shall have occasion, further on, to speak 
of the administration of quarantine at Hew York, it serves to mark t W 
progress and application of experience in this direction to note here some 
of the changes which have taken place at that port. In 1811, we fm 
that vessels arriving from infected districts were detained thirty days a 
quarantine, and passengers and crews twenty days after the occurience 
of the last case of yellow fever. In 1830, healthy persons arriving 
vessels from infected localities were permitted to proceed to the city, but 
without their baggage, notwithstanding that many pernicious restric- 
tions still stand upon the statute-books of the State, the enforcement of 
them is left to the medical officer, whose opinion is more and more recog- 
nized. It is now found practicable not to detain either healthy passen- 
gers or infected vessels. This arises from the generally accepted princi- 
ple, that healthy individuals do not convey the morbific poison of cholera 
or of yellow fever, but that the poison finds lodgment in confined clothing? 
and especially in the vessels themselves, under favoring conditions. To 
detain an infected vessel has been found to increase the virulence of the 
poison. Accordingly, the ship’s cargo is promptly transferred to lighters 
in the bay, freely exposed to light and air, and the.vessel, after thorough 
disinfection, is allowed to proceed. In strong contrast with the foregoing, 
is the practice pursued at Pensacola, on the Gulf Coast. In May, 1871, 
upon the arrival of yellow fever at quarantine, the City Council of Pen- 
sacola passed an ordinance which is here given in full;— 
“Saturday, May 30, 18Y4.—Board met, pursuant to call from Mayor. The 
object of the call having been stated, on motion it was resolved that all ves- 
sels arriving at this port from infected ports shall be compelled to remain 
in quarantine until frost; or said vessel shall be allowed to depart from this 
port at anytime during quarantine, at the option of the commander or captain 
of said vessel; but in no case shall any such vessel be permitted to load, take in, 
or discharge, cargo, within the limits of the quarantine station during the exist- 
ence of quarantine; nor shall any person being on board any such vessel be 
allowed to visit the city during quarantine. 
“ Resolved further, that the Mayor be requested, and he is hereby fully autho- 
rized and empowered, to employ a good and sufficient armed guard, with a good 
and sufficient boat, to patrol during the night on an established line between the 
quarantine station and this city ; and that the Mayor be requested to instruct 
said guard to prevent all communication whatever, by boat or otherwise, be- 
tween said station and this city, and to use sufficient force to attain that end, 
should it be necessary to fire into the person or persons attempting to violate 
said quarantine. 
“Attest: M. P. de Ejoboo, Clerk.” 
The results of these widely different methods may be stated in a few 
words; During each of the past five years, and more, a number of infected 
vessels arrived at the Hew York quarantine station. Many cases of yel- 
low fever were treated in Quarantine Hospital, but in no instance did 
the disease spread to the city, or affect a single attendant on the sick. -At 
Pensacola, in 1874, the infected ships were anchored near the quarantine 
1 Dr. Milroy, in an article in the British and Foreign Medico-Chirurgical Review, No. 
Ixxxiii., states that “in 1867 military cordons were drawn around the infected districts in 
Montenegro, and persons who dared to cross them were shot. The horrors ot famine were 
thus added to those of pestilence.” QUARANTINE. 
1061 
station. Communication from the infected vessels and from quarantine 
was had by night with the land ; and when, under the fostering condi- 
tions for propagation, the yellow-fever poison had gained sufficient viru- 
lence the disease spread to the city and the naval station near by, the 
quarantine medical officer himself falling a victim to the system which 
he had blindly endeavored to carry out. _ 
In passing to a brief notice of quarantine regulations at two other 
ports of the United States, it is proper to mention the fact that the con- 
trol of quarantine in this country is not assumed by the general govern- 
ment but that it is established and enforced by each seaboard State, or 
municipality, for itself. The only exception occurred during the war of 
the rebellion when the commanding general of the Union armies, upon 
the recommendation of the Surgeon General of the Army, directed (1) that 
all vessels arriving from ports infected with cholera, but having bad no 
case during their" passage, should be quarantined for fifteen days and 
thoroughly fumigated, and (2) that all vessels having had cholera on 
board during their passage, should be quarantined for fifteen days after 
the termination of the last case, and thoroughly fumigated. 
The quarantine regulations at the port of .New Orleans, in 1822, autho- 
rized the health officer, in his discretion, to continue quarantine indefi- 
nitely but provided that infected vessels should be detained not less than 
fifteen days after the recovery of the sick, and purification of the vessel. 
Healthy vessels from healthy ports were detained five days and “ ves- 
sels from any port of Europe, arriving between the first of May and the 
first of November, bringing more than twenty passengers, were not, how- 
ever healthy permitted to come within three leagues of the city, until 
after the first of November in any year.”1 A committee on quarantine 
for the State House of Representatives of Louisiana, reported that “ dur- 
ino- the last vear [18221, notwithstanding the strictest compliance with these 
laws our expectations were frustrated at the very moment when we 
thought we could indulge the hope of the most complete success. Under 
the present laws in force at the New Orleans quarantine, vessels hailing 
from ports infected with yellow fever are allowed to pass to the city after 
tTd.WmthTd.te (/leaving an infected 
is included the time eon.''United States in 18?8, 
remhnl.kfa;-seShqutih°ne required'by law, and having been twice 
fumtgated with chlorine, and carbolic acid 
she proceeded to the city, where the mate °„ ‘ . tlle 
fourth of July and dj^ed. 
rifesfirst UcaPs o X Cholem pernio of 1878, in the United States, 
occurred at New Orleans in the month of February, when quarantine is 
not enforced The man who first died of the disease had resided two 
Znths in New-Orleans, and at the time of the attack was engaged in 
discharging cargo from a Liverpool \esse . , Carolina ;n icon 
Tinder revised quarantine laws adopted m south Laioima in 1869, 
healtlw vessels arriving at the port of Charleston m that pate, from 
infected ports, are detained from fifteen to twenty days, and thoroughly 
■ History of Quarantine in Louisiana, from 1821 to 1846. 13, B. Dewier, M.D., New 
York Journal of Medicine, 1846, p. 160. 1062 
WOODWORTH, 
cleansed. If no case of disease be developed, the vessel is allowed to 
proceed to the city. If, however, cases of disease have occurred on the 
passage, the vessel is subjected to a quarantine of thirty days, or longer j 
all sick are promptly removed to the lazaretto, and the vessel is disinfected, 
as before. Under the careful enforcement of these rules, no case of yellow 
fever has entered the city, notwithstanding that the disease has been 
brought to quarantine every summer, except in 1871. In the latter year, 
when no recognized case arrived by ships, the disease broke out in the city- 
Turning from the diversity of opinion, practice, and results of quaran- 
tine, in this country, we observe a most rigid quarantine enforced by 
countries bordering on the Mediterranean, while England during 
late years, maintained the free pratique of her ports. Because England, 
from her climatic conditions, comparative isolation, and wise measures ot 
internal sanitation, is able to maintain this advanced position, it does 
not follow that the seaports of the continent can with impunity conform 
to her example. In India, the endemic home of cholera, quarantine has 
proved unavailing, and thence, from the standpoint of some ooseiveis iu 
that country, it is argued that measures to contravene the progress ot 
cholera are useless. Were quarantine to be established _in the Best 
Indies against yellow fever, it would require no prophetic foresight to 
predict the result. The conventions of Paris, Constantinople, and \ ienna 
have happily done much to harmonize the conflict of opinion which has 
prevailed in reference to the particular system which should be applied 
in quarantine. This system, however, must necessarily be modified } 
the geographical position and climate of the countries concerned. 
To ascertain, as nearly as possible, what precautions are necessary, and 
what restrictions superfluous, in the administration of quarantine, the 
next step will he to consider the characteristics of cholera and of yellow- 
fever propagation, in order to determine as nearly as may be the prophy- 
lactic value of Fort Sanitation, a term which most definitely expresses 
the practical measures indicated by experience. _ . 
Chdera.—Amongst the many views respecting cholera, it is generally 
admitted that the endemic home of the disease is India, especially^the 
valley and delta of the Ganges, and that it is caused by a specific poison 
capable of reproduction or multiplication. Whether the endemic exist- 
ence of cholera in India is due to peculiarities of air, temperature, soil, 
or water, or to the filth of uncleanly masses of people, is not determined ; 
hut it is undoubtedly true that each and all of these influence the pro- 
pagation of the poison, and the spread of the disease outside of India. 
Some of the apparently well-established facts respecting cholera in India 
are; (1) That it only prevails epidemically at intervals, usually ot 
several years ; (2) that since its first migration around the world, it has 
not passed the border of its endemic home to prevail epidemically in 
other countries, except at times when the disease has shown unusua. 
virulence and* diffusion in India ; (3) that the number of persons attacked 
in the same town or city, during different epidemics, varies considerably, 
even where the surrounding conditions are apparently equally favorable 
to the spread of the disease; (4) that it is possible to flee Irorn it,2 show- 
ing that a locality or place is the centre or focus of infection ; (5) that 
1 Dr. Lebby, the Health Officer at Charleston, has recently informed me that, at the last 
session of the legislature of South Carolina, the period of quarantine was reduced to fifteen 
* The mountains of Lebanon have always proved a safe retreat for the inhabitants of 
the cholera-stricken cities of Syria. QUARANTINE. 
1063 
recent improvements in the sanitary condition of jails in India have 
rendered them almost exempt from visitation by cholera, many escaping 
entirely and very few of those attacked suffering with severity -,1 and 
(6) that attendants upon the sick, in cholera hospitals removed from 
infected localities, do not suffer more than any other class, and usually 
"'I*)!- Cunningham maintains that the spread of cholera does not depend 
in any degree°upon the use of drinking water polluted by cholera evacua- 
tions Over against this statement is to be placed the fact that the mor- 
tality rate from cholera has greatly diminished in Calcutta,' since the 
introduction into that city of water less liable to contamination than 
formerly » The fact that those attacked by cholera, and those who 
escape, in 
be cmiveVed’through the medium of drinking water while the condition 
of individual susceptibility remains as an undisputed factor in the devel- 
opment of the disease. Many undoubtedly receive the poison who do 
not suffer from it Proof does not exist of cholera arising from impure 
water, uncontaminated with cholera dejections, but the cholera poison is 
unquekionablyiiitensihed in itsy-”;” t 
youtside of India-.abundantly proveskhaf the 
cholera principle portable; that it is earned by ships, and in clothing 
and bafkse when excluded from the light and air. Ihe spread of 
epiderah? cholera is characterized by localization in particular places, 
epiaeium vmp fVlpn become centres of infection. Ibe activity 
of'theseboci1 of infection, as well as the intensity or fatality of the dis- 
ease appear to depend upon certain causes associated with the aggrega- 
ease, appeal i axnd the attendant evils of impure air, impure 
water and filth. Wlien these are present a mild case of cholera serves 
to kindle an epidemic as readily as a spark from the hunter s flint may 
kindle a fire tn of' 
2^d“wd"ase,’who travel during the period of 
under ’“tf —^ 
at the places where they aie attaci • absent the cholera 
are both individual and local, and, when either aie absent, tne cnoieia 
aie Dotn mclVK!u i ’ its reproductive power altogether. The 
germ may slumbei, 01 may lose ms p .-d ]s nas ion 2. neen 
non recentivitv of certain localities, and of individuals nas long been 
recognized and is undoubtedly due to good sanitary conditions. _ 
The e is s ro. t reason for believing that cholera dejections, which 
appear to be Imnuless in their fresh state, become actively poisonous 
n a, „ VrUdemic of 1872, in Northern India; by J. M. Cunningham, 
p.*. 
’• « =— by 
ISult has been brought about by thorough and efficient drainage, 
and by purification of the water suPP|y- maintain that cholera is not spread by traffic 
4 Both Dr. 
or human intercourse. J h “ where the disease originates, are too apparent to give 
of the cholera-principle in a y Mcles which spread a disease, not contagious 
fnTelgi are contagions, can only be determined, if deter- 
ged at aU outeide of the endemic home of the disease. 1064 
WOODWORTH, 
with the commencement of fermentation or decomposition. Acid disin- 
fectants interrupt or prevent altogether the fermenting process, thereby 
destroying the poison. In like manner, the acid secretions of a healthy 
stomach are believed to neutralize or render innoxious a certain amount 
of the cholera-principle. The almost universal testimony is that good 
sanitary conditions lessen the influence of the attack, restrain its dis- 
semination, and frequently ward ofl‘ the disease entirely. Dr. Harris 
has remarked, in referring to cholera in Hew York, in 1866, “ interpret 
it as we may, the events in the experience of that visitation of cholera 
demonstrated the practicability of dealing with the transportable and 
exotic, or germinal, factor of the pestilence as an enemy to be held in 
restraint, and its propagating attribute to be destroyed—a pestilence to 
be stamped out by definite hygienic measures.”1 There is abundant proot 
that the specific poison of the first cholera epidemic in the United States, 
and of succeeding epidemics, down to the last one, was introduced by 
ships from Europe, and the testimony of European observers furnishes 
conclusive evidence that the disease was imported into that country 
from India. The last epidemic of cholera in this country has differed 
from previous epidemics, in that direct connection between the initial 
cases and an imported germ has not been established,2 but the fact re- 
mains that nearly two thousand emigrants from cholera-infected districts 
of Europe arrived in Hew Orleans during the month of the outbreak 
and that immediately preceding.3 It may be stated, as a general fact, 
that each period of epidemic prevalence of cholera in America has been 
associated with a similar period in Europe. 
The morbific principle of cholera has from time to time shown a dis- 
position to permanent lodgment by surviving the winter seasons ol 
Europe4 and America. In the epidemic of 1854, in this country, the 
disease spread to the Pacific coast, and was several times re-imported 
from Central America to the port of Hew York ; but the generative 
principle of each epidemic has finally died out, and each succeeding 
epidemic has depended upon fresh importations from India.5 Emigrants 
from infected districts have always been a prolific cause of intensifying 
and spreading the disease. “Itis a matter of common experience to find 
that at times, when the disease is only of occasional or sporadic occur- 
rence in Calcutta, emigrant ships leaving the port are scenes of severe 
outbreaks.”0 The readiness with which a vessel takes on the character- 
istics of a crowded community or city, and becomes a centre of infection, 
will be more readily appreciated, and the measures to prevent the spread 
of cholera by ships more wisely directed and applied, when it is con- 
sidered that a ship is but a town afloat. The ill-ventilated hold and 
' Reports and Papers of the American Public-Health Association, vol. i. p. 346. 
2 There occurred, in 1873, three later outbreaks at widely remote points in the United 
States, which were due to poison imported in personal baggage packed in the infected dis- 
tricts of Sweden, Holland, and Russia. Surgeon Ely McClellan, U. S. A., in his Report on 
the Cholera Epidemic of 1873, in the United States. 
3 Dr. McClellan, op. cit. 
4 Drs. Pelikan and Arkhangelsky have shown that cholera was present in Eastern Europe 
from 1847 to 1856, and again from 1865 to 1873, though evincing a feeble activity during 
much of the time. 
5 Prof, von Pettenkofer maintains that “ it is a fact independent of all theory, which has 
been observed in every epidemic of cholera, in every place, and on every occasion, that the 
attacks in each individual house terminate on the average within twelve or fourteen days.’ 
Cholera, How to Prevent and Resist it. By Ur. Max von Pettenkofer. Translated by 
Dr. Dime, 1875. 
6 Calcutta Review, 1869. QUARANTINE. 
1065 
foul bilges are the counterpart of the filthy sewers and cesspools of a 
filthy city. 
Yellow Fever.—Yellow fever is a disease produced by an invisible 
poison, capable of self-multiplication outside of the human organism. 
This something—the germ or miasm which has hitherto eluded micro- 
scopical demonstration—is a product of the tropics. It shows a disposi- 
tion not to spread in high, salubrious lands, but exhibits a preference 
for low regions, especially the filthy portions of cities. Filth and high 
temperature are as truly its concomitants as cleanliness and cold are op- 
posed to its lodgment or propagation. In this country, }7ellow fever 
has. prevailed in most of the Atlantic and Gulf cities, and in many of 
the towns along the Mississippi Hiv^j’.1 In some instances it has been 
carried inland with people fleeing from infected localities, but it has 
never shown a disposition to spread epidemically at points remote from 
the continuous water-roads of commerce. The cities ot the great lakes 
have always been exempt from the disease. 
In considering the morbific cause of the disease, we are necessarily 
restricted to an examination of its characteristics or comportment, exhi- 
bited in different places and under different conditions. We are, how- 
ever, met at the outset with the difficulty and uncertainty of distinguish- 
ing between yellow fever and the pernicious malarial fevers of the Gulf 
coast. The cases that end fatally furnish reasonable certainty of the diag- 
nosis given, but the milder cases that recover scarcely escape from doubt. 
This uncertainty in determining the nature of mild cases, divides the 
profession on the question of the endemic lodgment ot the disease on 
the Gulf coast, and serves, to complicate the question of quarantine. 
Whether the disease was endemic in the intertropical islands of America, 
before it was brought from Africa, is uncertain ; but there is no doubt 
now of its permanent lodgment in the West India Islands. Ihe fact 
that the island of Key West, off the southern extremity of Florida, is 
in daily communication with Havana, makes it extremely difficult to 
determine the question of importation at that particular point. Ihe 
weio-ht of evidence, however, is against the assumption of an indigenous 
origin of the disease in the border lands ot the Gulf, but it is probably 
true that the poison has there been preserved through the winter in, 
fomites, though it is believed that the United States is not affected epi- 
demically except by the imported germ. Ihe germ is transmissible. It 
is capable of being transported in the personal effects of passengers and 
sailors, but the damp, filthy holds and bilge water of ships are its favorite 
lurking places, where, it confined, it multiplies and increases in virulence 
to such an extent as not only to affect those on boaid, but even to exert 
its piernicious influence in the direction of the cuiients ot an to a con- 
siderable distance. A vessel anchored at a whaif in Havana, or other 
infected pilace, appears to become, for the time being, a part of the in- 
fected region; and in sailing to a distant pioit, the ship) transports the 
pioison as surely as could be done by transplanting a section of the infected 
island of Cuba itself, were this possible. ... 
Yellow fever is not communicated from the sick to the well, the sick 
being dangerous only as piossible carriers of the poison-germ or miasm j 
hence all persons from an infected district maj safely be considered as 
1 Greensville Dowell, M.D., of Galveston, states in his forthcoming work on the History 
of Yellow Fever Epidemics, etc., in the State of Texas, that “ yellow fever has spread to 
228 cities and towns, and in 28 States in the United States, appearing <4l times, and caus- 
ing 65,311 deaths.” 1066 
WOODWORTH, 
harmless when the period of incubation, which lasts from two to six 
days, has passed. This simplifies the question of quarantine, and indi- 
cates the direction of preventive measures to the vessel and cargo, or to 
the locality, if the poison have found lodgment on shore. 
We have come now to the question of practice, and to the consideration 
of the methods which should be pursued to secure the greatest protection 
to the public health against cholera and yellow fever, with the least restric- 
tion upon commerce. We may differ on the questions of the nature and 
modes of propagation of cholera and yellow fever, but it is believed that 
all meet on the common ground of prophylactic measures, and will 
accept the proposition of General Sanitation—applied to the endemic 
abodes of cholera and yellow fever, to ships, and to exposed countries- 
as the surest means of stamping out these diseases. The general question 
of preventive measures, is one intimately associated with that of higher 
civilization. Every improvement in India, in matters of drainage, in 
securing pure drinking water, and in personal cleanliness of the people, 
will tend to lessen the ravages of cholera there, and to diminish the 
chances of its spread abroad. In the West Indies, the harbor of Havana 
is most frequented by commercial people, and is the most prolific source 
of yellow fever. 
In a recent personal letter to myself, Dr. Peters has expressed the 
opinion in reference to Havana, which he had just visited, that “an 
international public sentiment should be created against the filthy and 
careless ways of the authorities, which cause so much suffering and death 
among the mercantile and public navies of the whole world. The harbor 
is small and landlocked; all the drainage and sewage of the city go 
into it, and very little gets out of it.” Dr. Peters suggests that a canal 
could be made at the head of the harbor, to the ocean, allowing the tide- 
water to sweep through the whole harbor, and thus remove its unhealth- 
fulness. A. vessel exposed to the influences of an infected harbor may 
not be able to escape, but the danger can be greatly lessened by enforcing 
strict cleanliness of the men and vessel. The bilge should be changed 
every day with sea-water, until the pumps bring clear water. The men 
should be compelled to bathe and change their flannels daily, when their 
work is done, and should not be allowed to sleep on the open deck, or 
in the lower part of the vessel. The same precautions should be con- 
tinued through the voyage from a yellow-fever port. Ventilation should 
be freely encouraged, and no confined air allowed in any part of the 
vessel, if it be possible to prevent it. There is an example of a ship 
trading between Hew York and Havana, on which these precautions 
have been strictly enforced for a period of twelve years, and not a single 
case of yellow fever has occurred on board.1 The proprietors of a line of 
steam-vessels, trading and carrying passengers between "West India ports 
and Hew Orleans, employed an experienced person on each vessel, during 
last year, to supervise its sanitary condition and to disinfect it after the 
discharge of each cargo, with a similar result.2 
I have already described the manner in which a ship becomes infected 
with cholera, and, as cleanliness is the great end to be attained, and 
maintained, on shipboard, the general preventive measures against this 
disease are not unlike those suggested against yellow fever. If, how- 
ever, one or more persons are seized with cholera on board a vessel, they 
1 Communicated by Dr. Yauderpoel. 
2 Communicated by Dr. 0. B. White. QUARANTINE. 
1067 
should be separated from the well passengers and crew; their stools 
should be disinfected with a solution of sulphate of iron, and at once 
thrown into the sea ; and all soiled clothing should be burned or thrown 
overboard. But if cases occur after the first four or five days out from 
port, it is safe to conclude that the vessel is the source of infection. 
Any suspected baggage should then be disinfected, and, for ten or twelve 
days, all water used on board should be boiled before being served out.1 
Experience teaches that a cholera-infected house, or ship, ceases to impart 
the disease after about twelve days, unless a new crop of the poison be 
introduced. An outbreak of cholera on shipboard can certainly be 
stamped out, and it is possible to do so during the passage of a steamship 
from Europe to America. 
The foregoing suggestions can be carried out by any master who 
possesses sufficient intelligence to navigate a vessel, and it is believed 
that by imparting such definite information to seafaring men, commerce 
will be relieved from most of the restrictions reasonably imposed by 
quarantine. The unreasonable hindrances imposed by quarantine can 
only be corrected by cutting loose from senseless traditions and theories. 
It is unreasonable, as it is impracticable, to apply a theoretically uniform 
quarantine to all places, without reference to climate, the relations of 
surrounding countries, or the natural history of the disease to be com- 
bated. The question should be settled, separately and practically for 
each country or place, by taking into account the liability to infection 
of the port of destination, the period of incubation of the disease, the 
length of time consumed in the passage, and the measures enforced by 
the vessel en route. Truq quarantine measures should commence as soon 
as the vessel has left an infected port, and, if commercial people find 
that their well directed efforts are recognized by the port health-authori- 
ties, a strong incentive to rigid cleanliness will be thereby at once estab- 
lished, infectious diseases will be measurably restricted in their course, 
and the problem of quarantine will be made comparatively easy of solu- 
tion. The practice of medical inspection and sanitation, as adopted and 
now carried out by Dr. Vanderpoel, at the port of Yew York, expresses 
the practical application of our present knowledge of cholera and yellow 
fever, as found applicable at that port. 
If, upon arrival from an infected port, it be found that a vessel is clean, 
and that no case of sickness has occurred on board during her voyage, any 
detention of passengers and crew beyond the time required to thoroughly 
air and disinfect their baggageand dunnage, is believed to be unnecessary, 
provided that the period of incubation of the disease has passed during 
the voyage. If cases of yellow fever have occurred during the passage, 
the passengers and crew are removed from the vessel; the sick, if any, 
placed in hospital, and the well detained in a comfortable, healthy place, 
until five or six days after the occurrence of the last case, when they are 
allowed to proceed to the city. Meantime the vessel is at once subjected 
to a thorough airing and fumigation, and the cargo transferred to open 
lighters in the bay, by men kept for the purpose. During the unloading, 
the vessel is daily fumigated, and, when the transfer is completed, every 
available part is cleansed with water, and, after a thorough disinfection 
and fumigation, the vessel is returned to commerce. It is not found 
practicable to lay down arbitrary rules in regard to vessels on which 
cholera has occurred. Each vessel is judged by the particular features 
• Plan recommended by Macnarnara. 1068 
WOODWORTH, 
which belong to it. If prompt and energetic measures be enforced at 
the first appearance of the disease, its spread can be cut short, as before 
stated, and when this has occurred on vessels coming from Europe, u 
has been found practicable to allow the vessels, passengers, and crew to 
proceed to the city with only such delay as has been required to defi- 
nitely ascertain the facts, and to perform disinfection. A vessel arriving, 
however, with cholera on board, the same precautionary measures are 
carried out as are enforced on the arrival of ships with yellow fever, and 
eight days after the occurrence of the last case, the passengers are allowed 
to leave. While the foregoing measures are necessary at Hew York, 
England wisely confines her supervision of cholera, from without, to the 
removal and care of the sick, and the cleansing of the vessel It would 
be futile for England to quarantine against ports of the continent, with 
which she is in daily communication. Mr. Simon has truly said that 
“contraband of quarantine, like ordinary smuggling, is developed so 
soon as the inducements for it are considerable.” bellow fever is less 
liable to find lodgment in England than in Spain and Portugal, or in 
Hew York. 
As it is the custom for many emigrants, bound for America from 
the continent of Europe, to embark at Liverpool or other healthy ports, 
when cholera prevails on the continent, this country is exposed to the 
introduction of the disease through the personal effects of such emi- 
grants, sailing on healthy vessels from healthy ports. In a recent report 
to Congress, I called attention to the necessity for “prompt and authori- 
tative information to threatened ports [of the United States] of the ship- 
ment of passengers or goods from a cholerafirtfected district,” and sug- 
gested that the consular officers of the government should be instructed 
to place themselves in communication with the health-authorities of 
their respective localities, and to advise promptly, by cable, of the out- 
break of cholera, and the sailing and destination of any vessels carrying 
passengers and goods from infected districts. By this plan (which the 
Honorable Secretary of State deems it practicable to carry into effect, if 
Congress provide the necessary means) the thorough disinfection of in- 
fected articles would be insured, and the danger from this source of 
infection would be lessened. 
In considering the value and practice of disinfection, the fact should be 
kept in view that disinfectants are not as much needed as is cleanliness; 
where the latter prevails, the former are not required. It is when there 
is not time to get rid of filth, or when the poison has found lodgment, 
that disinfectants are applicable, and then their application should be 
thorough. The value of the several disinfectants is recognized, but their 
use on ships depends chiefly upon the manner of application. Ordinary 
fumigation cannot be relied upon to destroy the poison of an infected 
vessel, without removing the cargo, as has been exemplified in many 
instances, notably in the case of the bark Valparaiso, before cited. Hr. 
Perry1 has devised an apparatus, which he used successfully at the Hew 
Orleans quarantine, in 1874, whereby either sulphurous-acid gas, carbolic- 
acid vapor, or heated air, can be forced into a ship through flexible 
rubber pipes, by means of blowers propelled by steam, all hatches and 
other openings in the ship having been first securely closed. Whether 
1 Effectual External Sanitary Regulations without Delay to Commerce. By A. W. 
Perry, M.D., of New Orleans. American Public-Health Association’s Reports and Papers, 
vol. i. p. 437. QUARANTINE. 
1069 
this process, in which are employed from thirty to one hundred pounds of 
sulphur, for a single vessel, will always prove effectual without removing 
the ship’s cargo, remains to he determined further trial. 
It must be admitted that the germs of infectious diseases may elude 
the most vigilant sanitary supervision of shipping which can be devised- 
hence the importance of municipal co-operation, to the end that all 
exposed cities may, through wisely directed sanitary measures, he ren- 
dered less susceptible of infection. The value of sanitary supervision of 
ocean-travel and traffic, and of preventive measures at home, is more 
und more recognized by civilized nations, and the enlightened and 
vigorous prosecution of these means gives hope of rendering exposed 
countries less liable to infection; but the repeated battles against cholera 
und yellow fever should awaken an international spirit, and a determi- 
nation to carry the war upon these diseases to their endemic homes, and to 
there instruct the people, and if need be compel them, to employ rational 
means of prevention. 
From what has preceded, the following conclusions appear to be justi- 
fied :—• 
I. The supervision of ocean-travel ought to be directed to securing 
good sanitary conditions for vessels at all times, out of as well as in port 
11. A system of Port-Sanitation should be adopted and administered 
for each country or place, separately, and should be modified in particu- 
lar cases by taking into account the liability of the port to infection, the 
period of incubation of the disease, the length of time consumed in the 
Voyage, and the measures enforced by the vessel en route. 
111. In some countries, the detention of passengers and crews of ships 
hailing from infected ports is warranted, but for such time only as is 
necessary to complete the period of incubation of cholera or of yellow fever, 
counting from the date of departure from an infected port, or of landing 
from an infected vessel; in no instance should passengers or sailors be 
held for observation on board an infected vessel, and such vessel should 
not be detained beyond the period required for inspection, and for 
thorough disinfection and cleansing. 
IV. Recognizing the fact that the morbific causes of infectious dis- 
eases may sometimes elude the most vigilant sanitary supervision of 
shipping, the importance of wisely directed internal sanitary measures 
can scarcely be overestimated. 
Y. As far as America is concerned, it is desirable that prompt and 
authoritative information should be had of the shipment of passengers 
or goods from districts infected with cholera or yellow fever, thereby 
insuring the thorough disinfection of infected articles. 
VI. The endemic homes of cholera and yellow fever are the fields 
which give the greatest promise of satisfactory results to well-directed 
and energetic sanitary measures, and to this end an international senti- 
ment should be awakened, so strong as to compel the careless and offend- 
ing people to employ rational means of prevention. 
Discussion on Dr. Woodworth’s Paper. 
After the reading of the preceding paper, Dr. A. S. Baldwin, of Jackson- 
ville, Florida, said:—ln the port where I have lived for the last thirty years' 
there has been no visitation of yellow fever as an epidemic. Isolated cases 1070 
WOODWORTH, 
have presented themselves, but there has been no spread. In one instance, t 
disease was brought in the contents of a valise. A gentleman, a resident o 
that section of country, had been visiting in Havana, and in the course o 
rambles had passed through the Yellow-Fever Hospital. In a valise, whic 
he had opened two or three times on the way, the disease was carried, a 
affected a nephew and niece who met him on his return. The niece ieco\eie i 
but the nephew died, and a post-mortem examination showed the liver to he 
a boxwood color. No other case of yellow fever followed from that outbrea • 
In 1857, a disease broke out in Jacksonville, supposed to be yellow lever, h 
it could not be traced to any foreign cause, and it differed somewhat in i 
symptoms During the summer a marsh had been cut off, and a railroad dep 
erected thereon. This was in June. On the 20th of August, an individual 
living near the marsh was affected with a fever; on the 20th of Septembe , 
the disease was still existing in that neighborhood, and had occasioned uiuc 
alarm, 100 deaths having resulted. But the fever was as unlike the cases 
yellow fever which have been brought to Jacksonville, as typhoid fever is unhk 
Dr.' Henry Hartshorns, of Haverford College, Pennsylvania, said If w® 
believe that yellow fever is not personally communicable, there should be no 
detention of the sick at quarantine. In regard to cholera, the fact mentione 
in the paper that persons escape by fleeing from the disease, is a proof that J 
is not more communicable than yellow fever. Efforts to disinfect the stoo 
of patients have notoriously failed to arrest the disease, while local samtaO 
regulations have in this country prevented its spread. Quarantine and deten- 
tion have caused many deaths on infected vessels. What is wanted, is to 0 
away with personal detention at quarantine, and to see that sanitation i 
enforced at sea and in port. A comparison has shown that rigid restriction 
have failed in Pensacola, while, in New York, less rigid restrictions have been 
attended with better results. ~ .. 
Dr S. Oakley Yanderpoel, of New York, said:—There are three distinc 
schools of belief, as to quarantine: One relies wholly upon a certain amount 
of detention, and with another, everything depends on cleanliness, following 
out the English hygienic system by which quarantine has been done away witn. 
I think that the modern‘school is the best, which employs a combination pi 
moderate detention and sanitation. lam willing to go as far as any one in 
praise of local sanitation, but there is a necessity for the detention of ves- 
sels coming from infected ports. I say too that yellow fever is not conta- 
oious from person to person, but I think that persons should detame 
until the period of incubation of the disease has passed. In New York there 
is no quarantine, that is to say, no forty days’ detention, as the name implies; 
there may be a delay of a couple of days, but the period of incubation must 
be allowed to elapse before passengers’ baggage and clothing are permitted to 
go into the city. There have been several instances in France in which disease 
has been carried away to the country in clothing. A Savannah steamer came 
into New York Harbor last Sunday morning. The crew and passengers were 
perfectly well, and the vessel had not been lying in that portion of the town in 
which the epidemic was raging, but I held the vessel twenty-four hours, to 
make up the five days out. Ido not call that a quarantine. Quarantine has 
killed more persons than it has saved. The epidemic in JSew Yoik, in 185 , 
was caused by the Health Officers placing a vessel with its cargo off Long 
Island. Exposed to the sun, and lying there for twenty days, it became a 
pest-ship, and soon from 150 to 200 vessels were strung along the Long Island 
coast all infected. Clothing and offal were thrown overboard from these, and 
people living within two or three miles of the coast suffered. In relation to 
cholera I believe that if the dejections can be disposed of immediately, the risk 
of contagion can be prevented. There is a period of from one and a half to 
two hours, in which the dejections are inert; after that, fermentation sets in, 
and they become contagious. As far as I have been able to study the subject, quarantine. 
1071 
cholera can be traced along the lines of travel. Even with the same atmos- 
pheric conditions, five or ten miles from the line of travel, the disease is not 
found There are seasons in which epidemics are intense, and others in which, 
if proper sanitary precautions he taken, cholera, though breaking out with 
great virulence, will last only a week or ten days. 
T)r T a K ’ of San Francisco, saidln the cities of China there are no 
municipal governments, and no arrangements are made for cleaning the streets 
The filth which accumulates remains in the streets until carried off by natural 
the filth which acmnnm Some streets are filled the whole year 
wVthfllth’ T witnessed Two ephdemics of cholera in China, but they did not 
ecm to be influe, cedby the filth, nor confined to the filthy sections. Why is 
tins when so much stress is placed in America and in Europe on cleanliness I 
s, w ncii so_ the absence of underground sewerage. 
“hr"cirre InafheiVl no system of underground drainage and the 
rue cites o nmifined Epidemics there are not worse than here, 
gases winch form are not confined- *4 arrangement of drain- 
Hie poisons "ticfi propane b)ame » anything elsc, 
ge here, and erm . to drainage, there is no confinement of 
In China where no attention « h =o’d||Ce ,liseaße, My observa- 
gases, and no concentration of m“uen°ef B'itish Army) whoi /m.ing tho 
ChtoeMwnrCoffsSS-ISST, vtaited cities where the accumulations of filth were 
obnoxious to stiangeis. easily seen that scattered filth is not as 
Dr. Haetshorne said :-It can be m remains that filth is one 
poisonous as when it is biu of incubation of cholera 
of the factors.of disease has appeared when a vessel 
is short, yet I haA e a c rmie morl)ific agent which produces cholera has 
has been two wee s a '.j tpe Ijp pas peen detained in quarantine, 
met a vessel out at sea, and thougn me smp naaaeneers showing 
Vet in all that time the disease has not passed to the cabin passengeis, snowing 
yec in an man renditions and migratory causes, 
that it is connectet ree wjtp pr. Hartshorne that cholera has ap- 
Dr. Yanderpob *. perfectly healthy ports, but inquiry has shown 
peared in vessels hailmg the disease’ has broken out, did not 
that the steerage-pas 0 ’ , started. For instance, most emigrants to 
beldng to the port fio = rDOO/yet they belong to Poland and other places, 
this country start fior 1 j J b traced to sections in which the dis- 
These outbreaks emigrants, there is undoubtedly 
ease has been iaging. .• b ;s well known, carries the disease, 
a large quantity of soilec ’ ’healthy port does not show that every 
The fact of the vessel comingf ftom acconnt for what Dr. Harts- 
one on board belongs to the < > 1 , ged mltd the vessel has got out to 
borne has related, by the bagg b trunks. That is one reason why the dis- 
sea; case after case has been - engers; steerage-passengers generally 
ease does not go among the cab.. 1 pabin?Lssengers have their trunks stored 
keep their baggage about them, while cabin passeng Begide the 
in the hold, and aimther point iihaVor of Dr. Harts- 
cabin-passengers aie more ueamj, 
home’s idea of sanitation. Jersey, said :—I remember a case in 
Dr. Ezra M. Hunt, and’ three weeks afterwards wore the same silk 
which a lady visited a 1j j the hospital. Scarlet fever broke out mi- 
dress which she had wo fiUh we have never yet had it proved to origi- 
medlately affcer^stand th^t filth is a nest for disease, some of which 
uate cholera. TV e 111 . d s not originate; and this is a good reason why 
it does, and some of w 1 that it does not originate cholera and yellow 
we should getrid oU . im ortance of not letting their contagia get into 
fever, does not weal *d of these diseases, we must stop baggage and 
“ ZX:rs ‘oo, if necessary, but not keep them on 
the ships. 1072 
A UNIVERSAL PHARMACOPOEIA. 
BY 
EDWARD E. SQUIBB, M.D., 
OF BROOKLYN. 
The idea of an International or Universal Pharmacopoeia, though by no 
means new, has within a few years past come before the medical and 
pharmaceutical professions with more than ordinary prominence, and 
much has been written on the subject. The rate of progress in the art 
of medicine in its utility to mankind, depends largely upon accumulated 
experience; experience is the result of research and observation; and the 
value of an observation is in direct proportion to its accuracy and com- 
pleteness. That classification and comparison of observations, the result 
of which is experience in the art, depends largely for its value upon the 
•uniformity of the conditions under which the observations are made, and 
hence the present strong tendency to control and to formulate the condi- 
tions under which experience accumulates, so that a larger proportion of 
it may take the rank of absolute knowledge. For example, we know, as the 
result of observation which has passed through the stage of experience to 
become absolute knowledge, that opium relieves pain. This reaction be- 
tween opium and pain involves two distinct series of phenomena, or is con- 
ditioned from two separate bases: First, the cause, nature, and quantity of 
pain, and this concerns the pathologist; and, second, the cause, nature, 
and quantity of the opium appropriate to the reaction, and this concerns 
the therapeutist. Pain is universal. Opium has, through knowledge, 
become almost universal. To formulate and condition the opium for this 
reaction upon the best results of general experience in the past, so that 
future experience may accumulate under uniform conditions of the medi- 
cinal agent—and may accumulate universally to the same single end, 
namely, advanced knowledge for universal good—is the object sought 
for in a Universal Pharmacopoeia. 
Some such train of reasoning as this, having for its basis, at least, the 
establishment of a universal standard of strength, composition, and 
quality, for medicinal agents, so that by accuracy in the agents the results 
of their use all over the world may be compared with accuracy, and thus 
more rapidly convert empirical experience into knowledge, has been 
generally advanced in support of the design. And it may be said that 
the same line of argument, and the same necessities which made Rational 
Pharmacopoeias first useful, and then indispensable, must, with the 
advance of civilization, apply with equal force to produce an International 
Pharmacopoeia. Thus the advantages to be expected from a Universal 
Pharmacopoeia are so great and so easily shown, and the arguments for 
it are so forcible, that up to this time all writers upon the subject, as far 
as seen, in all nations, have been on one side of the question. And yet, 
although ranged on the same side of the question, I have, by thoughtful 
consideration of the subject, gradually reached the conclusion that the 
design is premature, and for tliepresent age impracticable, for the follow- 
ing principal reasons:— A UNIVERSAL PHARMACOPOEIA. 
1073 
(1) The difficulties of constructing a Universal Pharmacopoeia which 
?ould be universal in anytime sense, would probably be at present insur- 
mountable, because, as in other international designs of a similar char- 
acter, the present national standards are so very different that they could' 
not be made to harmonize without radical changes, which the standard 
of medical education of the age is not high enough to admit; and because 
each prominent nation would at once seek to make its own pharmacopoeia 
Pie basis to which others should be changed, as the condition upon which 
lt would share in the undertaking, just as is done at present in the 
attempts to unify the coinage of different nations. And if a Universal 
-Pharmacopoeia should be constructed, with one or more prominent nations 
emitted from active co-operation, it would be but a sham, and would in 
the end be productive of more harm than good, since anything of the kind 
which might not be thorough and sound, would not stand, nor be authori- 
tative, and would but add to the present confusion. The complete idea 
°f a Universal Pharmacopoeia is, of course, that it should take the place 
of all national pharmacopoeias, and render these unnecessary, so that they 
should be abandoned. But short of this, there seems to 'be a popular 
idea which aims to embrace in the design only the making of the prepa- 
rations, or the compound medicaments whether chemical or o-alenical of 
a uniform strength and character, leaving the national pharmacopoeias 
to be as necessary as ever, but to be in accord in regard to the strength 
and quality of the agents of certain classes of remedies which have been 
long and commonly used in different nations by the same or similar 
names. For example, colocynth is used under the same name in all the 
national pharmacopoeias, but its preparations and compounds in the dif- 
ferent pharmacopoeias, under the same or similar names, contain it in 
very different proportions. To have such preparations and compounds of 
the same strength, and to have them designated by the same name every- 
where—and this only—leaving the national pharmacopoeias as they are 
with such exceptions of common accord, seems to be the less complete 
idea of a Universal Pharmacopoeia aimed at by some writers. But this 
I’eally involves no less difficulties than the complete idea, nor are the dif- 
ficulties of a different character, nor more easily overcome. For the 
primary substance itself must be uniformly defined or described, or other- 
wise it may vary so much in different countries and markets as to make 
its preparations and compounds as different and as variable from that cause 
as they would be from different proportions.. And all primary substances 
and chemicals would require the same definition and description in order 
to secure their uniformity in use. Hence the difficulties in making a Uni- 
versal Pharmacopoeia seem to be insurmountable in the present age. But 
let it be assumed that a proper commission or council could be had, and 
that the great amount of time and labor needful had been given to the 
Work, and that it had been harmoniously completed to the entire satis- 
faction of all nations ; even then, unlike coinage, and weights and mea- 
sures, it could not be considered as either established or completed, since 
in order to carry out the idea, and preserve its utility, it would have to 
be revised at short intervals, and the commission would have to be recon- 
structed from time to time, or would have to be permanent. 
(2) To have a Universal Pharmacopoeia, involves the idea of universal 
applicability. Could it be made universally applicable, or universally 
useful ? In civilized countries the civilization is not uniform in degree 
and between nations there is a still wider difference in this respect. All 
the normals of different nations differ, that is, geographic position 
68 ’ 1074 
SQUIBB, A UNIVERSAL PHARMACOPOEIA. 
climate, race, food, clothing, manners, habits, etc., make nations differ so 
much that their health and their diseases are not the same either in cause, 
course, or result, and are therefore not subject to uniformity in manage 
merit or treatment. , . 
(3) Again, the standard and degree of medical education is anything 
but uniform throughout the world, and therefore a uniform code for ffs 
use might not be generally applicable, any more than a universal grammai 
would be applicable to popular use in all languages. _ _ 
(4) Finally, all modern progress in the medical art points unmistakably 
to singleness and simplicity in medicinal agents, and in their application- 
The older and more complex formulas are rapidly passing out ot use, any 
single substances of more or less known physiological power, and of deli' 
nite constitution, are as rapidly taking their place in the only true ant 
permanent interest of the art; because upon such medication only can 
much accuracy of observation be claimed. Then, just in proportion to 
the progress in this direction, does a Universal Pharmacopoeia become 
less necessary and less useful. And by means of this progress, the idea 
of a Universal Pharmacopoeia becomes year by year more easily carried 
out, because simple substances of definite constitution and established 
character and power are perhaps alone applicable to universal uses, and 
because such are easily defined, described, and controlled. 
These apparent difficulties in the way of a Universal Pharmacopoeia 
are presented with hesitation, because the offering them may be construed 
into opposition to a design for improving the means whereby precision ot 
observation and of result is to be looked for. The suggestions are made, 
however, in no such spirit, hut simply to present a few points which may 
serve to awaken thoughtful attention to that side of the question which 
has not hitherto been sufficiently considered. 1075 
THE RELATIONS OF THE PHARMACIST TO THE MEDICAI 
PROFESSION. 
BY 
EZRA M. HURT, M.D., 
OF METUCHEN, N. J. 
The relation of Pharmacy to Practical Medicine is not merely collate- 
ral, but to the extremes! degree radical and essential. All the command- 
ments that form the decalogue of the physician find their summation in 
two avowed purposes. One is thoroughly to make out the disease and 
the other is thoroughly to make out the remedy. Anatomy, physiology 
and pathology, mean little to us professionally and practically unless 
thereby we establish standards for the normal and abnormal, and by com- 
parisons and observations are able to arrive at a diagnosis. Diao-nosis 
means but little unless it defines, and differentiates, and knows in°order 
to guide to correct treatment. But treatment is as impossible without 
accurate pharmacy, as is diagnosis without accurate physiology. Indeed 
the term diagnosis is as applicable to Materia Medica as to Disease It 
is just as indispensable to know through and through a medicine as it 
is to know thoroughly a disease. If there is failure at all either in the 
one or in the other, we have, as far as ignorance can accomplish it an 
absolute failure resulting, just as if both were alike defective. A polished 
steel bar on one side, elaborately finished and laid, and a tarred cable- 
rope on the other, never yet made a railroad track. Rone the better will 
there be efficiency in conducting onward this great science of ours, with 
elaborated diagnosis on one side, and a smeared pharmaceutics on the 
other. 
I am quite aware that in what may be called popular medical feelino- 
diagnosis of a disease outranks diagnosis of a remedy. There are a glow 
and an enthusiasm about anatomy, histology, physiology, and pathology, 
because of the subjects themselves, and of the accuracy of classification 
ot which they admit, but which has not as yet its parallel in the corre- 
sponding department. A human being is so much grander a thing than 
a poppy-seed, that it is much more attractive to pry into the cells and 
functions of the one than into those of the other. The old story of the 
Frenchman, who in his hospital rounds thrilled his pupils by his accurate 
demarcations between healthy and diseased action, is still pertinent. 
When asked the remedy, he turned away with a shrug, as if that was 
a matter in which he had no concern. Until with eq'ual identification 
and elaboration he had indicated this, he might be anatomist, histologist 
physiologist, and pathologist; but he could not be a physician. 
The anatomy, histology, physiology, and pathology of the Materia 
Medica must be studied individually and accurately, just as we study the 
subject Man. If, in a certain sense, the one is to be investigated as if the 
question of treatment would never occur, so the other may" be studied as 
if the drugs concerned were never to be employed as remedies. Such at 
least may be the tendency of the naturalist, in either department. But 1076 
HUNT, 
he must know that his studies, as thus pursued, are merely preliminary 
or collateral. His relations to medical practice (when he stops here) ar 
only those of the botanist, geologist, chemist, or comparative anatomist* 
Our practice, our profession, our art, has as its sole object our ability t 
make such an adjustment between the individual, corporeal man, and the 
substances found in nature outside of him, as will promote his healthful' 
ness. This, and this only, is the practice of medicine. 
Therapeutics, since it is the application of remedies to the cure of dis- 
ease, is almost a definition of the art of medicine. Hunglison defines ‘i 
therapeutist as “ a practitioner of medicine.” Watts is only a little 
more general when he says, “Medicine is justly distributed into pi°' 
phylactic, or the art of preserving health, and therapeutic, or the art o 
restoring it.” Let it then be axiomatic with us that none but a thera- 
peutist is a physician. The knowledge of the remedy in all its accuracy 
and in all its effects, is as essential as the knowledge of disease. It & 
the conjunction that marks the inflowing tidal-wave of medical knowl- 
edge, and that bears with it the skilful practitioner. So fundamental 
and essential is the concurrence of these conditions of medical art, and so 
palpable the proposition even upon its mere bare statement, that we can 
scarcely account for the existing contrast and discrepancy between the 
prominence given to the study of disease, and that tendered to the study 
of remedies. Handheld Jones wrote to me some time since, in a private 
letter, “a more perfect knowledge of the action of remedies is the great 
desideratum of the day.” . 
A recent prize essay of the Hew York State Medical Society (lob*J 
had this as its motto: “ Physiology has become a science by well-con- 
ducted experiments that have illustrated facts. Can therapeutics claim 
to be a science while so many of its votaries are content with assertions, 
without experimental facts to support them ?” We must at least affirm 
that unless therapeutics be a science, physiology cannot make the prac- 
tice of medicine an art. This necessitates as a basic condition, not only 
of success but of all experimental investigation, a certified reliability in 
the articles by which our therapy is tested and applied. What we need 
just now, is the most accurate assemblage and classification of experimen- 
tal and experiential facts as to medicines themselves, and the greatest 
safeguards as to purity and uniformity, in order that with scientific 
exactness we may trace and record their actions. Accurate study and 
adjustment here are very difficult to secure, as is almost everything ot 
value in our art. But only thus can that exactness of result be obtained 
which will make real treatment not only possible but actual. 
I have said thus much as to the general significance of therapeutics, 
and its essential foundations, in order to magnify and emphasize this 
fundamental condition of the progress of rational and practical medicine. 
Our definiteness must begin with definiteness as to the disease which 
we have to treat, and definiteness as to the medicines which we propose to 
use. To this end, uniformity of preparation and reliability of dispensa- 
tion must accompany a definite knowledge of what we have a right to 
expect from the quantity of each article named in our prescriptions. 
How absurd that we should seek for and watch the action of a prepa- 
ration, and expect and record salutary results from its use, unless the 
preparation itself be of an indisputable character. Thus it needs no 
argument to prove that the relation of what is called Pharmacy to the 
Practice of Medicine is vital. It has so to do with the essence of the 
ithino-, it is so much the centre and substance of our professional science relations of pharmacy to medicine. 
1077 
and art, that it is an accessory before the fact. It will not do to assign it 
to a territory adjacent to that of the medical profession. Such boidei 
land is always doubtful land. As well might I recognize my right toot 
or my right hand as an acquaintance : my only real prospect of material 
success is to recognize and have them a part of my integral self IN ay, 
the case is even stronger; it is wearing one of the vitaloVW 
the bodv to put the framers and formers of our remedies totally without 
the pale of our profession. Their department must have fundamentally 
the surveillance of the medical profession, and this can only be secured 
by its being within the adjudication of the faculty. Other assurances of 
competency may be occasional and accidental, but only this can be reli- 
able when the two branches of science are so closely connected When 
seeking aid in our diagnosis, we consistently go to him who while be- 
lono-ino- to our profession, may have made of one department a specialty. 
Whenlie puts himself outside the pale of the profession, or is so put by 
circumstances whatever his boasted attainments, we recognize that it is 
not for our interests, and still less for the interests ot medical science, that 
we should avail ourselves of his assistance. Yet for aid in the depart- 
ment of therapeutics, that other arm of the profession, a very great part 
of our dependence is upon those who are outside. The relation is a purely 
i GUI aej. fpmnts to demoralization. No profession can ever 
“u?rSulh°of’its practice, of its essentials, so totally outside of itself, 
and Syet conserve its best interests as a science or an art The efteot 
always will be to enfeeble the practitioner as to Ins knowledge of reme- 
always win know how to adjudge competency, or to 
verify thfassmanieoTreliability and accuracy, while another effect will 
be to make theevil must he to hold pharmacy to 
The first step ! |,y making it a part of the profession of 
accountability a specialty like every other medical specialty, 
medicine. It mmbe » jpemalty, J It must, like 
having its founda , bAade a specialty, only because it may 
ophthalmology and _J practitioner to attend to every department ot 
not be practicable for eath P act, ,o e f sth reater accu. 
medicine, and in order that oy gmM = 
racy may thereby be attameff hj Qf medicine, that this was just the 
It is a noticeable fac , oeounied. It was made a specialty not 
position that pharmacy 01 -i , „ to, yet outside of, medical 
that it might be a trade,as to require con- 
wf uS 
rHskii 11 -”1 
allbnruMrB”io°n which has occurred are so patent as to be 
llie lesuits oi tue f + i-,p notorious. The average American 
undeniable, and so himself of the patronage of the 
dispenser is a dry-g ’ the more to thrive as a. merchant of drugs, 
medical profession mtent medicines, fancy articles, liquors, 
calaltgui/g. The price-curl 
and manifold incicl • t York drug house, in over two 
rent for instance 0 ‘ labout forty devoted to drugs, and only one-half 
hundred pages, ha Ji(jinall Yot a few bear testimony that their 
ot these are use no&tvum^m which many of them have 
a%??prieTanry interest. The retailers differ very much as to their stock in 1078 
HUNT, 
trade according to locality; and. in that part of their business which Is 
pushed into prominence we know of but few who follow what from the 
medical, professional stand-point would, be considered in accordance with 
the rules of ethics. Under the elegant college-building of one of the best 
of American medical schools, the pharmacist posts his own cure for neu- 
ralgia, and prepares his own specifics for diarrhoea, and is at the same 
time well patronized by the profession with prescriptions. 
As the word from which “ apothecary” is derived, means a repository 
or storehouse, and as “ drug” is a general name for commodities employed 
for the purposes of medicine, dyeing, tanning, and other uses, these deal- 
ers may be excused for their employment of the terms, and may become 
general storekeepers. We do not object that honorable men should pur- 
sue as a legitimate business the sale of this combination of commodities, 
which the law permits. Our claim is that the preparation of medicines, 
and the dispensing of the same by physician’s prescriptions, should not 
by the physician be tolerated under such an arrangement. Medical prac- 
tice is demoralized by such association, and an incubus is thus put upon 
the real advancement of therapeutical knowledge among practitioners. 
The only question before the wholesale dealer, is how to carry on his 
trade to the best pecuniary advantage. If he acquire any pharmaceu- 
tical knowledge at all, it is not in the interests of legitimate practice, but 
that he may associate this with the other branches of the trade. We 
know of a leading house which pays a practising physician to acquaint 
it with the tastes of the profession, and to inform it of what is most likely 
to please. The laxness of the retailers, if not quite so outspoken, is often 
no less real. Prescribing pharmacists abound. The prescriptions of phy- 
sicians are used with freedom, and are repeated indefinitely without the 
knowledge of the prescribe!'. If in some stores the patent-medicine 
notices are not so prominent, the article is nevertheless kept in stock, and 
large sales of it are made. 
We are aware that there are three classes of pharmacists : Those of the 
first, and by far the most numerous class, do all in their power to gene- 
ralize their business, having not the least regard for the physician, except 
as a customer, and availing themselves with equal suavity of Jacob 
Townsend and of Austin Flint. Those of the second class desire the 
patronage of the profession more than they do a general business; they 
have a faint perception of the higher sphere of therapeutics, and so foster 
a prescription business, while feeling themselves necessitated to keep all 
things required in the general trade. We theoretically add a third class, 
of those who deal only in pharmaceutical preparations, and who dispense 
medicines within such bounds as a profession can recognize. But we add 
this class simply because many of the best of our pharmacists wish that 
it existed, and that they belonged to it. It is quite plain that while de- 
ploring the present state of things they do not see any way to improve it. 
At the last meeting of the American Pharmaceutical Association, Pro- 
fessor Maisch spoke of the immense traffic in patent medicines. The 
Association professed to be opposed to the sale of these articles, but it 
is added “the efforts of pharmacists in this direction would amount to 
nothing, as long as patent medicines are called for by the public.” 
Hothing could more plainly show the present status of the business. 
We might just as well say that the physician is compelled to prescribe 
patent medicines because they are popular with the public. It is merely 
the forced admission that the pharmacist does each day that which is 
antagonistic to the principle of individual prescription for each case. RELATIONS OF PHARMACY TO MEDICINE. 
1079 
And we do not notice any gain in the adaptation of the drug business to 
Professional ethics. A recent Yew York authority1 says that in that 
city “the sign, ‘Physician’s prescriptions accurately prepared,’ is Hanked 
on all sides by cure-all pills, wonderful lotions, and infallible pain-killers.” 
This is even more literally true in all the smaller cities and villages 
through the land. I have purposely examined some of the leading to- 
called pharmacies between Yew York and Philadelphia, and have found 
the evil magnified beyond expression. Ido not suppose that it will ever 
be possible to break up these bric-a-brac shops, or prevent the mongrel 
sale. Public demand will cause a place of supply. Stores will ever con- 
tinue to exist, at which, under the name of “ apothecary,” stationery and 
innocent toys, perfumery and cosmetics, soda water and liquors, blacking 
and garden-seeds, soaps and paints, window glass and putty, and all varie- 
ties of patent medicines will continue to be vended. Let the drug-grocer 
go on, and be recognized as such in his business, but let not such be the 
place to which we resort for the compounding of our prescriptions. If we 
give recognition to such establishments, we must not be critical because 
these bazaars are the points of departure from regularity in medical prac- 
tice. Quasi-elixirs and counter-doctors prescriptions are the inevitable 
results of such afflictions. Worse still, the public is educated into low 
views of our art, and among physicians themselves the relations of thera- 
peutics to practice are distorted. Manifold preparations are smuggled 
into professional use, which would not get there under proper medical 
supervision, and such pharmacy is in turn the progeny and the progenitor 
of lax therapeutics. 
We are not to expect that any radical reform will originate with the 
apothecaries themselves. Their relations toour profession being merely of 
a business kind, there are not sufficient motives for change amid the vari- 
ous mercantile interests pointing in other directions. We are told of late, 
on the best of authority,2 that there is danger that the United States 
Pharmacopoeia itself will go over “to the commercial interests of phar- 
macy.” Prof. Remington, in his address before the Philadelphia College 
of Pharmacy, March 14,1876, in view of the present degraded tendencies 
of pharmaceutists, says; “Do you regard your avocation as a profes- 
sion, or as a mere business calling ? . . . What shall it be ? Profession 
or trade, pharmacy or black art, pharmacopoeia or price current? The 
very character of the business decides that question for us, and decides 
too its reflex influence on medical science and practice. Definite and 
damaging results must flow to us from such untoward channels of com- 
munication with the populace. It is not surprising that the vender of 
patent medicines should himself become a compounder and prescribe!’, 
and that those whom we send for prescriptions should be beguiled by the 
beautiful signs, or influenced by the advertisements of nostrums, with 
which they meet. < 
For all this condition of things I hold the medical profession, in a great 
degree, responsible. I ho not complain of the Ameiican druggist that, 
placed by the consent and really by the action of the medical profession 
outside its guild, he should accept the situation and assume his relations 
to that profession to be merely commercial. I will not blame the College 
op Pharmacy of the city of JSTew TTork,' whose business it is to educate 
successful venders of drugs, that its Code of Ethics says that the “ ne- 
cessities of the times warrant the keeping of patent medicines, although 
1 Medical Record. 2 E. R. Squibb, Ibid., July, 1876, p. 691. 
3 Ibid., Oct. 30, 1875. 1080 
HUNT, 
it declares their sale to be “ not a legitimate part of our business custom-” 
But I do complain that our profession, by complicity with this systerm 
aids and abets a calling which, by its very construction and methods ql 
practice, compromises that profession, militates against scientific medi- 
cine, lowers our own estimate of therapeutics, and tends to remove the 
care of our curative forces outside the domain of our professional jurisdic- 
tion. The medical profession in blew York City regards it as so improper 
for a licensed practitioner to carry on the busines's of a retail druggist, 
that it excludes such an one from medical societies, and will not place 
his name in its register. If a physician cannot keep a modern pharmacy, 
as certainly he cannot consistently with proper professional feeling, I do 
not quite see how he can suitably patronize one. It would be well it 
it were practicable for every physician to refuse to send prescriptions to 
be compounded by any save those duly licensed in medicine, and who, 
having chosen this as their specialty, were bound in ethical propriety not 
to prescribe, to sell and to compound only in recognized pharmacy, and 
to hold themselves in the same relative position as a part of our profes- 
sion, as do others who pursue a particular branch. 
If, to-day, ten pharmacists in such cities as Yew York and Philadel- 
phia could be brought into this direct association with the profession, 
it would be a gain for pharmacy and therapeutics of the most reforma- 
tory and indisputable character. Such a relation, existing between one 
or more of our leading manufacturers and the medical profession, is an 
elevation of the whole domain of therapeutics, not because of their per- 
sonal attainments merely, but because they are thus held thoroughly 
responsible to those high therapeutic demands which are alike in the real 
interests of each department. When we bring the same conditions to 
bear on the retail dispenser, we shall have our greatest security for the 
purity and adaptability of medicines. All hope of reform from outside 
is Utopian, because the organic relation is wrong, and must first of all 
be righted. 
A method of this kind needs only to be initiated by such a medical 
school as that of Harvard, by such a State Society as that of Yew York, 
or by such a school of pharmacy as that of Philadelphia, in order to 
make of it an ultimate success. Enough of the better class of physicians 
would rally to the support of those of their own number who should thus 
thoroughly identify themselves with the interests of the profession in 
one of its specialties. Many a pharmacist, sighing for deliverance from 
his present mongrel trade, would gladly accept his place in our profession, 
and in this branch of it would contribute to its welfare. All chemical 
and microscopical examinations, and various similar aids which the 
general practitioner now seeks and pays for, might naturally be committed 
to this branch of the profession, as well as much that is now appropriated 
by the instrument-maker. Place the dispensary in its natural relation, 
in charge of a member of the medical profession by choice assigned to 
that department, and society would be shielded from exposure to irre- 
sponsible remedies, and from the temptation to self-medication to which, 
by the present system, it is constantly and cordially invited. 
The pharmacist, within the fold where he legitimately belonged, would 
have the status demanded by therapeutics, and would thereby become 
directly interested with other physicians in the advance of our art. 
There would be hosts of apothecaries on the outskirts, just as now there 
are hosts of irregular practitioners on the outskirts of the legitimate 
profession, but they would recognize themselves as belonging to the open RELATIONS OF PHARMACY TO MEDICINE. 
1081 
frontier and the outside common. The line of demarcation would be 
so pronounced, and the professional recognition so honorable, that the 
real pharmacist and the real physician would alike rejoice. Therapeu- 
tics, adjusting the relation between diagnosis and cure, has the right to 
claim such a union. It already takes every one of us by the hand, and 
shows us that it is not meet that we should divorce from us that which 
forms an integral part of our profession, and which is incident to our very 
life-success. Instead of leaving the pharmacist outside, let us invite him 
within the boundaries of legitimate practice, and let him become imbued 
with the esprit de corps which belongs to a noble profession. 
I am importunate in this regard, because I feel that the present me- 
thod of supply, or the medium of communication between ourselves and 
our patients, as far as remedial agency is concerned, is essentially de- 
fective. If it were a mere criticism as to feasibility of method, or as to 
expediency of convenient or financial management, it could be passed 
by; but the whole success of treatment, and therefore the welfare of 
both patient and practitioner, are alike involved. The medicine or thing 
prescribed is the result and means of conveyance of expressed skill— 
the deliberate verdict on a case more or less critical. It is entitled to 
the most assuring safeguard which the profession itself can furnish. 
This safeguard cannot be furnished by adjunct relations.. "We cannot 
afford to leave the work of preparing our remedies to the manipulation 
of an outside corps. Identify pharmacy as fully with the profession as 
any other legitimately followed medical specialty, and we at once throw 
around it a cordon of protection and give an assurance of reform. Such 
vastness of uncertainty as is at present distributed from the drug-shops of 
our land, and very much under our prescribing, must be abolished ; and 
this can only be done by reinstating pharmacy as part and parcel of our 
calling. 
This is peculiarly essential to medical progress, because for the next 
quarter of a century the most crucial questions of practical medicine 
will centre in therapeutics. The two great preliminaries for our progress 
are (1) to have physicians record clinical and experimental results most 
exactly, and to tabulate in extended classifications the symptoms of dis- 
ease, and (2) so to acquaint us with the physiological effects of medicines, 
and their effects in the various kinds and stages of disease, as to enable 
us in like manner to tabulate remedies. To do this, we must be assured 
of the precise quality, quantity, and precision of combination, of articles 
used, so that sources of error shall be indisputably eliminated. All of 
us who have examined and compared various specimens of medicines, 
know how much this means, and how much uncertainty is introduced 
into all chemical records by unreliable preparations. Hever shall we be 
able to exclude this disturbing factor, confusing all statistics, until the 
prevalent system of dispensing medicines is changed, and until the phar- 
macist takes his place as a member of our profession, glad to be held 
strictly responsible to its ethics, and finding it to his interest to practise 
his specialty in the interests of every other department. 
The foliowino- conclusions are offered as being vananted by what has 
gone before : tip- 
I. The interests of society and of the medical profession render it de- 
sirable that the furnishing of medicines should be sunounded with 
greater safeguards. 
11. There are reasons why pharmacy should be regarded as a specialty 
within the general bounds of the medical piofession. 1083 
SECTION ON MENTAL DISEASES. 
PRESIDENT OF THE SECTION. 
JOHN P. GRAY, M.D., LL.D., 
VICE-PRESIDENTS. 
OF UTICA, NEWYORK. 
E. GRISSOM, M.U., ISAAC RAY, M.D., 
OF NORTH CAROLINA. OF PHILADELPHIA. 
WALTER KEMPSTER, M.D., 
SECRETARY. 
OF OSHKOSH, WISCONSIN. 
THE MICROSCOPIC STUDY OF THE BRAIN. 
BY 
WALTER KEMPSTER, M.D., 
PHYSICIAN AND SUPERINTENDENT OF THE NORTHERN HOSPITAL FOE THE INSANE, OSHKOSH 
WISCONSIN. ’ ’ 
The microscopic examination of the tissues of the brain has added so 
touch that is new to the departments of anatomy, physiology, and 
pathology, that each demands more time for its consideration than can 
be given to it now. The microscopic pathology of the brain, as found 
to insanity, having engaged my attention more particularly, I shall 
devote myself wholly to this department of the subject. 
. Changes in the Meninges.—lnsanity, in its various forms, is found to 
involve all the cerebral tissues. Of the membranes investing the cerebral 
mass, the dura mater is the least liable to general histological change 
general paresis being the only disease in which it is found to be uni- 
formly altered. The alterations consist of thickening of the tissue, the 
increase in thickness depending upon the formation of a new membrane 
apparently due to a disease of the epithelium lining the dura mater • 
Hew vessels are formed in the membrane, generally tortuous and irregular! 
In the more advanced stages of the disease, minute hemorrhagic points 
are found scattered over the under surface, depending upon rupture of 
some of the most tender capillaries. This state of the membrane must 
be sought for particularly, as no great departure from the normal stan- 
dard is observed without the aid of a lens, the most characteristic chancre 
being the presence of a delicate, pink tinge, not found ordinarily in the 
normal state. Transverse sections of the tissue, carefully prepared will 
show this condition very perfectly; or the new membrane may be*torn 
from the dura mater, though it cannot then be so well studied. The 
large hemorrhagic clots found sometimes over the brain surface, in general 
paresis, occur between the dura mater and this new membrane, the latter 1084 
KEMPSTEB, 
separating the clot from the subjacent tissues, and forming a delicate 
film which, being stained by the blood, is often overlooked, and is re* 
moved when the membrane is torn away from the clot. ISTot unfre- 
quently the dura mater is found thickened in localized patches in other 
forms of mental alienation, the increase of thickness appearing then to 
depend upon an inflammatory condition which does not differ essentially 
in appearance from that found in ordinary inflammation. _ _ 
The arachnoid and pia mater are nearly always found diseased in ai 
forms of insanity, the most prominent changes being found in the vas- 
cular system, and consisting of deviations in the course, size, and struc- 
ture of the capillaries. The membranes are usually semi-opaque, and 
some cases thickened, and in thickening of the arachnoid, granules and 
the products of inflammation are found upon its external surface. The 
deviations in the course of the vessels, consist of increased tortuosity > 
the deviations in size, of aneurismal enlargement; and the deviations m 
structure, of hypertrophy and degenerative processes. 
In removing the pia mater from the convolutions, before the brain has 
been placed in any hardening agent, portions of the external layer of 
gray matter often adhere to the membrane, and patches of gray, matter, 
varying in size from that of a pin’s head to the entire width of a convo- 
lution,&may be removed with it. In the parts so removed, it is common 
to find changes of structure, having their origin in abnormal deposits on 
the vessels, in minute hemorrhages, dependent upon rupture of vessels, 
or in passive exudation, preparing the way for inflammatory changes, and 
for softening and destruction of adjacent nerve-tissue. 
The pia mater is composed of two layers, and in diseased states these 
layers are easily 7 demonstrated. Occasionally we find a hemorrhagic 
point between the layers, in which case the layer on each side becomes 
thickened by inflammatory changes; the thickening of the membrane 
arrests the circulation in the contiguous parts, sometimes completely 
shutting off the blood-supply to that part of the convolution which is 
covered by the membrane, and, the twigs conveying the blood to the 
external layers of gray matter being first closed, causes local softening of 
the gray matter. "The change here alluded to is often found in cases 
of general paresis, although it is also found in other forms of mental 
disease of an acute type. "When the hemorrhage occurs between the 
pia mater and the convolution, secondary changes do not appear to follow 
so frequently. Occasionally, changes occur in the pia mater which do 
not depend on hemorrhagic points; the simple thickening of the mem- 
brane from inflammatory processes may cut off the blood-supply, and 
necro-biosis of the tissue beneath then results. 
blew material is sometimes found on the external layer of the pia mater, 
increasing the thickness of the membrane three or fourfold, and being 
always the result of inflammatory processes. It is rare to find extensive 
lesions in either the arachnoid or pia mater, without both membranes 
being involved, though the pia mater is probably the first affected; this 
is especially noticeable when pus has been formed, the pia mater being 
then seriously diseased and thickened by deposits of plastic material upon 
its surface. 
Bloodvessels.—The most constant lesions observed in the cerebral tissue 
of those who die insane, are connected with the circulatory apparatus; 
and the first of these to be described, because probably laying the foun- 
dation for other lesions, is engorgement of the arterioles and capillaries. 
It will be remembered that the coats of the cerebral vessels are in their MICROSCOPIC STUDY OF THE BRAIN. 
1085 
normal state more inelastic than those of other vessels, and that their 
lumen is considerably larger than that of vessels of the same size else- 
where In the earlier stages of insanity, there is often fulness of t e 
cerebral vessels resulting either from rapidity of the heart s action, which 
forcibly dilates’ the capillaries for a considerable length of time, or from 
•“f Kioori depending upon disease of the vaso-motor apparatus. If 
l"„e^etlveed i A sWt time, the capmary=eß ite ordinary 
calibre, but the second distension is more easily effected than the hist, 
and the vessel is then less liable to resume its norma’ rmanlnt dis 
if frecmentlv repeated, leaves the capillary in a state of permanent dis 
tension The vessel is then irregular in form, being larger above a bitur- 
“than below, and presents the appearance of having been s lifted 
» the of 
which ociurstn the vessels is a tatty degeneration of the muscular coats, 
x- .1 mu „«natitntinff the walls of the finer capillaries. 
The first change noticecf in the coats of the larger vessels is the collec- 
tion of numbers of fine granules, apparently lying on the wall of the 
vessel or developed within its muscular coat; these are grouped together, 
vessel, oi aey f varying in size according to the stage of the de- 
the granulai P the walls of the smaller capillaries, each cell 
generative proce . slightly increased in size. Granules 
the cel. jhfch the 
nucleus becomes in| ]es the degenerative process continues until the 
appeals. In the disappear and till the vessel looks like a 
evidences oferial through which its outline can sometimes be 
mass of ‘rkable instance of infarction and secondary change, 
dimly traced. A conditions may occur Micro, was found 
illustrating theda I f the «e°d°™an epileptic convulsion immediately 
in the brain ofer had for years been epileptic, and during preg- 
after birth. Ibe n U epiiepti/seizures, followed by paroxysms of 
nancy had had iepeat 1 . convolution of this infant s brain, 
violence. In the l dilatations of the vessels, and fatty de- 
cysts were found, with of the vessels and capillaries. One 
generation of the wal st wherein abundant evidences of 
reTmS ‘of inflammation, existed, and where absorp- 
tion must have occurred d upon over distension and subse- 
A change which app K kinking; the deviation in direction 
quent relaxation ie[ co^rse t0 the formation of a complete loop, 
ranges from a simple \ y tied in the vessel. The tortuous vessel is 
as though a knot had form 0f mental alienation, but exists in 
not confined to any p i subsequent relaxation have occurred, 
all forms in which: . "kia! melanchoiia, dementia, and general 
and has been noted ■ ‘ th tortuous vessels in the brains of the lower 
paresis I have not those who have died sane, except 
in the brain If a man executed for murder, and who had been insane 
some years before. . rige to considerable discussion in the de- 
A condition that S ig the existence of what have been called 
partment of cerebu G „p® which the bloodvessels are found, and the 
the “ perivascular j „ „elqvaScular sheath,” which surrounds the 
u hyaline membrane oi penvascuu 1086 
KEMPSTER, 
vessel. The canal and sheath are not easily demonstrated in the normal 
brain, but in the diseased tissue they are readily observed. The mem- 
brane or sheath, as it is called, does not always envelop the vessel closely? 
but sometimes hangs loosely about it, and, where the vessel bifurcates, 
forms a triangular sac. Sometimes the sheath is found closely applied to 
the brain-tissue, this condition occurring where there has been excessive 
engorgement a short time prior to death, the sheath having been dis- 
tended, and the brain-tissue crowded back. After death, the vessel 
recedes somewhat, leaving the membrane attached to the nerve-tissue, 
and the vessel itself adhering to one portion of the membrane ; trans- 
verse sections show the vessel apparently lying in a tunnel, which is 
composed of the enveloping sheath applied to the wall of nerve-tissue. 
The vessel, partially distended with blood, is found in the canal, and 
tortuous vessels are sometimes found lying in comparatively straight 
canals. 
The various conditions of the perivascular canal are best studied in 
fresh specimens, as we can thus acquire a better idea of the parts as 
they actually exist, all hardening agents, causing some contraction ot the 
tissue. Injected specimens, especially those of diseased cerebral tissue, 
will aid materially in studying these interesting conditions, but for tracing 
the ramifications of the canal, the hardened tissue answers best. 
Lymph cells are found in the canal, in the fresh tissue, while smaller 
granular bodies glide over each other as pressure is made on the covering 
glass; it is the opinion of some Continental observers that these canals 
convey the products of waste from the cerebral tissue into a lymph 
space in the pia mater, an.opinion which appears to be based upon good 
reasons, for the perivascular canal can be traced into the space between 
the layers of the pia mater. In all cases in which engorgement has 
existed for some time, crystals of heematoidine are found both upon the 
walls of the vessel, and also in the perivascular sheath. This deposit 
varies considerably in extent, sometimes occurring only at the bifurcation 
of the vessels (where it is always most abundant), and at other times 
completely incrusting the coat of the vessel, and thickly deposited upon 
the sheath. Another deposit which is found upon the vessel, much 
smaller than the crystals of hsematoidine, appears as minute specks of a 
fatty character, varying in size from to 3 A,o of an inch in diame- 
ter; these are yellowish-brown in color, and under high powers appear 
crystalline, but they are not easily dissolved, nor are they affected in 
any way by staining fluids. 
As a result of the excessive engorgement of the vessels, we have fusi- 
form enlargements and miliary aneurisms. Fusiform enlargements 
appear to depend upon degeneration of the coats of the vessels, which 
sometimes rupture, when the blood is poured out into the perivascular 
canals, the hemorrhage being limited by the sheath ; these limited 
hemorrhages are found only in the course of the smaller capillaries, 
where the force of the blood-current is not sufficient to burst the sheath 
after escaping from the vessel. This is not a frequent occurrence, but 
has been observed a sufficient number of times to make it noteworthy. 
These fusiform enlargements often extend to a bifurcation, the vessel 
again enlarging beyond until the next branch is reached, and so on to 
the finer capillaries. In all cases of fusiform enlargement, fatty meta- 
morphosis, in varying degree, has been found. Miliary aneurisms are 
not as frequent as fusiform enlargements, but are more striking in ap- 
pearance ; they are larger, ranging from Ato of an inch in diameter, MICROSCOPIC STUDY OF THE BRAIN. 
1087 
and can sometimes be seen without the aid of a lens. The vessels upon 
which these aneurisms occur, do not appear to be as seriously diseased 
as those in which fusiform enlargements are found, but the aneurisms, too, 
depend upon morbid changes in the vessels’ coats: degeneration of the 
walls (the veri-arteritis of Charcot), together with engorgement appear to 
determine their existence in a certain number of cases, but other factors 
are concerned in their formation, as the aneurisms are not found in all 
cases of degeneration even though evidences of engorgement also exist. 
They are found in all parts of the brain-tissue, and m the mem- 
bra lies I have found them in the gray matter of the spinal cord; in 
one notable case, the sac was situated near the origin of the first cervical 
Hypertrophy and fatty degeneration of the capillaries are frequently 
noted1 in cases of protracted engorgement, this abnormal condition at 
times existing to sich an extent as to destroy the vessel, the mass form- 
fTa nidt abound which changes in the structure of the nerve-tissue 
0 ® Occlusion of the capillaries sometimes results from stasis follow- 
• cu ’ f minute thrombi being formed when the circulation 
hip-endorsement, the minuie LuiuiiiM o. 
is unneded If the circulation of a bat’s tying be arrested for a time, 
certain of' the blood-corpuscles are seen to adhere together, forming 
vf • f fi The agglomerated corpuscles are moved along with the 
minute thrombi, lb* agP f 1m „ caUbre where tfiey finally 
current until they jwb mto a b]ood the thr(/nibus if, 
thtgniu®Ted iapiilary becomes stationary, and a clot results, secondary 
vessels beyond the plug are in some cases found empty but m others 
distended with coafula, the adjacent brain-tissue being deeply stained 
wTtiftlie coloring matter of the blood. When we recall tor a moment 
witn tne cornu g f i ra;n the effect of closure of the vessels 
the great vascu ai y ur’e 0f abnormal cerebral action, inde- 
which follow as a consequence of the deprivation 
of nutrition. _ duration or where there has been serious 
In cases of insanity 0 th sometimes appears near the 
disorganization of hi ’ obeath into the brain-tissue; the growth 
SSftnS f i t': ......,, i. ... i..... o.- sopp 
one end of the mass, < surround theS vessel, the outline of which 
They sometimes appea of these growths are not 
« .mttvertnvX membrane. tL mass is,granu- 
white 
There are no X “ non of The dOri. caused by destruction 
wherever these growths occui, n them> They are not &tty, and 
of nerve-tissue can be matoidine upon them, but these may be seen 
there are no crystals Qoiq and palladium staining color the 
in abundance upon the v co]ors them, but not as deeply as it 
growths slightly , This microscopic mass is to be distinguished 
does the surrounding • tjlC deiiosits found in syphilitic cases, 
from amyloid found in the vicinity of capillaries, 
01 Inftfcfurse of obttoatTd vessels, has led me to infer that they are 1088 
dependent npon lesions of the circulatory apparatus. I have not observed 
them near the larger cerebral vessels. They are not aneurisms,!, and do 
not appear to have any direct connection with the vascular system. 
Miliary hemorrhages are found frequently in cases in which aneurisms 
do not exist, the amount of blood extravasated depending upon the size 
of the vessel. Miliary hemorrhages vary in size from one-eighth to one- 
thirtieth of an inch, or even smaller. The hemorrhage is usually limited, 
but occasionally it involves large areas and produces characteristic symp- 
toms. One point in connection with hemorrhage, not due to the rupture 
of aneurismal sacs, I have not seen noticed by any writer, and that is the 
tendency to extravasation of blood into the gray matter. This form ox 
bleeding I have usually found confined to the posterior convolutions. A 
section through a convolution thus involved, shows that all the vessels 
are more or less diseased, and that the hemorrhage has taken place from 
all of the vessels in the vicinity, and apparently at about the same time , 
the smaller capillaries show small clots, which may at first be mistaken 
for aneurisms, but careful inspection will reveal the difference. 
In these cases it is quite difficult to determine just where the capil- 
lary is ruptured, the closest scrutiny with the highest powers of the 
microscope sometimes failing to disclose the opening. It may be that 
the degenerated vessels permit a passive hemorrhage, the blood slowly 
transuding through the softened walls. This form of bleeding is not 
infrequent; I have found it in all forms of insanity consequent upon 
engorgement, but especially in those cases of dementia which some 
writers have denominated “acute.” The hemorrhage is not always 
confined exclusively to the cortical substance of the brain, but is much 
more frequently found there than elsewhere, and is more extensive than 
in the white matter. The results are the same as in other forms of 
hemorrhage; absorption slowly occurs, and cysts are formed, or local 
softening takes place. Nearly always the remains of a vessel may be 
found inor near the cyst. In the convolutions of the brain of the infant, 
already alluded to, numerous cysts were found, in some of which the 
vessels were apparently intact, but enveloped with granular debris. The 
microscopic appearances of the circulatory apparatus indicate that in a 
certain proportion of cases the initiatory processes of disease have their 
origin in the capillaries or arterioles. 
Nerve-fibres.—The nerve-fibres undergo changes which must seriously 
interfere with their normal functions, independently of the diseased 
tissues around them. The most common changes are hypertrophy and 
atrophy. Hypertrophy, though not frequent, is found in certain cases, 
and appears to depend upon increased growth of all the parts of the fibre. 
The tubular membrane, or sheath of Schwann, grows more rapidly than 
the other tissues, and is proportionately thicker than in its normal state. 
The fibres must be examined as soon after death as possible, and should 
not be placed in any fluid, as the outlines change rapidly after being 
immersed. In hypertrophied fibres, the tubular membrane sometimes 
appears to be formed of several delicate layers of tissue, presenting a wavy 
appearance. The myeline is increased in quantity, and is granular. 
The axis-cylinder contrasts strongly with the dark tubular membrane, 
and presents a molecular appearance. 
The most remarkable hypertrophy of nerve-fibres that I have ever seen, 
was found in the cerebral tissue of a person aged forty-seven, who had 
been maniacal for a year. The brain tissues, generally, were diseased, 
the vascular system presenting the enlarged appearances already de- 
KEMPSTER, MICROSCOPIC STUDY OF THE BRAIN. 
1089 
scribed, and the coats of the capillaries having in many places undergone 
fatty changes. Twenty measurements of nerve-fibres were made soon 
after the patient’s death, giving results as follows: one field contained 
a number of fibres of an inch in diameter; several fields showed 
fibres of an average diameter of of an inch ; others again of 3 of 
an inch ; while in one instance the entire field was covered with fibres 
ranging from T|g to of an inch. The largest fibres were found 
arranged in parallel bands. The same group of fibres, measured at dif- 
ferent places, gave the same general results, the fibres ranging from 
toTTigtg of an inch in diameter. The portions measured were taken from 
different parts of the brain, and there was no great difference observed 
in the several fields as to size. Atrophy of the nerve-fibres from pressure 
of adjacent growths, or from prolonged capillary engorgement, is of 
common occurrence in cases of chronic insanity, particularly in elderly 
people; so considerable is this atrophy, at times, that it is difficult to 
distinguish the tubular membrane, nothing but the axis-cylinder being 
clearly marked. 
Changes in the Neuroglia.—Since Virchow first demonstrated the neu- 
roglia, several forms of disease have been described which are attributed 
to morbid changes of this tissue. The most common form of change has 
been called sclerosis, to which name several affixes have been given; 
thus there are disseminated sclerosis, multiple cerebral sclerosis, and 
insular sclerosis. The varieties above enumerated can be seen without 
the aid of a lens, and they are believed to depend upon an increased 
growth of the neuroglia. This hyperplasia of the connective tissue, as 
it is sometimes called, plays an important part in several forms of 
nervous disease not necessarily involving the mental status of the indi- 
vidual affected. 
Certain changes in the appearance of the cerebral tissues, which have 
recently been brought to the attention of neuro-pathologists, have been 
described under the name of Miliary Sclerosis. In this form of disease, 
it is usual to find, scattered about the field of the microscope, a number 
of white spots, situated in the white matter of the convolution. These 
spots are not stained by carmine, and contrast sharply with the sur- 
rounding tinted tissue; they vary in size from 2iro f° A au inch in 
diameter; they are generally round, with well-defined margins; and the 
adjacent tissue has the appearance of having been pushed back, as though 
the new growth had formed rapidly. These spots are granular in ap- 
pearance, and on some, connective-tissue fibres can be seen. They are 
found in the white matter of the convolutions, in the corpora striata, the 
optic thalami, the medulla oblongata, and the spinal cord; some are found 
between the gray and the white matter, and some in the gray matter 
itself. The nerve-fibres appear to bend around the spots in some places, 
or they may terminate in them, fihis is particularly noticeable in the 
medulla oblongata, where it is common to find the nerve-fibres either 
bending around, or frayed out in, the spots. Occasionally one of the 
spots forms about a capillary, which it destroys, in and beyond the mass. 
Some of the spots are ovoid in form, and, when so shaped, the long 
diameter corresponds to the axis of the nerve-fibres; again they are 
sometimes found lobulated, the lobes generally being of unequal size, 
but apparently developed from a central point, some of the spots have a 
delicate greenish tinge, and this tint is the same whether the tissue has 
been previously hardened in spirits, or in other agents. 
These spots have been found in the fresh tissue; in one case, an entire 
69 1090 
KEMPSTER, 
section of the medulla, made soon after death, showed the tissue studded 
with them ; and subsequent sections made from the medulla, after it 
had been hardened, showed the same general appearance as in the fresh 
state. The spots are best studied, however, in hardened tissue that has 
been stained with carmine or with chloride of gold; when the latter 
substance is used, the spots are slightly colored, but not uniformly 
stained to the centre, except in the smallest masses; chloride of palla- 
dium colors them brown, and a solution of osmic acid turns them dark 
brown or black. When placed in a solution of osmic acid, they can 
be seen to change color immediately, before the adjacent nerve-tissue 
changes; three or four minutes’ immersion in a one per-cent, solution 
suffices to render them black, and when thus stained the spots appear 
more granular than when stained with other agents. 
There are several varieties of this form of degeneration, each one pre- 
senting distinct characteristics; sometimes the spots are decidedly fibrous 
in appearance, the fine stroma of delicate fibres being distinctly visible 
when examined with a one-tenth objective. In other cases they are 
amorphous, or but slightly granular, and with no apparent nucleus. 
The margins of some of the smaller granular spots are clear and distinct, 
while the margins of the larger spots in the same section may be irregu- 
lar and apparently interlaced with the surrounding tissue. In the 
fibrous masses, the fibres do not run in one direction, but interlace with 
each other at all angles. The fibrous spots occur sometimes in tracts 
affected with gray degeneration, which would seem to indicate that the 
two forms of disease are separate and distinct. In one well-marked case 
of gray degeneration, affecting the medulla, pons, and cord, in an epilep- 
tic, the degenerated masses were found in several sections to be situated 
directly in the tissues affected by the gray degeneration. It was ob- 
served that where sclerosis did exist, the spot was distinctly fibrous; 
where sclerosis did not exist, the spot was not fibrous, but presented the 
slightly granular aspect already described. In the case alluded to there 
were large patches, inch in diameter, in the sclerous portion, while 
in the tissue not affected by gray degeneration there were granular 
masses To'oo- inch in diameter; some of these smaller patches were 
lobulated, and had well-defined edges. As above stated, none of the 
masses had nuclei, and no characteristic granular spot could be dis- 
covered which could be regarded as a nucleus; nor could any of the 
detritus of broken-down nerve-tissue be found in the masses, excepting 
where sclerosis or gray degeneration had previously existed. Ho trace 
of resemblance could be observed between the diseased spots and the 
normal tissue, even in the most recent cases, and before chemical agents 
had been enrployed to prepare the tissue for preservation. 
Another form of disease, found quite frequently in certain cases, 
has been called Colloid Degeneration; the name does not appear satis- 
factory, for, except in color, the diseased parts do not resemble colloid 
growths, nor do they respond to the reagents which are known to affect 
colloid tissue. The so-called “ colloid growths” of the brain are much 
smaller than the masses above described, ranging from to of an 
inch in diameter; they are more numerous than the patches of miliary 
sclerosis, have well-defined margins, and are more even in appearance and 
smoother than the miliary spots. They occur altogether in the white 
matter, which in certain places is filled with them. 
In cases of insanity complicated with syphilis, growths of another 
form have been noticed ; these are as large as the miliary spots, but MICROSCOPIC STUDY OF THE DRAIN. 
1091 
ftot as distinct, the margins shading off into the surrounding tissue, 
"hey are more decidedly granular, or rather cellular, in structure, the 
cells having nuclei, and there being a fibrillar stroma. Still another 
*°rm of growth has a distinct margin, but the mass appears to be sur- 
rounded by a dense membrane, arranged in layers, the interior of the 
Bpot appearing smooth and slightly molecular, but without a nucleus. 
Five distinct forms of growth have been recognized, and subjected to 
such tests as experience has dictated, each presenting peculiar and dis- 
tinct reactions with the agents employed, and each having an affinity 
.tor certain special staining materials; though osmic acid, in varying 
degrees of intensity, stained all the sections subjected to it, with such 
differences, however, as to leave little doubt that they were unlike each 
other in structure. It should be stated that these tissues were sub- 
jected to tests for cerebrin and lecithin, and to the most delicate tests 
f°r albuminates ; and that the substance which the larger spots (miliary 
Sclerosis) most resembled, and of which the test gave the most decided, 
characteristic reaction, was cerebrin; but that the reactions noted at the 
time were not sufficiently certain to warrant the assumption that this 
Material entered largely into their composition. The smaller masses did 
toot give the same reaction, and we are left without certain knowledge as 
to their true structure. It should also be stated that comparative exami- 
toations have been made of the central nerve-structure of the lower 
Animals, as well as of the central nerve-tissue of persons who died sane 
and who were suddenly deprived Of life by accident. In nearly every 
the tissues were placed, part in alcohol and part in chromic 
acid, or other hardening agent, hurt, the results were substantially the 
Same as far as the diseased portions were concerned. 
The masses of degeneration are found most frequently in the anterior 
Portions of the cerebrum, in the white matter of the convolutions; next 
in the medulla, pons, and cord; and less frequently in the cerebel- 
lum. In some crises, they are most numerous in the upper part of the 
toiedulla, and it has been observed that while they are sometimes very 
Uumerous about the region of the olivary bodies, there are comparatively 
few in the olivary bodies themselves. These masses are frequently found 
in the lateral columns of the cord, sometimes encroaching upon and 
‘drnost obliterating the central canal, for a considerable distance; and in 
these cases the epithelium lining the canal is altered in structure,and often- 
times its outline cannot be seen. In attempting to follow the course of 
nerve-roots, these spots are sometimes found encroaching upon them, 
fraying out the fibres, and destroying the continuity of the root itself. 
In cases in which the roots of the nerves of special sense are seriously 
interfered with, hallucinations referable to the nerves aftected are observed 
the symptoms during life. 
Nerve-cells of the Cortex.—The nerve-cells are subject to changes in 
structure and form, being in some cases hypertrophied, in others atro- 
phied, and in others again in some stage of granular degeneration, or of 
Pigmentation. Changes in the nerve-cells are quite constant. There is 
toot a particular change for each form of mental disturbance, nor do I 
Regard this as important, but the change in the structure of the cells is 
fo my mind of the highest significance. While it has not been shown 
fhat the nerve-cells are directly concerned in mental processes, yet the 
Majority of writers consider that intellectual vigor is dependent upon 
fhe normal state of the nerve-cells, and that these are immediately con- 
cerned in all our mental operations; and when it is found, in a laro-e 1092 
KEMPSTER, 
number of cases, that degeneration of the nerve-cells is concomitan 
with impairment of intellect, it is fair to assume that mental integrity 
depends upon their being in a normal state. Granular changes in the 
cells are the most frequent in all forms of insanity, the degree of disor- 
ganization appearing to depend to some extent upon the violence of the 
disease ; the most complete metamorphosis of cell-structure is sometimes 
found in acute cases which have run a rapid course. This form 0 
degeneration has been denominated fatty, but the cells do not alwayß 
show the reactions incident to this condition ; the chemistry of the sub- 
ject is, however, as yet crude, and the tests employed cannot be relie*- 
upon when such delicate tissues as nerve-cells are involved. 
In the initial stage of granular degeneration, a tew yellowish speck8 
appear scattered about in the substance of the cell, at first not affecting 
the nucleus. These specks increase in number as the change progresses, 
until the entire body of the cell, including the nucleus, becomes involved, 
and the cell wall partakes of the same change ; ultimately the cell loses us 
contour, and is converted into a mass of granules, the polar prolongation8 
having previously become atrophied and indistinct. In atrophy, t e 
whole cell appears shrivelled, and its investing membrane is shrunken- 
The poles become considerably shorter, and appear to lose some of their 
substance, and the whole cell and its appendages seem to be surrounded 
by a clear space. This atrophic change sometimes continues until tb® 
cells lose their characteristic appearance, and the poles disappear. Tb® 
large pyramidal cells are sometimes found in a condition of hypertrophy 
but* it is not a frequent occurrence, nor is it usual to find hypertrophied 
cells in all the convolutions ; they appear most frequently in the parietal 
convolutions, and seem to depend upon some local cause. The atrophy 
and granular changes are nearly always general, as far as the pyramids 
cells are concerned. These large cells are often seriously affected, win'6 
the smaller cells do not present the same form of change in so distinct a 
manner. In cases of dementia of long standing, the large pyramidal cell 
are affected by the granular change, more generally, I think, than in any 
other distinct type of mental disease. In general paresis, the large cell9 
are also granular, but are less shrivelled, and contain pigment granule8- 
When the nutrition of the brain-tissue has been interfered with by 
thrombi plugging the capillaries, the nerve-cells in the parts deprived (> 
blood have been found atrophied and granular, and in these cases tn 
lesion is localized, appearing only in those parts of the convolutions whic 
are deprived of nutriment. That the same form of degeneration 
be found in mania and melancholia, for instance, does not milital 
against the inference that both forms of alienation may arise from tn 
same cause, the external expressions of the disease depending upon sotn 
other circumstances. Whatever may be the function of the cells,_ t 
cannot be properly performed when they are affected by a 
process which transforms a part or all of their substance into a materia 
so wholly unlike the normal structure that the characteristic features 
the cell are entirely lost, and its attachments to the surrounding nerve* 
fibres severed. 
That part of our subject which relates to the pathological states wine 
are characteristic of certain forms of insanity, must be approached w* j 
caution, as it is yet a comparatively new field; but it is the practice 
result which is expected to follow from a study of the morbid 
of the brain, and it must eventually play an important part in dete MICROSCOPIC STUDY OF THE BRAIN. 
1093 
fining the therapeutics of mental diseases. To illustrate this subject, 
i have selected typical cases from the well-pronounced forms of insanity! 
and will briefly describe the pathological conditions found in each. 
Acute Mania.—ln one case of acute mania, death having taken place on 
the tenth day after the earliest manifestations of insanity, the capillaries 
rye re found in the first stage of fatty degeneration ; the granules were 
situated along the inner walls of the vessels, and also between the vessels 
and their sheaths; and many of the capillaries which were undergoing 
fids change were found plugged by minute thrombi. The perivascular 
canals were not seriously dilated, and the adjacent brain-tissue had not 
Undergone atrophic change. The nerve-fibres were not impaired; small 
spots of degeneration were seen, but they were few in number, not more 
than six or eight being seen in a section; they were of an inch in 
diameter, and were molecular, but with no nuclei; the margins were 
distinct. Sections stained with carmine presented the same general 
appearance ; the perivascular sheaths were more distinct, and the con- 
trast between the patches of degeneration and the nerve-tissue was cheater • 
the patches were slightly tinged with the coloring matter. The pyra- 
midal cells were clearly defined, and larger than in the normal state- in 
these enlarged cells fine molecular material was found in the plasma.? In 
the parts of the convolution which had been deprived of blood by thrombi 
the cells were more seriously impaired, the molecular matter in the body 
of the cells being more abundant, and some of the cells being atrophied. 
In a case of puerperal mania, in which death occurred six weeks from 
the first manifestation of the disease, the pyramidal cells were found 
slightly enlarged, and molecular material was deposited in the plasma. 
The cells were not well stained, apparently repelling the coloring fluid, 
and the outlines were a little indistinct. The capillaries were under- 
going the first stage of fatty change, and many were found plugged; 
there was also slight engorgement. The white matter was studded with 
spots of degeneration, ranging from to of an inch in diameter ; 
these spots had no nuclei, and were not stained by the carmine. 
In a third case, in which the acute symptoms were prominent for six 
months before death, the changes were much more evident. The pyra- 
midal nerve-cells were decidedly granular and atrophied, the walls appear- 
ing shrivelled, and the poles having undergone atrophic change; the 
masses of degeneration were larger, ranging from to of an inch 
in diameter; they were characterized by a distinct margin, and were 
round, while their structure was molecular. Their cut surface appeared 
concave ; they were not stained by carmine, and presented a yellow tinge. 
Some large masses were found in the cortex ; these were ot an inch 
in diameter, and were lobulated, and without nuclei; they were un- 
stained, and were found near capillaries. 
Melancholia.—ln typical cases of melancholia of short duration, the 
lesions observed in the early stages were the appearance of fatty granules 
in the walls of the vessels, with slight hypertrophy of the muscular coats, 
and some irregularity in the course ot the affected vessels. The peri- 
vascular sheaths were slightly distended, sufficiently so to show a de- 
parture from the normal state, and to indicate that at some period the 
vessels had been engorged. The masses of degeneration were confined 
to the white matter, and ranged from 4o’oo t° 3nVo °f an inch in diameter; 
they were molecular and without nuclei. The pyramidal cells were 
cloudy, slightly granular, but with distinct nuclei; the polar prolonga- 
tions were unchanged. A notable feature was that the cells were 1094 
KEMPSTER, 
surrounded by clear spaces, although the bodies of the cells were not appa- 
rently atrophied. These spaces were more distinctly marked in recen ■, 
than in prolonged, cases of melancholia, in which latter the capillarie 
were found engorged, tortuous, and unsymmetricah The canals ant 
sheaths were well shown, the former being much enlarged. _ Crystals px 
hsematoidine were found in quantities about the bifurcations, and xn 
many cases there were miliary hemorrhages. The neuroglia was pro- 
liferating, the extremely fine fibres appearing coarse, so that its ramifi- 
cations could be easily followed. The pyramidal cells were distinctly 
granular, and some were much hypertrophied. The small spots of degene 
ration were found in large numbers, unstained by carmine, and withou 
nuclei. . j 
Chronic Mania.—The microscopic appearances of brain-tissue vaneu 
somewhat in these cases, but certain changes were quite constant. in 6 
evidences of engorgement were marked, the coats of the vessels belli-, 
extensively hypertrophied, and the remains of vessels being outlined xfi 
parts of the tissue. The perivascular canals were large, often dilated to 
six or eight times the calibre of the vessels. The sheaths were fibrous, 
and large quantities of minute crystalline material were found deposited 
upon them, this being noted even upon some of the finer capillaries. 
Crystals of hsematoidine were also found in greater abundance than in 
some acute forms of disease. The large pyramidal cells were extensively 
degenerated, the shrunken atrophied cells, and the granular masses into 
which the cells are sometimes changed, being quite common ; the nuclei 
were less distinctly seen than in other forms of disease, and the polar 
prolongations were impaired. It was in cases of prolonged insanity tha 
the hypertrophied nerve-fibres were found, although these were not com- 
mon, atrophied nerve-fibres being more frequently met with. The 
masses of degeneration were large, often of an inch in diameter, an 
could easily be detected without a lens, in carmine-stained sections. 
Dementia— In cases of long standing dementia, intense engorgement 
of the cerebral vessels was a prominent feature. Fusiform enlargements, 
miliary aneurisms, and miliary hemorrhages, were all frequently observed 
in this form of disease. The nerve-tissue adjacent to the vessels was 
stained with the coloring matter of the blood, and numerous small cysts, 
indicative of old miliary hemorrhages, wTere found in the gray matter. 
In a case of dementia of long standing, miliary hemorrhages were abun- 
dant in the gray matter of "the parietal convolutions, and the cysts of 
former hemorrhages were numerous. The nerve-cells were granular, and 
sometimes enlarged; the nuclei and nucleoli indistinct; and granulai 
masses often occupied the positions of the nerve-cells. In these cases, the 
granular cells appeared to have undergone disintegration, the_molecules 
spreading over a considerable space, and free oil-globules being found 
neal'* • 1 c , 
General Paresis.—The cases of general paresis presented some features 
in common with those of dementia. The lesions in the membranes have 
already been described ; well-marked cases had extensive fatty degenera- 
tion of the capillary walls, and tortuosity of the vessels ; of 
hsematoidine were found in great abundance, and the minute crystalline 
granules encrusted the walls of the vessels and the perivascular sheaths. 
The nerve-cells were shrunken and granular; the nuclei indistinct, or 
completely obscured ; and the polar prolongations not to be seen. There 
was a marked increase of connective-tissue elements. In the cortical 
substance, in several cases, a number of stellate, crystalline bodies weie MICROSCOPIC STUDY OF THE BRAIN. 
1095 
found; these varied from to of an inch in diameter, and 
had distinct black nuclei. The masses of degeneration were lobu- 
lated and were not as numerous as in other forms of insanity ; they 
were Usually attached to the walls of vessels, which were shrunken, and 
were often found close to the gray matter. The nerve-fibres were atro- 
phied and the appearance of the tissue was indicative of active degene- 
rate’ processes. In the spinal cord there were frequent departures from 
the normal state, involving the membranes, which were in many cases 
affected like the membranes of the brain ; the nerve-fibres of the poste- 
rior columns of the cord were atrophied in the advanced stages, and there 
was an increased growth of connective tissue. 
Insanity of Epilepsy.—ln insanity following epilepsy, the nerve cells 
were found pffmented to some extent, particularly in the medulla and 
upper part of the spinal cord. The cells of the posterior convolutions of the 
brain were similarly affected, the bodies of the cells being pigmented and 
atrophied while the prolongations were not so seriously affected, bmall 
cysts were found in some cases, and masses of degeneration appeared in 
the medulla in great numbers, the masses being of the largest size, cellu- 
lar in structure and with a fine fibrillar matrix. Changes in the nerve- 
fibres of the spinal cord were not infrequent; gray degeneration in its 
various stages was quite common, and longitudinal sections showed 
atrophied nerve-fibres, and increased growth of connective tissue. 
There are of course, broad divergences from the above described con- 
ditions. the great range of diversity being in the various states of the 
neurovlia and the masses of degeneration. We know very little about 
the physiology of cerebral connective-tissue, and still less of the influ- 
ences which affect its integrity. The spots may all be due to an abnor- 
mal state of this tissue, but up to this time I have not been able to 
demonstrate this point satisfactorily. It does not seem probable that the 
various changes can be due to different stages of the same disease. In 
the cerebral tissue in one case, there was gray degeneration of the col- 
umns of Tarek; and in this degenerated tissue, patches of so-called 
miliary sclerosis were found, and, at its side the smaller masses which 
have been described under the name of colloid degeneration. In the 
patches of gray degeneration, connective-tissue fibres were abundant; in 
?he masses of sclerosis situated in the degenerated columns, the spots were 
composed of cells imbedded in a fibrous matrix ; and m the adjoining 
tissue were found the small spots with 
atmntnrp TVip natches of gray degeneration weie deeply stained with 
gold the masses of sclerosis nmch less so, and the molecular spots not at 
fn 1,1 unstained sections, the differences were as marked as in those 
which were stained. The polariscope and tourmalines gave evidence 
that the formations were not all of the same structure, and aided mate- 
riallv in determining the differences of the several forms of disease; none 
of the spots, when under the polariscope, gave the black cross and ring 
°fFrora ad9tuodyeof these varying conditions the conviction lias forced 
itself upon me that the degenerations are not always the result of pro- 
ffer-,tion of the neuroglia, but that in some instances they follow slow 
irfffaramatorv processes, resulting in degeneration of portions of the 
mflaramat y P . atrophy 0f nerve-fibre by direct pressure. It is 
noteworthy’that in all cases in which well-formed spots of degeneration 
were found of whatever type, there was an inflammatory condition of 
the meniimes and an exudation of serous fluid into the sub-arachuoid 
space, and into the lateral ventricles. 1096 
KEMPSTER, MICROSCOPIC STUDY OF TPIE BRAIN. 
These observations are based upon an examination of one hundred and 
fifteen cases, embodying all common forms of mental alienation ; and 
while they do not cover the entire ground, the principle microscopic 
lesions observed have been given. It need hardly be said that one ot 
the results of this investigation, has been to place me among the ranks 
of those who believe in, the somatic origin of insanity ; and, further, X 
believe that the only successful method of arriving at a definite know- 
ledge of the pathology of insanity, is to be found in a study of the patho- 
logical histology of the cerebral tissues. We must appeal to the micro- 
scope for an explanation of those mysterious phenomena which, under 
the name of insanity, have so long baffled the Philosopher, Theologian, 
and Physician. The mysteries will yield to the careful student of Mi- 
croscopic Pathology, 
[Thirty-six photo-micrographs, illustrating the various pathological alterations of brain- 
tissue described in the paper, were then exhibited by means of the lantern.] 
Discussion on Dr, Dempster’s Paper. 
After the reading of the preceding paper, Dr, Isaac Ray, of Philadelphia, 
said :—J cannot see a paper of so much importance pass entirely without note 
or comment. Dr. Kempster deserves great commendation for his labors on the 
microscopic anatomy of the brain, and there can be no doubt that in this direc- 
tion is the way to successful inquiry into the pathology of insanity. In the 
case of two persons dying of mental disease under apparently very- similar 
conditions, we may find in the brain of one every possible lesion, and in that 
of the other, nothing at all. It is somewhat the fashion to sneer at these 
microscopic investigations, but however indifferent we may consider the results 
so far, it can scarcely be denied that it is to them that we are to look for further 
light on this obscure subject. It is foolish to taunt us with our inability to 
find a delusion packed away in some congeries of cells, or to see a crazy pro- 
ject stamped at full length on a slice of gray matter, but, certainly, if we learn 
from the microscope something of the initiatory steps in the morbid process— 
if we are made sure that in every case there is a dilatation of some cells, or a 
plugging of some vessels—we have made a substantial advance in our know- 
ledge. Very few of us, I suppose, feel competent to discuss such a paper as 
this, and all may not be prepared to accept the conclusions of the writer, but, 
none the less, it ought to receive our most careful study. 
The President, Dr. John P. Gray, of Utica, said:—l am glad to hear the 
remarks of Dr. Ray on the value of the microscope in the study of insanity. 
In the institution at Utica, where I inaugurated this work in the asylums of 
this country, though we have been engaged in these investigations for a num- 
ber of years, I consider that we are only in our infancy in regard to the devel- 
opment of this subject. Ido not understand Dr. Kempster to claim that the 
lesions which he has mentioned are constant and peculiar to, or only found in, 
certain forms of insanity; and indeed such a claim could not be sustained. 
Winslow remarked, a long time ago, that insanity was due to a peculiar inflam- 
matory process. A recent article in the British and Foreign Medico-Chirur- 
gical Review, on the other hand, in referring to the investigations at Utica, 
said that we were no nearer to the discovery of the cause of insanity, or to an 
explanation of its phenomena, through these researches, than our predecessors 
were through their methods. And it is maintained by good authority that 
similar morbid changes are found in other diseases of the brain. What we are en- 
deavoring to do by microscopic investigation, is to determine the exact character 
and extent of the morbid lesions in insanity, and we think that photographic 
illustrations and illuminated sections of tissues, such as Dr, Kempster has here 
thrown upon canvas, are valuable methods of demonstrating these lesions. 
And all this should tend to stimulate further investigation. 1097 
THE RESPONSIBILITY OF THE INSANE FOR THEIR 
CRIMINAL ACTS. 
BY 
ISAAC RAY, M.D., 
How far insanity should be received in excuse for crime, is a question 
on which as we all know, there still exists much diversity of opinion 
Notwithstanding that the study of metaphysics has, of late years, engaged 
the attention of "some of the profoundest thinkers of the time; notwith- 
standing that better opportunities for the study of insanity have been 
affordeif bv the modern practice of gathering its subjects into large 
receptacles^for care and custody; and notwithstanding that cases for 
leva! adjudication in the courts of justice have been increasing with re- 
markable rapidity, we are yet, apparently, as far as ever from well-settled 
conclusions respecting the exculpatory effects of mental disease. Among 
lawyers and among physicians; among men of science and culture as 
well ns among metwho pretend to neither; among men of extreme con- 
servatism as well as among those who are never satisfied with the 
present-in each and all of these classes, we find, on tins subject, most 
diverse and even opposite views. This we may be inclined to regard as 
unwarrantable under the circumstances, proceeding as it does from neglect 
or careless use of the information at our disposal,yet, considering the part 
which passion, prejudice, and illogical reasoning, have m the formation 
of all opinions it is neither strange nor extraordinary. 
T. the history of English jurisprudence, insanity, as an excuse tor 
crime scarcely made its appearance until within a comparatively recent 
period Towards the middle of the seventeenth century, it may have 
been recognized as such in some of its grower forms. Witli that better 
understanding 0f mental phenomena, and that miidei treatment ot 
miuerstanam r visible m the literature and science 
human infirmity, wincn uegau lu u nnnnAstinnaWp plpmcmi 
of a somewhat later period insanity became an dement 
both of moral and of legal irresponsibility. Lo d ' 
define, with some show ot precision, the exact extent of its influence upon 
the mental movements and consequently of ts effectin npami L. the 
•i•i• i. ifo onhieets In this attempt ne was uno^ues- 
respousibihty o meJdicaj opinions of his time, as he found them in 
tionably, by th f eminent members of the medical profession, 
hooks, and in discom eot e conclusion that insanity in 
its niikleTforins was* riot necessarily 
crime, while tM miglA beEmitted umfeirits 
t:;St successors on the English bench have been 
seekTnv for tome tests whereby these two grades of the disease might he 
seeking io from tpe other, but always with very mditterent 
distiugnibhe o by that spirit of humanity which has been 
steadily intting itself into the English law, their instructions in par- 
OF PHILADELPHIA. 1098 
RAY, 
ticular cases have become more and more frequently correct. The tests 
which have been promulgated from time to time, not being founded on 
any correct knowledge of insanity, have each and all proved unsatisfactory 
when scrutinized under the light of practical observation; but, notwith- 
standing, they are still put forth occasionally as the law of the land- 
The discredit into which they have fallen, has somewhat, but not in a 
corresponding degree, widened the application of the plea of insanity in 
criminal cases, while it seems also to have given rise to some extent to 
the very opposite condition, the now prevalent distrust of the plea being 
supported by reasons which, though far from being new, have recently 
become endowed with a significance quite unwarranted by what we know 
of mental operations under the influence of disease. They are no less 
satisfactory, however, to that large class of people who having taken 
their opinions from one another, with but little knowledge of the subject 
itself, find it convenient to allege some plausible grounds for their belief. 
In the light derived from a good deal of intimate intercourse with the 
insane, and from the study of various authors who have written on the 
subject, I propose to examine the reasons now most often given for with- 
drawing that exemption from punishment which, in a greater or less 
degree, the insane have hitherto experienced. lam not so sanguine as 
to suppose that any efforts of this kind will turn the current of opinion 
now setting against these unfortunate victims of disease, but the solitary 
inquirer, sincerely seeking for the truth, should not be obliged to seek 
in vain. 
Much, if not most, of the present feeling on this subject may be traced 
to the legal profession, by which the plea of insanity has never been 
very cordially received. To lawyers, it seems like an intrusive element 
having no proper place in our legal system, but which, nevertheless, can- 
not be kept out of it. It implies, as we all know, a scientific fact to be 
examined, and its significance determined, by the rules and in the spirit 
of modern scientific investigation. This is a task completely outside of 
the domain of law. The lawyer has had no scientific training, and his 
knowledge of physical, and especially of medical, science, is only that 
which floats on the surface of the current thought. The more that is 
learned about insanity, the more difficult does he find it, for lack of such 
training, to determine its exact relations to crime. Even when told that 
the insane, generally, know right from wrong, what is lawful and what 
is unlawful, and recognize the distinction between vice and virtue, he is 
still unable to see what element of crime is wanting in their criminal 
acts. He looks at them, not from the scientific, but from the legal, or, 
more properly speaking, the metaphysical, point of view. 
When a person commits a criminal act, knowing that crime is wrong 
and forbidden by the laws of God and man, incited to it, perhaps, by a 
rational motive—to gratify some passion, or to avenge some injury- 
evincing design and contrivance in the execution of it, the lawyer is con- 
strained to believe, as a strictly logical sequence, that such a person 
should be punished. In such an act, not a single ingredient of crime, as 
he has studied his books, is wanting. A person, he says, who imagines 
that another, sitting opposite to him at table,' is making faces at him, is 
led to this belief by some morbid condition of the perceptive organs, for 
which he is not to blame, certainly, but which furnishes no excuse for 
shooting his imaginary foe, because he knows as well as he ever did that 
killing or maiming another is wrong and unlawful. Besides, he acted 
deliberately, he had malice in his heart, and, as the old indictments used RESPONSIBILITY OE THE INSANE. 
1099 
to have it he was moved by the evil instigation of the devil. What then 
was wanting to render him responsible ? Nothing, certainly, if we leave 
out of the account those springs of action, no less real and potent, which 
are introduced into the mental mechanism by disease, and ignore entirely 
some faculties of the mind, as necessary for determining and regulating 
the conduct as those which are recognized. He can find no excuse in 
his philosophy for one who slays the dearest objects of his affection, while 
admitting the wrong and deploring the necessity which obliges him to do 
it simply because he has but a faint apprehension of the mental faculties 
chiefly concerned in the act, and scarcely any apprehension at all of how 
they are affected by disease. In short, of the two classes ot faculties 
or manifestations that make up the mind, one, considered as the subject 
of disease, is altogether ignored, while the operation of the other under 
stress of disease is greatly misunderstood. ... „ , 
And thus it is that in their theories respecting the responsibility ot the 
insane the lawyers, in their imperfect understanding of the nature and 
operations of the mind, commit two serious mistakes ; one is that, where 
the mental affection is too obvious to be overlooked, they measure and 
define the scope of its influence in an arbitrary manner, unsupported 
entirely by the facts of psychological science; while the other, as just inti- 
mated consists in regarding the affectional faculties—the sentiments, erao- 
tions, ’and passions-as without any part in the play o disease, or with 
so little that it may be safely ignored. The first mistake may be wit- 
nessed in the rule propounded many years ago by Hoftbauer a German 
jurist of great repute, that an insane person may be excused tor any act 
prompted by a delusion, only as far as the act would have been excusable 
had the belief been a reality instead of a delusion. That is to say, if an 
insane person imagined that another was approaching him with intent 
t. take hi, life he might kill him, and be excused on the plea ot insanity; 
bn if he on y imagined that this person was making faces at him, or 
Uri following him from one place to another, he should not be so 
e Wfflld the offence been real instead of imaginary, it would 
excused, De killing. Never has there occurred a more re- 
not have j •. mistake than that presented by the English 
markable instance ot this mistake ina.i i i A fmAp-n 
law lords in 1848 on the occasion ot the trial ot McNauonton, toi kill- 
nethesecretary if Sir Robert Peel. McNaughton was possessed by the 
defusion that he was pursued by enemies who though unknown and u„ 
seen completely destroyed Ins peace. In fact, he wa ab g der 
what is now called the mania of persecution. He had somehow connected 
Sir Robert Peel with this conspiracy, and concluded to shoot him ; but 
. -Kooeit i e t killed the latter instead of the prime 
mistook his secretary toi nim, ana hnt the rmhlio 
minister. He was acquitted on the ou‘P °f the matt’er was brbuAllt 
rebelled so strongly against the verdict that the matte was brought 
before Parliament, which instructed the law-judges twelve in number, 
before raiiiam , decide what the rule should be incases ot this 
Snd° the rule put forth by Hoftbauer, as above 
accordingly it was announced authoritatively as the law 
°f We mav well be astonished that a rule which is to decide the question 
vy e coming time, should evince the grossest ignorance 
: t, ee m S’operat'ons wlfen aft'ected by disease and should be put 
fbth hv a body of men who might be supposed to be more correctly 
The rule, be it observed, implies mental disorder, and conse- 
quen" i responsibility, the extent of which, however, is limited in an 1100 
RAY, 
arbitrary manner, with no reference at all to the pathological condition. 
It means that if a person imagine that enemies are waylaying him at 
every turn, he may not be accountable for that belief, because it has in- 
truded itself into his mind without any will of his own; but that, it being 
there, he is accountable, to some extent at least, for what he thinks and 
does about it. He is required to act respecting it very much as if he 
were perfectly sane—killing his fancied enemy if he apprehends from him 
a murderous assault, as a matter of self-defence, but resorting to the 
courts for redress, if his enemy has only assailed his reputation, or is 
preventing him from obtaining certain estates. That there is any ground 
for such limitation, no one can admit who has been much conversant with 
the insane. Indeed, the fallacy of the principle in question is obvious 
enough without any experience of this kind. Everybody knows that 
the man who imagines that his legs have turned to glass, goes about as 
usual, instead of keeping still and thus making his conduct consistent 
with his belief. 
How a principle so plainly and completely contradicted by the facts of 
science, should have obtained the currency that it has, is not easily ex- 
plained. In England, this, as well as some other mistakes on this subject, 
may, possibly, be attributed to a famous dictum of Locke, who said that 
madmen reasoned correctly from false premises. Locke knew as little 
about insanity as the English law-judges, otherwise he would have known 
—what the humblest servant in a hospital for the insane knows—that 
the insane may wander at every step of their reasoning, from premises 
to conclusion. It is no more than might have been expected, that one 
who insanely believes that his neighbor has been telling bad stories about 
him, should also believe himself justified in taking that neighbor’s life. 
The confusion of ideas, so flagrant and so common in discussions upon 
this subject, is well illustrated by the fact that the judge who presided 
at the trial of MoNaughton, and who approved of his acquittal, subse- 
quently joined the other judges in declaring Hoffbauer’s rule to be the 
law of the land. Under this rule, McHaughton should have been con- 
victed, for, crazy as he was, he certainly apprehended no personal harm 
from Sir Robert Peel. Another instance of this confusion of thought 
was exhibited by one from whose multifarious knowledge and keen 
sagacity something better might have been expected. Lord Brougham 
said in Parliament, on one occasion, that he could conceive of “ a person 
whom Deity might not deem accountable, but who might be perfectly 
accountable to human laws.” In other words, a mental disorder which 
would render a criminal act excusable in the eyes of God, might be 
entirely ignored in the judgments of men. In this statement Lord 
Brougham did not merely mean to declare—what nobody would deny— 
that man, with his limited apprehension, might fail to discern mental 
disturbances that would be perfectly obvious to the eye of Omniscience; 
he meant to assert the doctrine that a kind and degree of mental disorder, 
equally obvious to God and man, might lead one to excuse, and the other 
to punish, any criminal act that might be committed under its influence. 
How such a monstrous conclusion could be reached, except in defiance 
of all reason and religion, is not very obvious. We can account for it 
only on the supposition that, to the mind of the thorough-bred lawyer, it 
seemed imperative that the legal theory of guilt and responsibility should 
be upheld at all hazards. For certainly the act in question had in it all 
the elements of crime, and, of course, the doer of it must be punished, 
even though God undoubtedly were ready and willing to excuse him. responsibility of the insane. 
1101 
The other mistake pervading the theory of the law respecting the 
responsibility of the insane, is to leave out of the account altogether the 
moral faculties of our nature—the sentiments, passions, and emotions. 
Here ao-ain is another of those inconsistencies which abound in the cur- 
rent reasonings on this subject. While every one admits that in these 
fa on 1 ties are the °reat springs of human conduct, that they incite men to 
srood or to evil and furnish the motives and impulses by which they are 
governed, the idea that they,or rather the cerebral organism with which 
they are connected, may become diseased as well as the reflective facul- 
ties is rewarded as preposterous and of dangerous tendency. And yet we 
have theime proof of the one fact that we have of the other. The con- 
ditions of health and disease are precisely the same m both. Both are 
manifested by the same material organ, the brain, by far the larger portion 
of which according to the most prevalent opinion, is given to the raora 
powers ' Disease fn any part of the brain must necessarily be followed 
hv derangement of its appropriate function, so that it is in the order of 
nature that when a certain part of the brain is diseased there will be 
some disorder of the affectlonal faculties. How this conclusion can he 
denied bv any one who believes that disease of the brain may produce 
loss of memory of judgment, of attention and of mental application, is 
not very obvious. The only possible explanation ot this curious incon- 
sistency is that disease of the moral faculties so often resembles manifes- 
tations of moral depravity, that it has bee,, mistaken for the latter, 
especially by those who are not accustomed to regard tins subject from a 
physiological point of view-their notions, as tar as they imply any ex- 
biTofthomrht behm founded solely on metaphysical considerations. 
eTPd hPPe wge see the influence of that school of mental ph losophy in 
which our predecessors were trained We may safely say, I thimc, that 
ad Herbert Spencer, and Bain, and Mo,-ell, lived and written in the 
kr TnLn Locke the popular notions respecting insanity would not 
mv Pe precisely what they are. Under their teaching, the affectional 
faculties would have held their rightful place in the menta, economy 
and would have played as necessary a.part n its ope.f4'o 8 1‘ 
the others in completing the grand result implied m a thmfcn.a, social, 
responsible beiim. Until they are regarded in this way, we need not 
PS much improvement in the law ot insanity. The tests of respo,,- 
continue to be what they now are-confined exclusively to 
siniiuy win w • nnwPra The question will continue to he, 
the action of P°"?Tdidhe know that the act was com 
did he know right nom wiong. evince 'forethought and 
trary to the laws of God and man?-did he evi t tl gl t 
contrivance in executing me ilrsH ad he 
eon Id he see the moral complexion of the act m its ti ue colors . naa ne 
the power6unaffected by disease to pursue the right and avoid the 
wroul to resist the natural impulses to wrong-do, by the superior 
» KSS; 
dttL°bTbymthe intrusion of a foreign 
of mechanism could be 
deranged only ®e infusion of ideas, there has occurred a lack 
ofthforaityTthp praPtical application ot the rules of law which, 
Pons deP P the momentous issue involved, suggests no very comfortable 
—IB The court may be satisfied of the irresponsibility ot the 1102 
EAY, 
prisoner, while, under a strict construction of the rules, he must be 
regarded as guilty; or the jury may prefer to found their verdict on 
the matters of fact disclosed in the evidence, rather than on the rules of 
law laid down by the court. And such must always be the case as long 
as the matter ot insanity is treated as a question of law rather than as a 
question of tact, for here is the source of much of the error that has been 
committed on this subject. It is especially visible in the current doc- 
trine—as current now' almost as it was in the time of Lord Hale—in 
regard to the exculpatory effect of what is called partial insanity. In 
some forms of disease, the patient does not seem to be entirely bereft of 
reason. On some subjects he converses with no lack of correctness or 
propriety; some business he transacts with his customary shrewdness ; 
and many people meet him in the ordinary intercourse of life without 
suspecting any aberration of mind. It is not questioned that he still is, 
in some degree, a rational creature. And certainly it is not surprising 
that the world should be slow to admit such a mental condition as an 
absolute excuse for crime. If the person have been entirely rational for 
some purposes, or in some relations, why may not this circle of rationality 
have embraced the act for which he is tried? This is a fair question, 
undoubtedly, and is entitled to a respectful answer. What wTe complain 
of, is that, instead of being answered in the light of that knowledge of 
the workings of the insane mind which is derived from long, clinical 
observation of the disease, the question is supposed, in actual practice, 
to carry its answTer with it. The logic runs thus; the act may have 
been the product of the reason left untouched by disease; therefore it 
was. We insist that the fact should be proved, and we claim in the 
interest of true science, as well as of humanity, that the burden of proof 
lies with the side that denies the influence of the alleged disability. 
The existence of insanity in never so small degree being shown, it is for 
the other side to show that it had no part nor lot in bringing about the 
criminal act. How we do not deny that this is ever possible, but we do 
say that in most, if not all, cases, we are positively unable to fix the 
limits of the operation of disease, and to say that the act in question was 
not the offspring of disease. Ho man pretends to discern all the springs 
and turns of thought even in the rudest sane mind, and it certainly is no 
easier when the subject of observation is thrown out of its ordinarv 
courses by a disturbing force. We know enough, however, on this sub- 
ject, to be convinced that, very often, thoughts apparently the,most 
remote and disconnected from one another, are found, on further re- 
search, to be closely associated, and thus to lead to conduct otherwise 
most strange and mysterious. He must have been a superficial or care- 
less observer of insanity, who has not often discovered the most violent 
acts to be the outcome of a wild and tortuous succession of thoughts. 
To say that we see no logical connection between the mental condition 
as obviously manifested, and the criminal act, is simply a confession of 
ignorance, not a display of knowledge. 
In contending that in criminal prosecutions, when insanity is pleaded 
in defence, the burden of proof should fall upon the side that resists it, 
we are only following the rule most .used'in civil cases. There, the ex- 
istence of insanity having been shown, it is incumbent on the party 
wishing to establish the act in question, to prove that the person had 
recovered, or that the act was performed quite independently of, and was 
untainted by, disease. If a will be in dispute, and the testator be shown 
to have labored under some unquestionable delusion or weakness of mind, RESPONSIBILITY OF THE INSANE. 
1103 
the presumption is that the will is rendered invalid by the mental affec- 
tion, and it is left for those who would establish it to prove the contrary, 
and the rule is the same in reference to contracts. It goes further even, 
for many a contract has been voided which displayed no indication of 
Unsoundness, and which could not be traced to undue influence. There 
is not the slightest reason for this difference, in the nature of mental 
disease. Its agency in the occurrence of crime is as far beyond all our 
resources of detection, as it is in the making of a will or contract. If any 
difference is to be admitted, it should be the other way, inasmuch as an 
issue of life or death is a far more serious matter than one of property 
alone. 
There is nothing in the popular conception of insanity so common or 
with so little foundation in the nature of things, as the idea that the 
extent of the malign influence exerted by insanity on the mind, can be 
accurately measured by the external appearance and deportment as viewed 
by the casual observer. It is supposed that a person who can converse 
sensibly, behave properly, and transact business, cannot be so insane as 
to be irresponsible for his criminal acts. In every trial where insanity is 
pleaded in defence, this idea is generally the main stay of the prosecu- 
tion. A host of witnesses is summoned, who testify to perfect soundness 
of mind. One had frequently met the defendant, passed the time of day 
with him, and talked about the weather; another had employed him in 
some ordinary trust or duty; another had had some business-transactions 
with him, selling him, perhaps, some little necessaries of life, or paying 
him a trifle of debt or interest; another had met him mingling with 
company at a watering-place, or at some social gathering; and these 
persons, one and all, declare that they witnessed nothing strange or un- 
natural in his looks, discourse, or deportment; and those who had busi- 
ness-dealings with him, and especially if they got a good bargain out of 
him, declare him to have been uncommonly shrewd. This evidence, 
though entirely negative, is none the less effective with most of those 
it. Its force is scarcely weakened by the statement, which 
they may admit in general terms, that insanity often leaves some opera- 
tions of the mind untouched, and thus escapes the notice of the casual 
observer. And yet this trait of insanity would seem to be too common 
to be so disregarded in actual practice, for every hospital report, every 
newspaper that we take up, bears witness to its frequency. 
In the normal condition, nothing, under ordinary circumstances, is 
dearer to a man than his life. To preserve it is one of the most power- 
ful instincts of his nature, and, it in certain exigencies he willingly part 
with it, it is for the rational purpose of securing what seems to him a 
greater good, or of avoiding a present, real, unequivocal evil. And yet 
a large proportion of suicides are committed by persons urged by no ap- 
parent motives, in the possession of eveiy outwaid circumstance calcu 
Jated to make life desirable, and giving no indication whatever of mental 
disturbance. Up to the last moment, they may have tiansacted business, 
conversed sensibly with friends, and in all the iclations of life conducted 
themselves with their customary Yet who will venture to 
say that, notwithstanding all these appaient indications of good mental 
health, suicide, committed under the ciicumstances just mentioned, does 
not signify a kind and degree of insanity as destructive of moral free- 
dom and responsibility as the most demonstrative forms of the disease? 
It is also a well known fact that many of those peisons who attempt un- 
successfully to commit suicide* while appearing to the casual observer 1104 
RAY, 
entirely sane, subsequently have only the most dim and uncertain con- 
sciousness of the attempt. Now, there is no reason to doubt that homi- 
cide, and perhaps some other criminal acts, may be committed in a similar 
state of mind—evincing just as much coolness, deliberation, and contri- 
vance, and just as complete an absence of all the demonstrative signs of 
mental disease. It is not creditable to the intelligence of our time, that 
the apparent eorrectness and propriety of the person in the common 
relations of life, should be regarded as incompatible with the presence of 
insanity, or, at least, with any such insanity as should exempt him from 
responsibility. 
Unquestionably, during the present century, the tendency of public 
sentiment, following, no doubt, that of the clinical study of mental dis- 
eases, has been to enlarge the exculpatory effects of the latter. Now and 
then there have been signs of reaction, never stronger, probably, than at 
this present moment. To men whose opinions are formed by the current 
prejudices around them, rather than by any careful study of facts, it 
seems as if the plea of insanity had been making crime a little too easy, 
and that a wholesome check to this facility would be found in punishing 
the insane like other criminals. The argument by which this doctrine 
is generally supported is that many of the insane know right from wrong, 
that they are governed by motives, and may restrain their passions. The 
facts implied in the argument, we willingly admit, for nobody denies 
that many of the actions of many of the insane are rationally considered 
and rationally performed. Nobody denies that their conduct may be 
determined by the hope of reward or the tear of harm. One patient 
strives hard to obtain a privilege or a favor, while another is deterred 
from an assault upon a fellow-patient by remembering the threshing he 
got in a former encounter. The same man who believes that he is coming 
to want, and destroys himself and family to save them from misery, may 
refrain, if he please, from exposing his person, from soiling his clothes 
or from assaulting his neighbor. Why then should he not be punished 
for offences that are not inspired by his disease ? To those much con- 
versant with the insane, the reasons against it are obvious and conclu- 
sive. The more that one learns of insanity, the more inscrutable are the 
movements of the mind affected by it, and the less confidence is felt in 
any attempt to discern exactly their connections, and to say which can 
be safely attributed to sanity and which to insanity. If this be so, under 
the daily and hourly observation of a skilful inquirer, what confidence 
can be placed in any positive conclusions founded on the testimony of 
those who have seen the accused at remote periods, who know nothing 
of insanity beyond what is learnt by the casual sight, now and then, of 
a person reputed to be crazy, and who are unable by lack of culture to 
convey to others the impressions thus made on their own minds. If any 
one could tell us—physician or philosopher, court, counsel, or jury—by 
what means, with the slightest approach to certainty, we might make 
the distinction between the working of the sane and that of the insane 
element, we would not object to the proposed rule. At any rate, let the 
burden of proof rest on the party which alleges that the criminal act 
was prompted not at all by the presence of disease. 
There is another reason for not punishing the insane, which, feeble as 
it may be to the common mind, is conclusive to the close observer of 
mental disease. Admitting, as we do, that much of the daily life of the 
insane shows no trace of disease, we are none the less sure that the 
presence of disease, however limited it may appear, is generally incom- RESPONSIBILITY OF THE INSANE. 
1105 
patible with the most correct and vigorous exercise of all the faculties 
of the mind. It impairs the freedom of the will; it blunts the sense of 
light and wrong, of the good and true; it weakens the power of self- 
control, and diminishes the normal amount of restraint upon the ap- 
petites and passions. Ho one engaged in the service of a hospital can 
have failed to observe how fiercely the passions of the patients are excited 
by little provocations that would scarcely have ruffled their tempers 
before; how disproportioned to the offence is the measure of their reta- 
liation ; how grossly exaggerated are every feeling and impulse awakened 
by the ordinary experiences of life; how often native propriety of man- 
ner and delicacy of sentiment are replaced by a rude demeanor, and by 
a coarse, reckless disregard of the rights and feelings of others. Even 
when the criminal act seems most clearly beyond the range of the morbid 
influence, there is always reason to suspect, if not to positively believe, 
that it would not have been committed except for this enfeeblement of 
the power of self-control, or this blunting of the moral perceptions. 
Such beino- the fact, it shows how groundless is the doctrine, some- 
what countenanced just now, of a limited responsibility, as applied to 
the partially insane, according to which the}- are always to be punished 
for their criminal acts, though in a less degree than they would be if 
Unquestionably sane. I need only allude to the doctiine, as its unsound- 
ness has been sufficiently shown by the views already expressed. A. 
moment’s reflection must convince any one that no device of legislation 
could make the application of it in practice otherwise than absurd. The 
idea of a court or jury constructing a scale of insanity according to its 
severity, and graduating the measure of punishment thereby, is simply 
ridiculous, and would be rendered still more so by any attempt to apply 
it to a given case. . 
Recently, we have seen the revival of a doctrine, never much in vogue, 
however that the insane should be punished in order to deter them, by 
force of’example, from breaking the laws. In support of this view, 
instances are related of insane persons, who, when talking over the 
criminal acts of others understood to be insane, have said to each other 
with much self-complacency, that, being insane, they would not be 
punished. In this belief, they would natuially use no self-contiol, and 
would feel free to break every law on the statute-book. Unquestionably 
the insane know very well that they may not be punished for theii offences, 
as they know a great many other things. They aie able to leason cor- 
rectly on the subject, as they do on many other subjects. Ihe fact is not 
extraordinary, nor has it recently come to light, and, considered in con- 
nection with other facts, it implies no responsibility. le truth is, that 
very few of the insane believe that they are insane ; consequently, irnmu- 
nity from punishment does not present itself to them as an inducement 
to commit crime, nor to relax in the slightest degree their control over 
their passions. While they perceive well enough the abstract nature of 
crime, they cannot see it as applied to any particular act in their own 
cases They are outside of the range of such application, and are a law 
to themselves. Some are urged by a necessity which they cannot resist, 
even knowing that they do wrong,and knowing the usual consequences. 
Some are prompted by strange suggestions: the voice of an unearthly 
presence, a terror that overrides every thought of consequences or a spur 
of savage ferocity unraingled with the slightest sense of humanity. 
These people act without reference to law or gospel, under motives and 
impulses as remote from their natural dispositions and principles as the 
70 1106 
RAY, 
poles are asunder. The fact that persons reputed to be insane had suf- 
fered the usual penalty for their crimes, would have no more restraining 
influence than blows or threats in hushing the cries of a new-born infant. 
No human law can be more imperative than that higher law within him 
which impels many an insane man to some act of violence, and no con- 
sideration of justice or pity can come in to lighten the stroke provoked 
by the trivial offence of a neighbor. Indeed, this idea of the insane 
being deterred from criminal conduct by penal laws, is utterly destitute 
of foundation, and we challenge its advocates to produce a single instance 
in point. 
In order to make this idea practically efficient as a means of restraint, 
some steps would be required to give it an authoritative character, for 
unless the insane were somehow convinced of their responsibility, clearly 
and fully, of course it could have no restraining power. There would 
seem to be an insuperable difficulty in the way of making this idea im- 
mediately effective. If left to the courts, the most that could be expected 
would be now and then a decision declaring insanity to be no excuse for 
criminal acts. And supposing these occasions to become more and more 
frequent, until the rule should generally prevail, there still would be a 
considerable period of doubt and uncertainty as to the actual state of 
the law. The case could be properly met, if at all, only by an act of the 
legislature, and, in the present state of public sentiment, nothing is less 
likely to happen than an act making insanity, of whatever kind or de- 
gree, no excuse for crime. If, however, the legislature, without going 
to this extent, should undertake to specify what forms of the disease 
should or should not have this effect, as it has in some European countries, 
the result wmuld be a lamentable failure, producing only confusion and 
distrust. Our notions of the actual limits within the operation 
of any form of insanity is confined, are too vague for such a purpose, and 
the imperfection of our nomenclature would prevent any approach to 
uniformity of meaning. And thus we stand: The legislature is indis- 
posed to act, and the rules adopted by the courts are irrelevant, inade- 
quate, and conflicting. Nor from this unsatisfactory condition of the 
law can we expect any relief, until the whole question of insanity shall 
be regarded as a question of* fact, not of law, as at present; and, thus 
regarded, shall be taken altogether from the court, and, like other mat- 
ters of fact, be given to the jury, which would be governed by the weight 
of evidence and the individual convictions of the jurors. This course is 
virtually taken by juries, even now, and it is held up as a flagrant in- 
stance of our scandalous indulgence of crime, that many a verdict of 
“ not guilty, by reason of insanity,” is rendered, in spite of the instruc- 
tions of the court. 
I cannot leave the subject without adverting to an argument in favor 
of punishing the insane like others,on which unusual stress has been laid 
in some recent trials. It is represented that in our hospitals for the insane, 
the discipline is maintained by the use of rewards and punishments. 
This implies that the patients are deterred from wrong-doing by the 
understanding that it will be followed by punishment, and the inference 
is drawn that the same motive would operate in the same way outside, 
as well as inside, of a hospital. If the statement on which this reason- 
ing is founded were strictly true, it should be taken in connection with 
the other well-known fact, that many of the insane are not deterred from 
violence or any other wrong by fear of any consequences whatever. 
Neither threats nor blows, nor death itself, can turn them from their chosen RESPONSIBILITY OF THE INSANE. 
1107 
course. And thus arises the difficulty which has already presented itself 
in another shape, that of determining to which of these two classes the 
accused may belong. By what kind of evidence are we to be convinced 
that the prisoner at the bar would have refrained from committing the 
offence for which he is on trial, had he believed that he would be 
punished? 
But we are really not reduced to this dilemma, ihe idea that the 
inmates of our hospitals are punished for their delinquencies, is false— 
entirely without foundation in fact. They are deprived of a privilege or 
of an indulgence which they have shown themselves unable to use with- 
out harm to themselves or others—an inability which may have been as 
much* beyond their control as the usual manifestations of bodily suf- 
ferino-. Such deprivations, as well as rewards for good behavior, are 
Used a*s a means of trying and strengthening the power of self-control— 
a power which in the insane is confessedly weak. Its exact degree of 
Weakness or strength, no one much acquainted with them will undertake 
to measure- and who then can measure it for the purpose of apportioning 
the proper ’amount of judicial punishment ? So far is it from being true 
that the patients in our hospitals are punished tor any reason whatever, 
that the attendants are prohibited from returning a blow, or retaliating 
for insults or injuries, on pain of dismissa ; and yet, when provoked by 
serious assaults, they might often say with truth, he knew better; he 
knew he was doing wrong; and a little summary punishment will he p 
to make him do better in the future.’ But ft to punish the insane be 
good law in a court of justice, why should it not be in a hospital? We 
would have it distinctly understood that it is not good law in the latter, 
not because there is never a case in which punishment might prove a 
powerful help to improvement, but because no insight shoit of Omnis- 
cience can ever know for certain which are such cases. It may be urged, 
perhaps, that exception should he made of cases m which it is shown by 
satisfactory evidence that the accused had often been deterred from 
wrong-doing by the fear of punishment. The statement is quite too 
vague to serve as the ground of a general rule ; and besides it ,s open to 
thl objection of showing a negative rather than a positive state ot facts. 
What a man refrains from doing under certain cucumstances, is no safe 
measure of the extent of his self-control under other and very ditiere.it 
That there has been, of late years, much practical disregard of the rules 
of law on the nart of nines, must be admitted; but the couise of judicial 
decishnsknd verdicts within a very recent period, shows how grievously 
potent they still are. About two years ago, one 1 ordham, a patient in 
an asylum for the insane, murdered an attendant. It appeared m evi- 
i hi ,i „„„ rmiianfip nuarreisome, and otten violent, that he 
(dice la ic wa < P P ’ and had declared that he would have 
had quarrelled with the a 
lfoeXman%Zgh & j«<7 that thfe hTnodoubt 
“hvhfht S'JLW If « - killed another ” 
said he “ while under a delusion that he himself was about to be killed, 
and that he was acting in self-defence, he would not be punishable; but 
jf a maj cid 80 for some supposed injury to his character or fortune, then 
e won dbe responsible.” Sentence of death was passed in the usual form, 
but the punishment was afterwards commuted to penal servitude for life. 
Some three or four years ago, Mr. Lutwidge, one of the members of the 1108 
RAY, 
Board of Lunacy, while passing through a hospital which he was visiting 
officially, was assaulted by a patient, who inflicted upon him a wound 
from which he soon died. The patient’s insanity was unquestioned, 
though he had not been supposed to he dangerous. In speaking of the 
case, in their annual report, the twenty-eighth, the Board say that the 
man “ was quite responsible for his actions.” Since this case occurred a 
man named Blamfield has been tried for murdering a fellow workman. 
The act was done suddenly, without apparent premeditation or provoca- 
tion. Blamfield had been a patient in a lunatic asylum, from which he 
had been discharged, uncured, some months before. The medical super- 
intendent of the hospital testified that, while in his charge, Blamfield 
had had a fear of punishment for misconduct, and had been governed 
by this feeling. He, therefore, considered him responsible for his acts. 
The man was convicted of murder, and sentenced to be hanged ; but his 
punishment was subsequently commuted. 
Such are the more prominent difficulties now in the way of making 
the plea of insanity in criminal cases as effective as it should be. The 
question may naturally be asked; How can these difficulties be most 
readily removed, and the law be administered in conformity with the 
truths of science? It is scarcely within my purpose to speak upon this 
point, but it may not come amiss to indicate very generally the direction 
from which reform may come. 
Let me say, in the first place, that if courts are to continue to measure 
the exculpatory effects of insanity by certain arbitrary tests, they are 
bound to avail themselves, as did Lord Hale, of all the existing medical 
knowledge on this subject. Instead of repeating, one after another, rules 
and distinctions, of which the sole claims to respect consist in the fact of 
their having been uttered before, it is their duty to learn as much as 
possible of the nature of insanity from the only true source of knowledge 
—the practical observation of the insane. Legal knowledge is, for the 
most part, so technical that the decisions of the courts on most matters 
are received by the public in faith, nothing doubting ; but on this subject, 
the public will have an opinion of its own. The people who would shrink 
from the presumption of understanding a question of contingent remain- 
ders, or of eminent domain, may have little respect for any rule of law 
touching the responsibility of the insane. Have we not a right to ask 
the judges to make themselves acquainted with the nature of insanity by 
all the means within their reach, so that, instead of directing the jury by 
a servile repetition of something that others have said before them, with 
no other authority than the fact that it has been said, they shall present 
only the established facts of science, and such considerations as are natu- 
rally suggested b}7 them ? Let it be remembered that we are dealing 
with a branch of medical jurisprudence, and, therefore, that the study 
here recommended belongs as well to the lawyer as to the physician. X 
do not suppose, indeed, that the soundest instructions would always be 
followed by a proper verdict, for juries are too fond of manifesting their 
independence by disregarding whatever may conflict with their own 
foregone conclusions. But it would remove somewhat the distrust now 
felt of judicial decisions, in which the advancement of knowledge is 
entirely ignored, and would prepare the way for a better and more 
satisfactory administration of justice. 
A still better step, as above intimated, would be that already taken 
by the courts of ]Srew Hampshire, whereby the question of responsibility responsibility of the insane. 
1109 
is treated as a matter of fact, not of law, to be determined, like other 
matters of fact, bv the jury. In the performance of this duty, juries 
would be o-overned by the evidence, aided by the explanations of the ex- 
perts. This would not necessarily insure a correct verdict; for the evi- 
dence might be conflicting, the experts might disagree, and the jury might 
be governed more by its prejudices than by the real merits of the case. 
It is doubtful however, if anything better could be obtained under our 
mode of procedure, and this is not likely to be changed at present. Some 
improvement might follow from putting into the jury-box men of higher 
personal character, moral and intellectual, than such as are often found 
there. * This improvement could be more easily made, I am sorry to say, 
than could one equally if not more efficient, whereby the experts should 
prepare themselves more carefully for their duty, and should discharge 
it, divested of every unworthy bias. 
Discussion on Dr. Ray’s Paper. 
After the reading of the preceding paper, Dr. Clement A. Walker, of 
Boston said-—1 wish to express my sense of obligation to Dr. Ray for the 
clear and distinct manner in which he has presented this subject in his 
valuable paper. Just now, such papers are much needed, tor there seems to 
be at present a reaction setting in against the insane, causing them to be 
held responsible for acts committed while under the influence of insanity. 
This reaction is particularly strong in Massachusetts, where the action of 
the executive in commuting the death penalty to impi isonment, in the case 
of a man convicted of murder, and who was by many regarded as insane, has 
been received with astonishment, and has been condemned as an unjust act. 
There are some in our specialty who may differ with the ideas of Dr. Ray in 
regard to the limited responsibility of the insane, but his views in this 
respect have my full endoisement. . . 
The President Dr. John P. Gray, of Utica, said;—l do not agree with Dr. 
Rav in drawing such a distinct line between the intellectual and moral elements 
of the mind, for this would divide the mind into parts, and would give, as a 
logical result, moral and intellectual disorders, independent of each othei. I 
believe in the essential unity of mind, and I cannot assent to his view either 
as beiim sound psychology, or as true in clinical observation I obseive, how- 
ever, that, though Dr. Kay makes this theoretical separation, yet when he 
comes to treat of actual insanity, and of respons.bihty, he remotes the moral 
and intellectual faculties. 1110 
THE SIMULATION OF INSANITY BY THE INSANE. 
BY 
C. H. HUGHES, M.H., 
LATE SUPERINTENDENT AND PHYSICIAN OF THE MISSOURI STATE LUNATIC ASYLUM. 
The literature of insanity feigned by the sane mind is extensive, and 
dates back to the earliest period of recorded history. The feigning of 
Ulysses in profane, and of David in sacred, story, are familiar to all, as is 
likewise the history of Lucius Junius Brutus, who saved bis life by suc- 
cessfully assuming imbecility, and Shakspeare’s two oft-quoted examples 
in the characters of Edgar and Hamlet—the latter, I think, blending some 
actual mental disease with simulation; but upon the subject of the present 
paper, the simulation of insanity by the insane, not much has been written, 
though enough is known to make it a proper subject of inquiry. 
Not less interesting to the student of morbid psychology than the well- 
defined, well-recognized forms of insanity, are those obscure, anomalous 
conditions of mind which occasionally appear, but in regard to which he 
fails to obtain any light from the standard books. Though more nume- 
rous, probably, than they are generally supposed to be, yet they are com- 
paratively so rare, and so imperfectly understood, that, for the most part, 
after exciting a little temporary curiosity, they pass from attention, and 
are forgotten. And yet they must ever constitute a very important class 
of mental disorders, for the reason that their existence, however infre- 
quent, must necessarily modify the conclusions that might be drawn 
from the more common forms of mental disease. In fact, no physician 
needs to be told that many important steps in the progress of his science 
have been made by the careful and persistent observation of what, at 
first, seemed to be anomalous and exceptional cases.1 
The meagre record of cases of simulation by the insane, to be found in 
the literature of psychiatry, may be due partly to the fact that the ne- 
cessity ot searching these cases out, has not been so imperative as the 
detection of feigning by the actually sane, who so often simulate insanity 
to defeat the ends of justice, and for other sinister purposes ; partly to the 
fact that proof of simulation, in the case of persons already adjudged to 
be insane, possesses no real, practical value ; but mainly to the fact, which 
I think observation has established and will continue to prove, that the 
insane do not, in general, assume either different degrees or forms of 
insanity from those with which they are actually afflicted. 
We might here paraphrase a familiar quotation, and say in mania 
veritas, for the lunatic is generally true to the promptings of, and mainly 
dominated by, his acquired, morbid nature. To the practised eye, a tinge 
of insanity colors nearly all that a general lunatic says or does, and it is 
doubtful if, in the acute stage of profound and constant general mania, 
the actually insane do ever simulate. The general insurrection and 
rebellion of all the ideational and emotional centres which seem to 
1 Dr. I. Ray, Remarks introductory to case of Bernard Gangly : American Journal of 
Insanity, July, 1865, SIMULATION OF INSANITY BY THE INSANE. 
1111 
characterize this form of mental alienation, the universal tumult into 
which all the faculties of the mind are at this time thrown, would seem 
to leave no room for the planning and contrivance essential to simulation, 
thou o'h it he never so imperfectly done. The assuming of a character 
different from the dominant and all absorbing morbid impulses of the 
individual would be contrary to all observation in acute, general mania, 
and is to my mind impossible, notwithstanding the existence,_ in this 
form of mental disease, of considerable method and shrewdness in plan- 
ning and executing in the direction of morbid fancies and molmations. 
To attempt simulation would only seem possible, it possible at all in tins 
form of mania, after the violence and excitement had passed away and 
the disturbed faculties had become comparatively calm, with the return 
of some decree of rational appreciation of acts committed and of 
penalties incurred, and to be avoided and with an obhv.ousness, on the 
part of the individual, of the fact of his insanity. Here the question 
would present itself as to the actual existence of insanity at the time of 
feigning, while its pre-existence might be readily conceded _ 
Feigning has the nature and quality of rationality, and is rarely, if 
ever, practised without a motive. It proceeds pnmafae,e from a rational 
mind: just as motiveless acts proceed from a mmd deranged; 
yet we know that all acts without motives are not the offspring of in- 
sanity, as we know that acts prompted by rational motive do not proceed 
from ihe sound mind only. We sometimes see however, a kind of un- 
conscious imitation, in some exceptional, morbid mental states, of psy- 
chopathic and neuropathic conditions seen m others, and occasionally 
a kind of simulation lacking the conscious element in real in an,ty-a 
mere freak of disease-which, however, is scarcely worthy to be called 
true simulation. The insane appear at times, when they have an object 
j u,„tl an(l different from, what they really are; 
IhuTthe L’sTrWhich we<us’e the term Bimulatiou’ and thi3 COndition 
18 Ofcou°r^hwVdoenoT find feigning in advanced general de- 
Ut eourse we v vain m the intervals and remis- 
mentia; hut we may _ mania; after the mania trausitoria; 
sums of recurren 01 p forms of what is called chronic, general 
possibly in certain s a ‘ mrtia] forms, the so-called monomanias ; and 
mama; in tbehystei < ‘ 0f insanity—the “manie sans delire” of 
m the moral or afleco Ibe hJin. that in that profound, general 
Pinel. Let me, howevei, repeat, io uo ]. » i-i dnnends mohablv 
involvement of the mind in disordered action, winch depends piobabiy 
involvement 01 tne _ . f tpe whole brain, and which we term 
upon more or less rmp c . pj seem an impossibility. The psy- 
acute, general mania, eig g Qne pand to simulation, and on the 
cbical conditions essential on ti i dLp-mp sppm 
other to the truthful acting out o ac is would not be sane enough 
inpommtihlp• the real victim of such a malady would i>toe .a ee uftn 
lo siZte! except during a so-called lucid interval, and comparative or 
ets:u“whTelrparSeesupres « degree of sainty, 1-not require 
that the patient should be fof 
by a convalescent P‘ the Tucspital or for some other reason. Supposed 
remaining louge to | c a case of acute, general mania, should 
feigning, m what « " ( 0f our diagnosis, and to review the steps 
ead us to suspect the con ectne the is actuJ 
ZaZ I am not Spared to say this much of other forms of mental 1112 
H UGHES, 
disease, except dementia. We may admit the possibility of subsequent 
feigning after the subsidence of a paroxysm of acute, general mania, and 
still hold to its general improbability, simulation being, as has been said, 
an attribute of sanity, just as is the existence of a reasonable motive, 
though both do often actuate the mind deranged. We should fall into 
a grave error, however, should we deny the possibility of other forms of 
insanity than those which I have excepted, being accompanied with 
either acts of feigning, or motives ; an error which facts of daily obser- 
vation among the insane fully prove. 
The government of insane-asylum households, as every physician 
knows, is conducted upon the idea that the insane, like the sane, though 
in a degree more or less modified by disease, are actuated by ordinary 
motives, and can be kept within certain rational limits of conduct and 
expression by the conditional rewards and inducements to correct be- 
havior there employed. The rude and indecorous often act with pro- 
priety when such a course is made the condition upon which they are 
permitted to take part in the amusements and religious exercises of the 
asylum, or to have other rational indulgences allowed them. Proper let- 
ters are written, and delusions suppressed by the writers thereof, in some 
instances, after the patients have learned that very insane letters are 
discountenanced by the superintendent, and returned to the writers for 
improvement in regard to their rational tenor. The love of absent wife 
or husband, father^son, or daughter, as the case may be, and the natural 
desire to communicate with them, sometimes leads to compliance with 
the superintendent’s somewhat compulsory request, and to the expunging 
of all evidences of insanity from their letters, by the patients themselves; 
and at this point the re-establishment of the rational exercise of volition, 
in restraining and refraining from the expression of morbid fancies, 
sometimes commences, and the patient’s convalescence begins. 
The fact, therefore, that the insane are more or less influenced by 
rational restraints and motives, like the sane, though in an impaired and 
lessened degree, would seem to need no further illustration. All who 
have much observed them, know that they are constantly induced to do 
the above and other acts which may result in benefit to themselves. 
They not unfrequently pretend to have abandoned cherished delusions, 
and to have entirely recovered their reason, with the view of securing a 
premature discharge from the asylum; and even good judges of insanity 
among medical superintendents have sometimes been deceived by the 
plausible pretences of such patients, who, failing to convince the asylum 
medical-officers, have sometimes succeeded in getting the hearing of 
courts, and have been released on writs of habeas corpus, only to convince 
every one, after a time, of their perfect fitness for perpetual restraint. 
_ The co-existence of insanity with the power of devising the most plau- 
sible explanations of erratic and insane conduct, is sometimes seen before 
courts of justice, as in the case of Col. M., District Attorney in one of 
the Southwestern States, under President Jackson, as detailed by Dr. 
Kay.1 Mr. M. entertained the delusion that he was cousin to the Duke 
of Wellington, and to Napoleon; he cut off his own nose, and, after the 
rhinoplastic operation had been performed, cut out the cicatrix on his 
forehead whence the nasal flap had been taken. “He was a passionate, 
dangerous lunatic,” according to Dr. Bell, and yet so plausible in expla- 
nation and extenuation of his conduct, and in defence of his personal 
1 Medical Jurisprudence of Insanity, 4th ed., p. 196. SIMULATION' OF INSANITY BY THE INSANE. 
anil w rights, that no asylum could hold, and no tribunal seriously 
celebrated suit of Wood v.Dr. Monroe, in England for false im- 
prisonment, as cited by Bueknill and other writers also illustrates how 
a really inskne person may succeed in concealing his mental weakness 
for a time from the most astute observers. The severest examination 
failed to detect Wood’s mental infirmity until be was asked what bad 
become of the Princess with whom be corresponded in cherry-juice, 
which immediately caused him to reveal his insanity and 1m lost his 
caso Discovering the cause of bis failure, he renewed the suit in Don- 
don,'and then alf the ingenuity of the bar, and the authority ot the 
court, could not elicit an exposure ot bis delusions, though he still enter- 
taThe Emulation of insanity would seem no more difficult than the 
nc3«nrrmtinn of sanity by the insane. It they can conceal, or explain 
kwav so as to deceive the best judges, mental defects which they actually 
postiss whf may they not assume abnormal traits which they do not 
Possess’ In the corridors of an insane asylum we sometimes see one 
lunatic'contemptuously or in sport caricaturing the whims and vaga- 
ries of another all the while fancying himself the sanest ot men, while 
he regards his brother lunatic as the simplest of simpletons, or the most 
knavish of knaves. “ Amidst our criminal population, too, are hundreds 
who can hardly be said to be sane and responsible, but who, in the lower 
ranks of life, commit a succession of crimes of no great magnitude, which 
lender then the almost perpetual inhabitants of jails. Some of them 
Ire so violent, outrageous, and destructive-so silly in their motiveless 
toy and so childish in mind-that we may call them imbecile or insane 
and have good grounds for our opinion.”1 These are the illy fed and 
dothed bfdly raised and housed, inhabitants of the densely populated 
riortions of our large cities, or the neglected children of drunken, ep.lep- 
or otherwise mentally maimed, parents, whose blood has been 
tic, 01 Otnen nicotine, and the noxious vapors usually 
poisoned with alcohol, ;bortionß come forth and grow up 
abounding he maturity At the maternal fount they drink 
into dwarfed ™ j e, Aly weil-never sound 
m disease, and ai - act out a natural life. When these human 
in mind and nev hood and womanhood, having led a life of 
abnormities glow p to pN,| them simulating insanity as 
deceit, we might reasonably expect incarcerated for, criminal acts, 
beiLTflhTwhilAnTonscious that they are already really victims of 
dlse^ea should rec^ve^more^retul^examumtmn^w^i^view to 
the-discover}7 of sunu a fact”pat sufficient search for them has not 
recorded may hej c actually insane not having, until a corn- 
been made, simulation by thecae % writers. p can recall the 
paratively iece“*J?®itiea’ more remote than Griesmger and Baillarger, 
ThTlaveAmlued tie possible co-existence of simulation with real 
lately “ 
Amirtan J*JnTo/ Insanity for 1863, but the most recent and unequiv- 
; Parle docleur ArmaadLaurent. Parie, 1866 1114 
HUGHES, 
ocal recognition of the fact of simulation conjoined with actual disease, 
by high authority, is to be found in the report of the case of Michael 
Trimbur, in the number of the same journal for October, 1874. 
It would be interesting to know what might have been the modifica- 
tion of Dr. Parchappe’s view of the mental condition of Lambert, whose 
case is reproduced by Di\ Ray,1 had the physician of the asylum at Rouen 
had in view the possibility of blended simulation with some remaining 
insanity. It will be remembered that Dr. Parchappe pronounced the case 
one of simulation of unconsciousness, after the prisoner had come to him- 
self, in older the better to escape responsibility for his acts, he having, in a 
paioxysm, induced either by the virus or by the fear of hydrophobia, mur- 
dered his mistress and another woman without provocation, and giving 
as a justification for the homicidal act, in regard to the former of his vic- 
tims, the insane reason that he desired to bestow her money in charity, 
which, he said, she would never have done had she lived. On the day of 
the murder, Lambert admitted killing his mistress, and repeatedly 
exclaimed, “ Jesus my God, my fortune is made,” and begged his captors 
to release him because, he said, he “ had eight more murders to commit.” 
On the following day he denied having killed his mistress, but said “ if 
I did, Ido not remember it. Four days after the murder he recognized 
the hatchet with which he had done the deed, but denied all knowledge 
of the murder. Ido not offer this as certainly a case of simulation con- 
joined with insanity. It may or may not have been such, and, as my 
pin pose is lather to elicit discussion than to advance positive opinions, 
I have deemed an allusion to it not out of place. Dr. Ray, in summino’ 
up this case, concludes that it was one of feigned insanity, while Dr. 
Parchappe, as w?e have seen, thought that it was an example of simula- 
tion aftei lecovery. May not the simulation have begun before recovery 
had been completed, after a realization, upon the part of Lambert, that 
Lg had committed heinous crimes from the penalty of which there 
appeared to him no escape, except in assuming unconsciousness of his 
acts ? 
Cases like that of the criminal in the prison at St. Ange, as related by 
Prof. Monteggiaand translated by Marc and Ray, and like that of Samuel 
S. Rich,2 which occurred in this country, come to mind, in this connec- 
tion, as having shown perhaps phases of simulation, which might have 
been ie\ealed had the possibility of simulation co-existing with insanity 
been entertained by the profession in those times. There was no history 
ppbepsy in the case related by Prof. Monteggia, and though no such 
rigid search could have then been made for epileptiform complication as 
would be made now, there is not the slightest suggestion of anythiuo- of 
this character in the history of the case as it has come down to us. 
It may not be transcending the limits of scientific propriety, to sug- 
gest simulation in connection with real insanity as a possible explanation 
of some of the features of the famous case of Joseph Waltz,3 still fresh in 
the minds of all. There was undoubtedly simulation, and it was most 
bunglingly done ; Waltz pretended to be suffering from dementia, which 
was certainly not the case. His “don’t know” answers, made so often 
to interrogatories concerning facts which he clearly knew (such as the 
names of his mother and father, and his own age), and the post-mortem 
examination, clearly prove this point. 
1 Op. cit., p. 415. 
3 Ibid., July, 1874. 
2 American Journal of Insanity, April, 1860. SIMULATION OF INSANITY BY THE INSANE. 
1115 
Just here the thought occurs, that when equally honest and expe- 
rienced experts view a case, which they have had equal opportunities 
of observing; on the one hand as one of insanity, and on the other as 
wholly one of feigning, it may be reasonable to look for coexistent simu- 
lation and real disease, to explain the discrepancy of opinion, ihe case 
of Waltz also suggests another possibility, viz., that in some cases, the 
eao-erness of "counsel to make out a case of insanity from too meagre data, 
aided unintentionally by the suggestive questionings of the physicians 
who visit the prisoner at the counsel's request, may sometimes lead a 
prisoner, not in the beginning so disposed, to attempt feigning; and that 
if the sane may thus obtain an idea that simulation can be successfully 
Practised we need not be surprised to see the same thing undertaken by 
some real though not pronounced, lunatics. 
In a letter from Dr. Bucknill, referring to the case of Jesse Pomeroy, 
whom Dr B had visited with Dr. Edward Clarke in the jail at Boston in 
Anril 1875 the writer says “ some physicians had suggested concealed 
enilensv ’ as the cause of this boy’s blood-thirsty propensities, and 
Dul miestioned him as to the existence of an aura. Whether this boy 
had dea into his head or not I know not,, but he told Dr. Clarke 
and myself that he often had the feeling hat a light leather was drawn 
across his forehead from one temple to the other. Now,as Di. Claike 
remarked to me at the time, this is not the accurate description of an aura, 
which follows the course of nerves.” 
“Generally after the acute stage has passed off, a maniac has no 
difficulty in remembering his friends and acquaintances, the places he 
has been accustomed to frequent, names, dates and events, and the 
occurrences of his life. The ordinary relations of things are, with some 
exceptions, as easily and clearly perceived as ever and his discrimina- 
tion of character seems to be marked by his usual shrewdness ■ H,s 
replies to questions may or may not indicate delusions or other extrava- 
gances of thought, while his whole demeanor and conversation may 
ttaices it is not difficult to S 
oro“hL"ri^Which1 knows that he has’been seen toTornmit, and 
from the penalty of which there seems to him no escape except through 
iiom me penaiiy to simulate such a form of insanity 
the plea of insanity, might conclude . c y nersou raio-ht 
as in his opinion would secure his exculpation, buch a peison mioht 
afe 1 , ],;s own real mental disease, and might 
not believe in the existence oi ms ov\ u ■ inorednlmm . 
fear that those who were to try him would be equally incredulous , the 
teai mat mose ~ ;-10a8 0f the extent and degree of their 
insane are not generally cons _ , tu existence of a sufficient 
mental derangement. Admitting, then, the existence ot a sumcient 
mental aeranBei insane person, to prompt to an effort at self- 
degree of rationality, man msa. K . pi nrohahlv „„nmp „ 
u reservation through the act of feigning, would He probably assume a 
pieseivation tnro » mpntai disorder, inst as sane men usually do 
more exaggeratedXmm of' munUi d and with the'ks- 
with the view ofnakm a doteetion ? We cannot reason out an 
tomary result °L°TLn l.nf practical illustrations are too few to enable 
answer to this question, ana 
us to generalize on an inmate of an asylum, would 
there haw opportunity to become familiar with the ordinary character- 
1 Ray, op. cit., p. 390. 1116 
istics of insanity, and would not, I think, be so likely to assume the 
tragic and exaggerated forms of madness, as one more ignorant. His 
capacity to successfully reproduce what he had observed in the asylum, 
would depend upon the degree of mental soundness existing in him at 
the time at which he had been an inmate, and remaining with him at 
the time of attempted feigning. Insanity is a crippled, rather than a 
destroyed, or obliterated, mentality. 
liorn the nature ot insanity, we see that feigning is possible oftener 
than it k shown by experience to occur in connection with the usual 
forms of the disease. Insanity is an impairment of one or more of the 
mental faculties, by reason of disease involving the brain ;’and as it may 
exist in every degree, observing the same pathological laws as any other 
disease, it is evident that acts which in themselves are rational in cha- 
racter, may be done by the insane. A sick man is seldom so sick, unless 
it be in the last and hopeless stage of his malady, that he can do none of 
the acta which he could perform when well. Among the acts, therefore, 
which the insane must be deemed capable of performing, we must include 
simulation. It is not uncommon for the healthy human mind to dis- 
semble, especially in civilized life; and this natural trait does not always 
wholly forsake the mind diseased, though it must be confessed that the 
insane wear less of a mask than the mentally sound, and thus we come 
again to the general truth as applied to the insane, in mania veritas. 
feome exceptions to this rule have come to my notice, and further obser- 
vation may discover more; but not enough to invalidate the rule as 
applied to insanity in general: JExceptio probat regulum. A mental phe- 
nomenon worthy of note here, but not germane to the subject, is the 
unconscious or semi-conscious imitation, rather than simulation, of in- 
sanity, which is displayed on certain occasions by those who largely in- 
herit the insane neurosis. It consists in a sort of sympathetic takino*-on 
of an evanescent form of insanity by other members of a family, under 
£'f.at excitement, as when one of their number has become profoundly 
afflicted with some marked form of mental disorder. A father or mother, 
for instance, brings to the asylum a son or daughter, when, from the ex- 
aggeiated and unnatural conduct of the parent, aside from the natural 
manifestation of grief to be looked for on such an occasion, but which is 
sometimes wanting, the superintendent finds it difficult to determine 
which for the time acts the most insanely, parent or child. The conduct 
of the parent appears anything but rational, yet a return to home, di- 
vested, in a measure, of anxiety and the weariness of watching, with a 
season of rest and sleep, and better appetite and digestion, suffice to re- 
store the disturbed balance of the mental faculties, and the parent, by 
reason of regular life and habits, escapes the affliction of positive insanity, 
though possessing and transmitting a neuropathic diathesis but one re- 
move from it. 
HUGHES, 
Insanity, as Prichard observes, sometimes co-exists with an apparently 
unimpaired state of the intellectual faculties; though “the ideational 
poi tion of the faculties, as Blandford remarks, “is so intimately joined to 
the emotional,that the two must be sound together, or unsound together.” 
Admitting the existence of so slight an intellectual in cer- 
tain kinds of insanity, that the intellectual lesion is more theoretical 
t lan apparent, it is easy in such cases to concede the possibility of simu- 
ation on the part of the patient, to extenuate erratic and immoral con- 
duct, the result of disease. The subjects of moral insanity sometimes 
simulate inebriety, as well as insanity, to palliate and excuse what ap- SIMULATION OF INSANITY BY THE INSANE. 
1117 
pears to them and to others, not expert in detecting mental aberration, 
inexcusable conduct. The case of Col. M., already alluded to, was one 
of this kind- many of his freaks were excused and explained away, 
when they could not he denied, upon the plea that he had drunk a little 
too much on that particulai occasion. . . ~ . 
It is not easy to perfectly imitate diseases involving the mind in dis- 
order notwithstanding that Zacchias has said that feigning is easy, and 
detection difficult. The unconscious “ method that is in madness, the 
. . i consistent reference to the predominant idea, which the 
La\ oliv tteots amidst the greyest irregularity of conduct 
and iano-uace requires all the mental faculties in their fullest vigor, 
and unimpaired bv discase, for successful personation, and is then rarely 
r ii LAn-nPfl before the eye ol the physician who is experienced 
“S till''true taihls of morbid Lhality. While, therefore, 
we nnv concede the possibility of occasional successful feigning by the 
mind'in full possession of all of its faculties, we should not expect the 
crippled mind of an insane person to deceive us, and the fact of simula- 
tion being detected should not preclude the possibility of co-existing 
Dr" Kay oflhe case of Trimbur* says ; “ The criminal 
classes to which most of these sirau ators belong, know as well as every- 
body else that %%%?£ 
™ra3eindyPwhen they become insane themselves.” This was the 
acr accoi - y « being unconscious ot his own real insanity, 
buTwith mind enough’to understand his situation and to remember 
what he had heard about insanity in connection with crime, concluded 
toT^edhhSwing case,'communicated to the writer by Dr. Joseph Work- 
% Invyears the distinguished medical superintendent of the 
man, for many y Asylum, seems equally illustrative ot blended 
“ioW^Sfand, as it has nlver been published. I give it 
here in Dr. Workman’s words:— 
, „,yn t met fsays Dr. Workman] with a case of 
Some ten or.twelve^' <■ murdered his wife. He had previously 
genuine simulation . t r w]ieil he undoubtedly was insane, 
been a patient under my ca« e, lto about ay recovered, he eloped. I did 
Just as I was on the pom ■ him. °He went home to his farm, and got on 
not use much exertion to i P , • forra Gf jealousy of his wife, which, 
well until his insanity re nr ’ge‘legs = one day, in the sugaring season, in the 
I need not say, was utt V - fire Wood. He was apprehended—did not in 
hush, he killed her wit i‘ crime, and was tried at the next assizes. I 
fact try to escape ad a . and pad a long interview with him in the 
was summoned as an exPe at’first glance, and asked him if he did not 
jail before the trial. 1 knew bun did not tMnk that he had 
remember me. He sai „ T -d u you must remember me well; you lived 
ever seen me. Why .J°i iW i and talked with me hundreds of 
in the same house wit y n vlum ?” No! He had no such recollection, 
times. You remember ein= had deen there. “ Well, you have not forgotten 
but people had told hu steward?” He did not know him at all, and so on 
your old friend Mr. r had‘the most thorough conviction of this man’s 
throughout all our col oq v. - and at the same time of his insanity 
rsii i ***bom.»the JB,y. H. was 
1 Ray, op. cit., p. 388. 
2 American Journal of Insanity, October, 1874. 1118 
HUGHES 
acquitted on the ground of insanity, and was committed to the asylum for 
criminals, at Kingston, where he is still detained. 
Iwo or three years after his trial, as I was passing through the asylum in 
company with the medical superintendent, a patient stepped up and held out 
lus hand, addressing me very courteously, and inquiring after all my family. 
1 did not recognize him until the medical superintendent told me that he was 
my old friend J. C. “Oh ! John,” said I, “how is it that you know me so well 
to-day, but did not know me at all in Guelph jail ?” His reply was “ I did 
not want to know you that time.” This man had certainly a very powerful 
motive for simulation of mental frailty, but he played his part too unskilfully 
to impose on my credulity. Jealousy was not the cause, but the form of his 
insanity, and when he had forever got rid of the subject of his delusions, a 
sober after-thought assumed the government. He was, as I believed, still in- 
sane, yet possessing that degree of stupid cunning which not a few sane people 
evince. He knew that he would be hanged unless acquitted on the ground of 
insanity, for in Canada murderers generally have but little chance of escaping 
the death-penalty. Had he been thoroughly sane, he would have known that 
sufficient proof of his past insanity, both in the asylum and afterwards, could 
have been produced, and he would have abstained from his clumsv simulation, 
or he would have acted his part more cleverly. I could not say that he com- 
mitted the common error of simulation—overdoing his work. He did not rave 
babble, or declaim, or indulge in foolish antics and grimaces. 
In criminal cases, when an individual, in whom there exists undoubted 
evidence of mental disease, actually pretends to have a form or symp- 
toms of mental disorder not in harmony with the kind of insanity which 
actually afflicts him, or not in the natural course of his disease, the pre- 
sumption is reasonable that there also exists in him a sufficient decree 
o± rational volition and appreciation of surroundings to modify the de- 
giee of his responsibility to law. The perplexing question then arises as 
to whether the individual’s state of mind at the time of feigning be the 
same that it was at the time of violating the law; the presumption is in 
favor of a clearer mind at the time of the simulation than at the height 
of the insanity, and this appears to have been the case with Dr. Work- 
man s patient. The mind disturbed by disease, varies in the intensity 
and degree of its disordered manifestations at different times, even as 
the healthy mind is known to vary on different occasions in the display 
of its natural peculiarities and powers. 
Other questions are here presented, of a medico-legal character, relative 
t™uia responsibility and testamentary capacity in certain cases 
which, in the present state of our knowledge of psychology, cannot be 
satisfactorily answered in general terms. Eminent alienists all admit, 
in the abstract, the existence of different and variable degrees of rational 
capacity and responsibility in mental disorder. There are, as Locke 
says “degrees of madness as there are of folly,” but to determine pre- 
cisely what amount of impaired mind-power exists in particular cases, 
may often puzzle the most learned and experienced psychological experts. 
Ihe law has attempted to cut the Gordian knot, to untie which has so 
long baffled the most thorough students of the mind diseased, by deciding 
that the capacity to distinguish right from wrong, should settle the 
question of responsibility to law in criminal cases; but practically we 
know that an individual may clearly know right from wrono-, and yet 
under the overpowering influence of cerebral disease, be irresistibly im- 
pelled to do the wrongs The importunities of the insane to be restrained, 
.en, suggestions of violence, prompted by morbid states of the brain 
arise in the mind, and when the patient’s own recollection of his past SIMULATION OF INSANITY BY THE INSANE. 
1119 
experience teaches him that resistance to his insane impulses beyond a 
pertain limit is impossible, are familiar to all accustomed to come much 
iu contact with the insane in asylums. The physiological fact of uncon- 
scious cerebration is applicable to the mental operations in disease, as 
as in health, and to many acts of the insane, especially of the epi- 
leptic class, but certainly not to all. The legal test therefore fails, and 
Indeed it has been much qualified of late in the rulings of the courts. 
re must concede, however, that this test can be justly extended much 
further than at first blush would appear to be proper, for unconscious 
cerebration in a paroxysm of insane fury would save many a lunatic who, 
a short time before or after, would fully comprehend the nature and 
quality of his acts. 
The facts admitted in this digression would tend to prove the possi- 
bility of simulation by the insane, even it it were not.established by expe- 
rience; knowing, as many insane persons do, that they have unconscious 
states in which their irresponsibility is conceded by all, it would not be 
strange for an insane man to pretend to have been in such a state, when 
be really had not, to escape censure or punishment for some act which 
he knows that he ought not to have done, and the impulse to do which 
be knows that he could have resisted. Ido not now allude to those acts 
of the insane which, from their history, we might expect them to com- 
mit, such for instance as suicide in the suicidal form of madness, homicide 
in the homicidal, burning in the pyromaniacal, stealing in the kleptoma- 
niacal, etc. 
There is one fact which might in some instances deter insane persons 
from feigning, even when the disposition and capacity existed, and that 
is the knowledge which they possess of the estimation in which they are 
held, as irresponsible. Who, accustomed to live with the insane and thus 
made familiar with their true character, does not know how keenly con- 
scious they are of the existence of this erroneous estimate of. their real 
condition as regards responsibility, removed, as they are in the asylum, 
from those sources of irritation which have caused, or which tend to 
keep fresh opened, their mental wounds? A patient once told me that 
be would have his liberty, or kill me. I said, “ I hen you would be 
hanged.” He answered, “ They could not do that, lam insane.” “ But,” 
said I, “you would not be insane on that subject. You know it would 
be wrong, and your insanity is not homicidal,’ He said, and said truly, 
“ Yo jury would ever hang a lunatic for anything that he might do in an 
insane asylum.” Hot being able thus to intimidate him, I approached 
him ever afterwards with caution, and always dodged, when practicable, 
the discussion of the question of his personal liberty. This patient used 
the word lunatic sneeringly, for, though admitting that he was pot al- 
ways right in his mind, he did not consider himself seriously insane, 
though, at times, he was realty very much so, his paioxysms of excite- 
ment lasting many days at a time. It is easy to conceive of circum- 
stances under which such a patient might simulate, as well as rely upon, 
his reputation for insanity. 
The .fact of unconscious cerebration, befoie alluded to, as we see it 
manifested in cases of hysteria, mingled with conscious and partly 
volitional, mental activity, explains the simulation of real insanity 
which sometimes co-exists with this singular morbid state. In hysterical 
insanity, there seems to be a morbid desire to act out actually control- 
lable vagaries, as well as those realty insane promptings which are beyond 
the control of the will. The insane of hysterical tendencies often act in 1120 
HUGHES 
a seemingly controllable, but very insane, manner, apparently through a 
morbid craving for extraordinary sympathy and attention. Occasionally, 
however, their actions are apparently wholly motiveless, as with other 
and aggravated forms of insanity. 
Though simulation is rarely practised without motive, it is possible 
tor the to be sometimes a very foolish one, and, while it may 
be unaccompanied by delusion, yet scarcely explainable upon the hypo- 
thesis of perfect sanity. Such a case would lead to great perplexity in 
the mind of the physician. 
. The egotistic feeling so often uppermost in the mind diseased, caus- 
ing the insane to seek in so many ways to attract attention, or excite 
wonder and commiseration, is only an exaggeration of a not uncommon, 
natural trait of rational minds. It may be doubted whether the case re- 
ported by Dr. Dell, an abstract of which may be found in Dr. Ray’s1 excel- 
-11 WOS °‘‘ tlbe. jurisprudence of insanity, was without real disease as 
well as blended simulation. Dr. Ray, in introducing the case, regards it 
as ‘ somewhat curious, considering the youth of the subject, the apparent 
want or motive, and the severity of the symptoms.” 
1 ie lad, thirteen years old, had fallen on his head two years previous to 
admission, and ever since that period had exhibited some anomalous symptoms 
ol disease, which had been referred by his physicians to derangement of the 
digestive organs. For the last few months, the symptoms had been more 
severe and decided. He had refused food for long periods, had had spasms, 
had lain with Ins eyes fixed and his legs drawn up, would hold his breath and 
strike. On admission to the asylum, he presented the appearance of a sickly, 
emaciated boy, under puberty, unable to stand, exhausted by suffering, breath- 
mg quickly, and passing his evacuations in bed. Every few minutes lie had a 
frightful spasm, commencing with a convulsive shaking of the head, pawing of 
tie hands, and turning up ol the eyes. Soon his hands would vibrate against 
ns sides and chest, his countenance would be dreadfully distorted, ancf then 
would commence a horrid scream that might be heard over the whole premises, 
in this condition, with occasional remissions, and the addition, at one time of 
diarrhoea, he remained for about a month. . . . Being watched through a 
hole in a blanket hung before his window, he was observed to jump up and 
stride about his room as actively as any body, but at the slightest noise 
lesumed his old position, screaming and groaning. 
„ Di: BgII broke in upon him before he could regain his bed, chided him 
for his deceit, and bade him walk into the hall. “ The spell is broken,” 
says the record, “ the feeble knees are made strong, the convulsed and 
distorted visage is calm and smooth, and the young deceiver goes forth 
clothed and in his right mind.” Dr. Chipley, commenting on this case,2 
says, “ We can scarcely conceive that one would assume a character so 
painful to sustain, without some deliberate purpose, or an end to be accom- 
plished ; and yet no motive such as might be supposed to actuate the 
rational mind, is at all apparent in this case. The fact of the boy’s hav- 
nig retrained from his usual manifestations on the unexpected appearance 
ol Dr. Dell, whom he doubtless held in no small degree of awe as the all- 
powerful head ol the establishment, while it proves a power of control 
over the actions under great external influences, and is strongly presump- 
tive ol feigning, does not, to my mind, conclusively establish the fact of 
entire sanity. There nothing absolutely incompatible with insanity 
in sudden cessation of its symptomatic manifestations. If this youth 
1 Op. cit., p. 405. 
2 American Journal of Insanity, July, 1865. SIMULATION OF INSANITY BY THE INSANE. 
1121 
Was willing to make sucli continued, great, and painful saciifices of com- 
fort and character for the ridiculous and unreasonable purpose of exciting 
Wonder and commiseration, such a motive,_ coupled with the youth’s 
history and all the attendant circumstances, is well calculated to excite 
our suspicions as to his entire mental soundness. There were at the 
time, doubtless, others in the hospital more insane than this boy, and 
perhaps others, regarded as undoubtedly insane, who were fully as rational 
ag he. A o-ood deal of sanity may still exist among those who are too 
insane to mingle with the rational woild. 
Visitors passing through the corridors of a hospital for the insane, 
often remark this fact, and the asylum-officers are often asked why cer- 
tain patients are restrained of their liberty, because of their presenting 
to the casual observer so little appearance of insanity. So proper are the 
manners and conversation of patients, at times, that an unfounded dis- 
trust of public hospitals for the insane has sometimes been engendered in 
the public mind from this source—the insane themselves behaving so 
Well in the presence of visitors, and at other times, under the present 
wise and scientific system of classification, medical and moral manage- 
ment, and restraint-—the latter, in this country as in England, hardly 
exceeding non-restraint. , . . 
It would unduly lengthen this paper to detail the many instances which 
might be gathered of insane persons, on certain great occasions which 
made profound impressions upon their minds, having behaved with unac- 
customed propriety, and having suspended for the time-being all manifes- 
tations of insanity, or to mention instances of great and unexpected events 
having been the beginning of recovery. Every one accustomed to the care 
of large bodies of the insane, knows that grand and unusual occurrences, 
which would startle and profoundly impress the rational mind, sometimes 
favorably impress the insane, notwithstanding that, in the mam, they 
are either regarded with indifference, or cause aggravation of existing 
excitement. Some instances in point might he mentioned in connection 
with the burning of asylums. No such event has ever happened in ray 
own experience, but the burning of a large stable and barn on the asylum 
premises at Fulton, early one evening, m lull view of a good portion of 
The patients, gave opportunity to witness, in some degree, the different 
conduct of different lunatics under such circumstances. A very few o 
the patients were more excited than usual, ie majoi i y weie iik i eren , 
and some gave us valuable aid in our efforts to suppress the flames and 
a The coercive methods of treatment, recommended and practised by 
Celsus, demonstrated the power of self-restraint in some cases, under 
the influence of overmastering fear; and ... our own day hrea s and 
punishments, though for obvious reasons neither practised nor advised 
as curative agencies, are not without some influence in subduing some 
refractory and noisy patients into submissive offence, as may he learned 
by visiting some of the almshouses and jails to which many ot these 
unfortunates are vet consigned in the United States. It may be con- 
ceded that to be influenced by fear to such an extent as to suspend all 
display of insanity is, in some cases, good evidence of feigning; bat it 
nus not hi“ w«ried in all. FoiM has been criticized, by a writer 
from whom I have already quoted,-for having relied upon the test of 
fear in the case of a female, who acted her part, if she were only acting, 
1 Dr Chipley, American Journal of Insanity, July, 1865. 1122 
HUGHES, 
so perfectly that the doctor was on the point of certifying the case. He 
returned to her door, however, and said with a stern voice, “ To-morroW 
I will visit her again, and if she continue to howl, if she be not dressed, 
and her chamber not put in order, you must apply a red-hot iron between 
her shoulders.” He found things in order the next morning, and on 
this proof alone, with strong evidence to the contrary, immediately de- 
cided that it was a case of simulation. “But was this decision justified, 
asks the writer, “ by the simple fact that the patient changed her con- 
duct under the terror inspired by severe threats ?” And he answers the 
question by referring to the self-control exercised by patients under the 
influence of fear, or the hope of reward. The potency of authority in 
suddenly suppressing through fear all appearances of mental derange- 
ment in those who are really insane, is, of course, exceptional; I can 
hardly conceive of such instrumentalities being successful in aggravated 
cases of general cerebro-mental disease, yet their occasional influence in 
controlling the less general forms of insanity, especially where simula- 
tion co-exists, is not to be doubted. 
In hospitals for the insane, the power of one having authority is some- 
times shown in the restraint which some patients put upon morbid and 
quasi-morbid displays, in the presence of the chief physician, and the 
arrest of paroxysms of hysteria by commands and threats, before the 
disease has reached the point of recognized insanity, is nothing new to 
the profession at large. This characteristic of partial control under 
ordinary circumstances, reaching the point of entire control under 
extraordinary circumstances, in cases of hysterical insanity, is too 
familiar to the profession to need further notice; it extends also, as X 
have endeavored to show, to other cases. 
The power of self-restraint implies the power of simulation. Hys- 
terical patients are undoubtedly more prone than others to “put an 
antic disposition on,” as Hamlet has it, and are more disposed to act 
insanely than to exercise aright what power they really possess of at 
least restraining within more rational bounds the ridiculous displays 
which they often make. 
The following case presents, I think, some interesting features:—■ 
Reuben S., set. 25, married, of limited education and of intellect below the 
average,1 with a history of domestic infelicity, masturbation, and three weeks’ 
insanity before admission, entered the Missouri State Lunatic Asylum on 
April 6, 1867, and was discharged, recovered, on November 15 of the same 
year. He had been an attache of a sort of travelling circus, and theatrical 
and minstrel troupe, before the development of his insanity. After becoming 
insane, he had been seized with a sudden desire to preach, and, securing an 
audience in one of the country towns of Missouri, he conducted the services 
in such an obscene, blasphemous, and outrageous manner, that he was driven 
from the pulpit. His insanity becoming apparent to the neighborhood soon 
after, he was sent to the asylum. 
At the asylum he endeavored to preach in the same way, but being put into 
an empty, quiet room, with a single window looking out on the lawn, and no 
audience, he soon grew tired of addressing vacancy, and changed his perform- 
ances to tearing up his bedding and clothing, and soiling the walls and floor 
of his room. His occupation in the corridor changed to negro minstrelsy of 
the most ridiculously insane character, mingled with some really good hits at 
men and things which he had learned. He was fond of applause, and much 
1 I doubt this statement as to his natural intellect. His history was not given by near 
relatives or by those who had known him long. SIMULATION OF INSANITY BY THE INSANE. 
1123 
encouraged when he excited laughter. The manner and intensity of his per- 
formances could be very much varied by our signification of approval or dis- 
approval. He would seriously hurt himself, if permitted, in his attempted 
feats of ground and lofty tumbling. I never had the slightest doubt of his 
insanity, and have not to this day. 
This patient’s propensity for acting, after he had come to eat and sleep well, 
gradually wore off, but, during his convalescence, the least encouragement 
from officers or attendants would start him to performing. To keep him 
quiet it was necessary that no notice should be taken of his antics, and the 
attendants were instructed accordingly. After his discharge from the asylum, 
he went to a distant part of the State, but soon returned to Fulton, and en- 
gao-ed in the business of a barber. He did not change his name, but denied 
ever having been in the asylum, though all the attendants knew him as our 
former patient and often met him. He conducted his business properly 
enoimh as far as I know, but the attendants who visited him, none of whom 
he would ever recognize, still thought him insane. It soon got noised about 
that he had been an inmate of the asylum, and he and his brother, who was 
also his partner, left for other parts. _ . 
There was no reason for believing this man to be wholly feigning. There were 
no charo-es of any kind against him, and no friends were interested in having 
him shielded from any punishment; moreover, he made several clever attempts 
to*escape, at one time remaining away for a whole day before being recaptured. 
It is true that his performances were mainly given when he could get an audi- 
ence and were prompted by love of applause and notice; but he slept very 
little’ when not narcotized, and occupied himself at all hours of the night in 
teariim his blankets, littering his room with straw, and doing every conceivable 
mischief in addition to soiling his room and person. Before we had concluded 
to employ the necessary restraint, he was always doing something ludicrous 
or destructive and the poor fellow’s antics and appearance excited more 
laughter than’any other patient on the male side of the house. When he 
came to the asylum he was extremely emaciated, indifferent to food, and, 
indeed to everything except notice and applause. Egotism was constantly 
uppermost with him. His pulse was quick, and he was never known to be 
Quiet while awake. As he convalesced he grew quiet and thoughtful, his pulse 
became slower, and he slept better, and improved in appetite and flesh. 
This case was certainly a remarkable one; Could any conceivable 
motive have been found, we should have suspected simple feigning. The 
patient was evidently not aware that he was acting the part of a lunatic 
to an audience of insane persons, and in this respect the case differs from 
others, the simulator, sane or insane, generally appieciatmg, in some 
degree, the nature and extent of his acting and surroundings Still the 
case serves to show the power which the insane possess of acting some- 
what for a purpose, much after the manner of othei people. 
Though a mania for display is not uncommon with the insane, its ap- 
preciable modification by the applause or disapproval of those about he 
patient would be taken, in most instances for pure feigning without the 
co-existence of rerebral disease. Everythin* in tins case but the one 
fact of the patient’s acting most insanely when most observed contra- 
dieted the notion of feigning. His physical condition, his antecedent 
history the nature of his acts, and, after recovery, his changed demeanor, 
all pointed to the existence of real insanity. 
I turn now briefly to a class of cases regarded by many as more devilish 
than lunatic, viz., the morally insane; who know how they are con- 
sidered and why they are in the asylum, and who take advantage of 
their reputed insanity to do many things from which they might perhaps 
refrain if they chose, but to which disease really prompts them. They 1124 
HUGHES, 
sometimes pretend to a degree of intellectual impairment not natural to 
them in their diseased condition. 
These patients know where they are and why they are there, and to a 
certain extent are able to behave themselves with propriety when motives 
are powerful enough to induce them to do so, particularly under the 
absolute authority which they know that they have over them at the 
asylum—exercised, it is true, in the mildest and least irritating way, but 
usually with firmness and certainty. At home, with those whom they have 
been accustomed to manage, they are uncontrollable, and behave them- 
selves like very devils, so that they get no sympathy. The world outside 
does not understand them, and cannot get along with them, and indeed 
those in charge of asylums wish that these patients could be cared for 
elsewhere. 
With distorted views of men and things about them, just short of 
delusion; dissatisfied and suspicious, often without the shadow of a 
cause; sometimes devoid of affection and gratitude; sleeping and eating 
poorly ; never in a state of mental composure, but always quarrelling 
with the cook, the laundress, the attendants, or some fellow-patient ; 
with bowels often habitually constipated, circulation disturbed, and 
general appearance of ill health, if these patients are insane—and I think 
that they are—they can also simulate to an aggravating degree, when 
it serves their purpose, abnormal mental states not actually existing in 
them. 
rihe possibility of self-control under exceptionally powerful external 
influences coming to the aid of the will of persons reputed to be insane, 
does not preclude all possibility of the existence of real insanity. A 
more or less modified power of self-control exists in the incubative stage 
of most forms of insanity, even under ordinary circumstances, and per- 
sists oftentimes until the case has passed into the form of final and hope- 
less After recovery, our patients sometimes tell us bow they 
resisted morbid promptings to extravagant words and conduct, before 
these found unwilling and resistless expression. Suicides and homicides 
by the insane are seldom without premonitory preparations, threaten- 
ings, and warnings, and much of the freedom of intercourse, coupled 
with safety, of asylum-life is due to this fact. Even in cases of well- 
advanced insanity, morbid impulses of various kinds are sometimes long 
and repeatedly resisted before their final consummation. 
The power to restrain and suppress insane promptings, so frequently 
exhibited by the insane, implies the power to simulate the features of 
insanity. In all asylums for the insane, there are chronic cases in which 
the original delusion, though still persisting, ceases to dominate the pa- 
tient as in the beginning—cases in which the aggravated demonstrations 
nnd exclamations of the patient are disproportionate to his delusion. 
The insane man’s oft-repeated actions and expressions become a sort of 
second nature, as habit becomes with the sane. There is a kind of 
automatic simulation here; these patients act out a state of feeling 
which is not real to them. If once tormented with a painful delusion*, 
they cease to suffer as acutely as in the beginning, if they suffer at all, 
and their attention is more easily diverted from self. 
Our asylums afford many examples in which the patients, yielding 
more or less to their delusions, also more or less modify or suspend the 
expression of them. This fact is illustrated and recognized in the moral 
treatment of the insane. Even sane persons are not free from dis- 
simulation, and while insanity in the main reverses the natural charac- SIMULATION OF INSANITY BY THE INSANE. 
1125 
ter it sometimes throws off the natural disguise put upon the conduct 
and conversation in health; thus we may find the natural disposition 
to dissemble in not very profound forms of mental disease, displaying 
itself less guardedly than in health. Hysteria is_ an apt illustration of 
this fact both before and after it becomes actual insanity. 
The insane like the sane, though on the whole more truthful than the 
latter are not always and altogether what they seem in acting out their 
real psychic impulses. They are sometimes more crazy than they appear, 
and sometimes appear more insane than they really are. We have gene- 
rally to scrutinize an insane character closely to fully comprehend it. 
Esquirol’s estimate of the value of constant observation, m order to 
become familiar with the subject, expressed very nearly the truth : We 
must live with them to fully know them Simulation of insanity may 
exist in connection with actual psychical defect, the result of disease of 
the brain, just as disease of the stomach, lungs or other organ, may be 
accompanied with a greater or less degree of healthy function On y 
death obliterates and destroys aU function, while disease, short of death, 
modifies and perverts organic activity. . , ~ 
Phvqirnl disease involving the so-called physical organs in contradis- 
tinction to the organ of the mind, is not always or usually entire physi- 
cal destruction; and so disease involving the mind and its organ, is not 
always or usually entire mental overthrow or obliteration; rather is the 
latter the exception, than the rule. Do we not therefore, err it we seek 
to find in every case of apparent mental aberration all simulation, or all 
insanity ? Is there anything in the nature of insanity as we recognize 
its different forms, incompatible with simulation? I think not, except 
it be in profound and advanced general mama and dementia ; and from 
this cursory survey of a field which grows wider as we view it I con- 
clude that it is not only not impossible for the insane to simulate in- 
sanity, for a purpose, in any but its graver forms of profound general 
mental involvement, but that they do sometimes actually simulate acts 
nnd forms of insanity for which there exists no pathological warrant 
ftattn be discoverel in the real disease by which they are affected. 
Discussion on Db. Hughes’s Paper. 
After the reading of the preceding paper, Dr. Isaac Bay, of Philadelphia, 
said—Until the present century, insanity was seldom put forth as an excise 
fo crime Its frequent occurrence in our day has made it a duty ol phy- 
sicians to make themselves acquainted with its phenomena far more aeon- 
S than was before required. It often becomes their duty to say, m a 
matter of life or death, whether a certain person is sane or apparently insane, 
Si latter, whe her the apparent insanity is real or simulated. Most 
of the insane know as well as other people that insanity is an excuse for 
crime and here t no reason why they may not strive to use it as such 
dime, ana ye • ■ „ some manifestations of the disease over and 
when occasion calls by tog ""S « ticulal. fonn 0f the malady. To do 
above those be ong ;» . j and self-command than it does to conceal 
"S”: aTtbey somSes do. The fact that they are already 
then delusior , { the need of simulation, for the well-known reason 
raat”t‘heCtine’kCiiny do ilot recognize their own infirmity To them, the 
need of the'excuse seems just as strong and just as apparent as it would to 
“‘dTHughes’s mention of Dr. Bell’s case calls to mind a form of mental dis- 1126 
HUGHES, SIMULATION OF INSANITY BY THE INSANE. 
order, not unfreqnently met with in general practice, in which the real and the 
simulated are curiously mingled together. It occurs mostly in women, begin- 
ning usually in a morbid fondness for sympathy, and for the attentions be- 
stowed on the sick and suffering, and originating either in some hysterical 
condition, or in a decidedly insane temperament. There is nothing which 
persons thus disposed will not endeavor or endure, and the aches and ails 
which they affect, from a simple cough to fits and dislocations, no man can 
numbei. We are all familiar with them, no doubt. I knew of one who, not 
content with keeping a couple of watchers up all night for months together, 
would, when at all displeased, dislocate her jaw; and another who would, 
under similar circumstances, dislocate her hip. In such cases there is, un- 
doubtedly, much mental disease, and also much downright simulation. And 
it is not always easy to determine what is to be attributed to the one, and 
what to the other, ydiile a mistake may lead to great wrong and suffering. I 
call to mind the case of a young girl of some culture and refinement who kept 
hex bed moie than a year, unable to move without assistance, and regarded by 
friends and physicians as extremely ill. At last some one, walking in the 
garden, observed her, through a window in her room, rise from the bed and 
jump about as lively as a cricket. Of course there was an end to this sort of 
performance, but there soon appeared a good deal of mental disorder, which 
finally made her so troublesome that she was placed in our hospital. There, 
for weeks together, she behaved with the utmost propriety, evincing neither 
in conduct nor in conversation the slightest sign of insanity. This condition 
would alternate with periods when she lay in bed, unconscious apparently of 
everything around her, her face highly flushed, and her pulse fast and full. 
She took food only through the tube, and passed her evacuations in bed. 
Fiom us she passed into the charge of an Indian doctor, by whom, it was said, 
she was cured. Some light is thrown on the psychological history of this case 
by the fact that a brother and sister were spiritualists, and that her mother 
presented many indications of the insane temperament. Now, had this young 
woman committed a criminal act, I fear that the plea of insanity would have 
availed her little in view of this instance of detected simulation. 1127 
ON THE BEST MODE OF PROVIDING FOR THE SUBJECTS OF 
CHRONIC INSANITY. 
BY 
CHARLES H. NICHOLS, M.D., 
SUPERINTENDENT OF THE GOVERNMENT HOSPITAL FOR THE INSANE, WASHINGTON, D. C. 
Man lives by reason; the brute by instinct. The greater size and 
complexity, and the higher organization, of the organs of reason render 
them more susceptible to derangement than those of instinct • while the 
complex necessities, motives, and struggles, which belong to a life of 
reason, evolve the numerous exciting causes of such derangement just in 
proportion as the reasoning being develops his pre-eminent intellectual 
powers, and puts his feeble instinct into abeyance. When reason or 
motive is perverted by cerebral disorder or defect, man is both a depen- 
dent and an aggressive being. The utter incapacity to provide for him- 
self which causes him to be regarded as an infant, in the eye of the law 
is more apparent because of its most frequent occurrence at a time of life 
when he is most independent in his normal powers, and when both his 
absolute and artificial wants are most numerous and pressing. Intensity 
of purpose and action is often in direct ratio to perversion of judo-ment 
or motive, and the insane man is not only disqualified for providing for 
his numerous wants, but has the inclination and power, if left to himself 
to be exceedingly dangerous to life and property. 
Insanity is a term used to express the mental symptoms of a physical 
disease or defect which generally admits of partial relief, and which 
often admits of entire cure. If cured, the subject of the disease regains 
all his inestimable, human prerogatives—the ability to mingle in society, 
and freedom to will and to do of his own good pleasure. If relieved, as 
far as each case admits of relief by the diligent and skilful use of the 
appliances of modern science and benevolence, a life of sickness and pri- 
vation is rendered comfortable and often measurably happy. Such a 
helpless, dangerous, privative, and yet remediable when not curable, in- 
firmity, appeals not only to the deepest sympathies, but to the self- 
interest of the whole race among which it prevails. Insanity is every- 
where regarded as the chief ill to which flesh is heir; and it is the sen- 
timent of enlightened Christendom, however imperfectly and variously 
that sentiment may be expressed, that the insane of all classes should 
have all their needs provided for, because they cannot provide for them 
themselves; should have the medical and moral treatment that will 
alleviate, if not cure, their'grievous disease; and should, as a rule, be 
restrained of their liberty, because it is unsafe for them to be at laro-e. 
If not cured, the pathological conditions of the brain which give rise 
to mental derangement, rapidly pass into a chronic condition, whose 
average duration is about equal to one-half of the mean length of human 
life. The result of efforts to establish by observation and pathological 
research the relations between the duration of mental disease and its 
curability, is the practice of classifying cases of not more than one year’s 
duration as recent and presumptively curable, and those of more than 1128 
NICHOLS, 
one 3'ear’s standing as chronic and probably incurable. Experience 
shows that this generalization is useful in estimating the tendencies in 
respect to recovery, or duration of illness, of large masses of the insane, 
and the provisions required for their proper maintenance and treatment; 
but when it is considered that, under the circumstances most favorable 
to recovery, about fifty per cent, of all the cases of insanity that occur 
in a community pass this arbitrary boundary-line which has been set to 
divide recent from chronic mental disease, while the rapidly diminishing 
probabilities of recovery are not found to be extinct in individual cases 
until the expiration of the third or fourth year after the invasion of the 
malady, it will be seen that such a generalization can be only an approxi- 
mation to the truth, with many exceptions. As the recent insanity of a 
community imparts an increment of not far from fifty per cent, of all 
the cases that annually occur, to those of technically chronic mental dis- 
order, while an uncertain period of several years expires before individual 
cases become hopeless, the two classes are, for a considerable period at 
least, inseparably linked with each other, and either a philosophical or 
a practical consideration of “the best mode of providing for the subjects 
of chronic insanity,” should obviously form a harmonious part of a com- 
prehensive scheme of providing for the treatment of insanity of every 
duration and form. 
In the year 1866, the Association of Medical Superintendents of 
American Institutions for the Insane,1 a body of the highest acknowl- 
edged authority in America in relation to ‘the wants and claims of the 
insane, after an exhaustive discussion of the exact subject of this paper, 
adopted the following five propositions, the first four unanimously, and 
the last one by a considerable majority of the members present at the 
meeting of that year:— 
I. The large States should be divided into geographical districts of such 
size that a hospital, situated at or near the centre of each district, may be 
practically accessible to all the people living within its boundaries, and avail- 
able for their benefit in case of mental disorder. 
11, All State, county, and city hospitals for the insane should receive all 
persons, belonging to the vicinage designed to be accommodated by each hos- 
pital, who are affected with insanity proper, whatever may be the form or 
nature of the bodily disease accompanying the mental disorder. 
111. All hospitals for the insane should be constructed, organized, and 
managed, substantially in accordance with the propositions adopted by the 
Association in 1851 and 1853, and still in force.2 
1 Including those of the United States of America and of the Provinces of the Dominion 
of Canada. 
2 Propositions offered by Dr. Kirkbride, and adopted at the meeting of the Association 
of Superintendents held in Philadelphia, May 21, 1851: 
(1) Every hospital for the insane should be in the country, not within less than two miles 
of a large town, and easily accessible at all seasons. 
(2) No hospital for the insane, however limited its capacity, should have less than fifty 
acres of land devoted to gardens and pleasure grounds for its patients. At least one hun- 
dred acres should be possessed by every State hospital, or other institution for 200 patients, 
to which number these propositions apply unless otherwise mentioned. 
(3) Means should be provided to raise ten thousand gallons of water, daily, to reservoirs 
that will supply the highest parts of the building. 
(4) No hospital for the insane should be built without the plan having been first sub- 
mitted to some physician or physicians who have had charge of a similar establishment, or 
who are practically acquainted with all the details of their arrangements, and having re- 
ceived his or their full approbation. 
(5) The highest number that can with propriety be treated in one building is 250, while 
200 is a preferable maximum. PROVISION FOR SUBJECTS OF CHRONIC INSANITY. 
1129 
IV. The facilities of classification or ward separation possessed by each in- 
stitution, should equal the requirements of the different conditions of the 
(6) All such buildings should be constructed of stone or brick, should have slate or 
metallic roofs, and, as far as possible, should be made secure from accidents by fire. 
(7) Every hospital having provision for 200 or more patients, should have in it at least 
eight distinct wards for each sex, making sixteen classes in the entire establishment. 
(8) Each ward should have in it a parlor, a corridor, single lodging rooms for patients, 
an associated dormitory communicating with a chamber for two attendants, a clothes-room, 
a bath-room, a water-closet, a dining-room, a dumb-waiter, and a speaking-tube leading to 
the kitchen or other central part of the building. 
(9) No apartments should be provided for the confinement of patients, or as their lodging- 
rooms, that are not entirely above ground. 
(10) No class of rooms should ever be constructed without some kind of window in each, 
communicating directly with the external atmosphere. 
(11) No chamber for the use of a single patient should ever be less than eight by ten 
feet, nor should the ceiling of any story occupied by patients be less than twelve feet in 
height. 
(12) The floors of patients’ apartments should always be of wood. 
(13) The stairways should always be of iron, stone, or other indestructible material, 
ample in size and number, and easy of ascent, to afford convenient egress in case of acci- 
dent from fire. 
(14) A large hospital should consist of a mam central building, with wings. 
(15) The main central building should contain the offices, receiving rooms for company, 
and apartments, entirely private, for the superintending physician and his family, in case 
that officer reside in the hospital building. 
(16) The wings should be so arranged tnat it rooms be placed on both sides of a corridor, 
the corridor should be furnished at both ends with movable, glazed sashes, for the free 
admission of both light and air. 
(17) The lighting should be by gus, on account of its convenience, cleanliness, safety, 
and economy. 
(18) The apartments for washing clothing, etc., should be detached from the hospital 
building. 
(19) The drainage should be under ground, and all the inlets to the sewers should be 
properly secured, to prevent offensive emanations. 
(20) All hospitals should be warmed by passing an abundance of pure, fresh air, from 
the external atmosphere, over pipes or plates containing steam under low pressure, or hot 
water the temperature of which at the boiler does not exceed 212 degiees 1 ahr., and which 
are placed in the basement or cellar of the building to be heated. 
(21) A complete system of forced ventilation, in connection with the heating, is indis- 
pensable to give purity to the air of a hospital for the insane, and no expense that is re- 
quired to effect this object thoroughly, can be deemed either misplaced or injudicious. 
(22) The boilers for generating steam for warming the building, should be in a detached 
structure, connected with which may be the engine tor pumping water and for driving the 
washing apparatus and other machinery. 
(23) All water-closets should, as far as possible, be made of indestructible materials, be 
simple in their arrangement, and have a strong downward ventilation connected with them. 
(24) The floors of bath-rooms, water-closets, and basement-stories, should, as far as possi- 
ble, be made of materials that will not absorb moisture. 
(25) The wards for the most excited class should be constructed with rooms on but one 
side of a corridor not less than ten feet wide, and the external windows should be large, 
and should afford pleasant views. . 
(26) Wherever practicable, the pleasure grounds ot a hospital lor the insane should be 
surrounded by a substantial wall, so placed as not to be unpleasantly visible from the 
building. 
The following propositions, also offered by Dr. Kirkbride, were adopted at a meeting of 
the superintendents held in Baltimore, May 10, 1853: 
(1) The general controlling power of a Hospital tor the Insane should be vested in a 
board of trustees or managers; if of a State institution, selected in such manner as will be 
likely most effectually to protect it from all influences connected with political measures or 
political changes; if of a private corporation, by those properly authorized to vote. 
(2) The board of trustees should not exceed twelve in number, and should be composed 
of individuals possessing the public confidence, distinguished for liberality, intelligence, 
and active benevolence ; above all political influence , and able and willing faithfully to 
attend to the duties of their station. Iheir tenure of office should be so arranged, where 1130 
NICHOLS 
several classes received by such institution, whether these different conditions 
be mental or physical in their character. 
T"* ie enlargement of a city, county, or State institution for the insane, 
which, in the extent and character of the district in which it is situated, is 
conveniently accessible to all the people of such district, may be properly 
carried, as required, to the extent of accommodating 600 patients, embracing 
the usual proportions of curable and incurable insane in a particular con? 
inunity. 
. STo one of these propositions has since been either repealed or modi- 
fied, and the experience of the ten years which have elapsed since they 
changes are deemed desirable, that the terms of not more than one-third of the whole 
number shall expire in any one year. 
(S) The board of trustees should appoint the physician, and, on his nomination, and not 
otherwise, the assistant physician, steward, and matron. It should, as a board or by com- 
mittee, visit and examine every part of the institution, at frequent, stated intervals, not 
less than semi-monthly, and at such other times as it may deem expedient and should 
exercise so careful a supervision over the expenditures and general operations of the hos- 
pital, as to give to the community a proper degree of confidence in the correctness of its 
management. 
(4) The physician should be the superintendent and chief executive officer of the estab- 
lishment Besides being a well-educated physician, he should possess the mental, physical, 
and social qualities to fit him for the post. He should serve during good behavior and 
should reside on, or very near the premises, and his compensation should be so liberal as 
to enable him to devote his whole time and energies to the welfare of the hospital. He 
should nominate to the board suitable persons to act as assistant physician, steward, and 
mation ; he should have the entire control of the medical, moral, and dietetic treatment of the 
patients, and the unrestricted power of appointment and discharge of all persons engaged 
in their care ; and should exercise a general supervision and direction of every department 
of the institution. J 1 
(5) Ihe assistant physician or physicians, where more than one are required, should be 
graduates of medicine, of such character and qualifications as to be able to represent and 
to perform the ordinary duties of the physician during his absence. 
(6) The steward, under the direction of the superintending physician and by his order 
should make all purchases for the institution ; keep the accounts ; make engagements with 
pay, and discharge those employed about the establishment; have a supervision of the 
farm, garden, and grounds ; and perform such other duties as may be assigned him 
(7) The matron, under the direction of the superintendent, should have a general super- 
vision of the domestic arrangements of the house, and, under the same direction do what 
she can to promote the comfort and restoration of the patients. 
(8) In institutions containing more than 200 patients, a second assistant physician and 
an apothecary should be employed, to the latter of whom, other duties, in the male wards 
may be conveniently assigned. 
(9) If a chaplain be deemed desirable as a permanent officer, he should be selected by 
the superintendent and, like all others engaged in the care of the patients, should be 
entirely under his direction. 
(10) In eveiy hospital for the insane, there should be one supervisor for each sex exer 
cising a general oversight of all the attendants and patients, and forming a medium of 
communication between them and the officers. 
(11) In no institution should the number of persons in immediate attendance on the 
patients be in a lower ratio than one attendant for every ten patients; and a much larger 
proportion of attendants will commonly be desirable. 
(12) Ihe fullest authority should be given to the superintendent to take every precau- 
tion that can guard against fire or accident within an institution, and to secure this an effi 
cient night-watch should always be provided. 
(13) The situation and circumstances of different institutions may require a considerable 
number of persons to be employed in various other positions ; but in every hospital, at least 
all those that have been referred to, are deemed not only desirable but absolutely necessary 
to give all the advantages that may be hoped for from a liberal and enlightened treatment 
of the insane. 
(!4) All persons employed in the care of the insane should be active, vigilant cheerful 
and in good health. They should be of a kind and benevolent disposition, should be edu- 
cated, and in all respects trustworthy, and their compensation should be sufficiently liberal 
to secure the services of individuals of this description. 3 PROVISION FOR SUBJECTS OF CHRONIC INSANITY. 
1131 
were adopted, has fully established their soundness and practicability 
(except, possibly, in respect to the last, which fixes an arbitrary maximum 
dumber of patients that may be accommodated in one institution), not 
less than ten States and one Province, if not more, having proceeded to 
provide for their insane upon the principles which they enunciate, and to 
embody them in their statutes. As I have intimated, the best provision 
for the subjects of chronic insanity should be embraced in a comprehen- 
sive plan of providing for the insane of all classes. The above proposi- 
tions were intended to embrace such a plan, and, as I was their author, it 
will suit my convenience in the treatment of this question to attempt to 
reproduce the considerations that led to the views which they express: 
and perhaps this mode of presenting the matter will be more satisfactory 
to the Section, and more useful to the public, than any other. I propose 
to consider the propositions seriatim, and to lay particular stress upon the 
bearing of each upon the care of the subjects of chronic insanity. 
The first proposition declares that “the large States should be divided 
into geographical districts of such size that a hospital situated at or near 
the centre of each district, may be practically accessible to all the people 
living within its boundaries, and available for their benefit in case of 
mental disorder.” The obvious purpose of this is to affirm that institu- 
tions for the insane must be within the reach of the people whom they 
are intended to accommodate, in order that their insane may be sent to 
them ; and it was framed in view of the fact that many hundreds of per- 
sons suffering from acute insanity had not received the hospital treatment 
that had been provided for them, and had consequently run into the 
hopeless stages of the disease, because of the long, fatiguing, and expen- 
sive journeys necessary to reach either the nearest hospitals, or those to 
which they were entitled to go. It is obvious that the principles of this 
proposition lie at the very foundation of an adequate provision for the 
insane, whether the form of their disease be recent or chronic. In an 
article on “ The Use of Insane Hospitals,” in the number of the Journal 
of Insanity for January, 1866, by Hr. Edward Jarvis, will be found a table 
which shows that, in the course of a series of years, twenty-two institu- 
tions in the United States and the Dominion of Canada received annually 
an average of one patient to 3974 of the population of the districts in 
which they were situated, and that the ratio of patients to population 
constantly and rapidly diminished in every case as the distances from the 
institutions increased, until an average of only one patient in 18,978 of 
the population of the fourth tier or belt of counties from the hospital cen- 
tres, was sent to them. It is not reasonable to suppose that institutions 
for the insane breed insanity in the populations immediately surrounding 
them, nor that insanity is of more frequent occurrence in their near 
neighborhood than in more remote districts, and hence the only reason- 
able conclusion is that the remote districts were, solely on account of 
their remoteness, to a great extent deprived of the use of hospitals. This 
less use of hospitals by distant districts, is doubtless in some part due to 
the less acquaintance with their management and benefits than is acquired 
by people situated nearer to them, but in greater part to the disinclina- 
tion of public authorities, and the inability of friends, to incur the ex- 
penses of transporting patients long distances with the necessary escorts, 
and to the apprehended danger to the lives of delicate persons from the 
exposures and fatigues of a protracted journey. 
It follows, as Hr. Jarvis says, that hospitals aie somewhat local in their 
operation, and that, in order that their benefits may be enjoyed in case H32 
NICHOLS, 
need, they must be, in the language of the proposition, practically 
accessible to all fhe people residing within the boundaries of the district 
winch each is intended to accommodate. A necessity so vital to the 
welfare of the people,_ becomes the bounden duty of the State. No rule 
limiting hospital districts to an exact and uniform area can be laid down, 
indeed, it would not be possible to divide the States and Provinces in such 
a way that a central institution should not be more or less difficult of 
access from one or more remote corners of the district which it was 
intended to accommodate, but intelligent legislators will in most cases be 
able to approximately meet the requirements of the proposition, if they 
are imbued with a sense of its vital importance to the needs of an afflicted 
class of their constituents. In districting States and Provinces having 
huge areas of unsettled, or partially settled, territory, reference should be 
had to the probable direction and extent of the growth of their popula- 
tions, Jest a sufficient number of institutions for the whole area of the 
State or I rovmce should be so placed in the original centres of population 
as not to accommodate the subsequent settlements. Indisputable facts 
show that the_ remote inhabitants of a district must be able to reach its 
lospi a by a journey that can be made during the waking hours of a 
single clayq or they will not avail themselves of its benefits. Such a 
generalization will aid in the practical solution of this problem, for it will 
ieac i y be seen that insane persons can be conveyed to a hospital by rail- 
road from a distance of seventy-five or a hundred miles with more con- 
venience and less expense than they can be conveyed half that distance 
by ordinary carnage-roads, and that the number and directions of the 
raifroads and the character of the carriage-roads of a proposed district, 
10uId have much influence in determining its size and shape, and the 
situation ot its hospital. The practicability of the early treatment of 
acute insanity will increase the number of recoveries, and proportionately 
dimmish the number of cases of chronic insanity to be provided for. 
ns brief discussion of this first and fundamental element of all ade- 
quate public provision for the insane, is, therefore, pertinent to the par- 
ticular question under consideration. F 
I now come to the second proposition of the series. It is that all 
btate county, and city hospitals for the insane, should receive all persons 
that belong to the vicinage designed to be accommodated by each hospi- 
tal, who are affected with insanity proper, whatever be the former nature 
ot tiie bodily disease accompanying the mental disorder. Except in 
some of the IS ew England States, the ordinary poor of the United States 
are generally maintained in county alms-houses, and, in harmony with 
that practice, and mainly from mistaken motives of economy, most county 
authorities are disposed to provide for their insane poor as well as for 
. ieir otlier dependent classes. The populous and wealthy counties, whose 
insane are numbered by hundreds, and are sufficient to fill one or more 
institutions of suitable size, may properly establish and maintain hospi- 
tals of their own, and thus save the cost of transportation, and secure the 
benefits of local employment and trade, and of easy access. It may with 
reason be maintained that as State legislators and officials are from their 
position, if not from their personal character, likely to entertain broader 
and more hberal views of their duty to the sick and unfortunate, and to 
e less under the influence of petty local strifes and parsimonies, than the 
officials of the subordinate municipalities, the States and Provinces should 
take direct charge of this class of their dependents, so'peculiar in its 
wants and in its liability to suffer from neglect or abuse. There are PROVISION FOR SUBJECTS OF CHRONIC INSANITY. 
1133 
several county and city institutions the material appointments and man- 
agement of which are equal to those of the average State and Provincial 
asylums, and it is due to truth and professional character to declare, in 
this public manner, that the unsatisfactory condition of others is attribu- 
table to defective means and organization, and not to the very respect- 
able medical gentlemen who now have, or have had, charge of them. 
Without exception, these gentlemen appear to have discharged their 
duties with humanity and ability, and with very remarkable industry 
and perseverance in view of the difficulties and discouragements that have 
attended their work. City institutions for the insane are subject to the 
same objections as those of the county, and to the additional objection 
that a city will seldom, if ever, be able to afford within its limits the area 
of ground necessary for salubrity, privacy, and cultivation; and rather 
than that a city should go outside of its territory to establish and main- 
tain an institution for its own exclusive benefit, it would be more feasi- 
ble for the common authority over the city and neighboring municipali- 
ties to take charge of this sacred function of government, and administer 
it for their equal benefit. 
To effectively prevent the peculiar abuses that are liable to creep into 
institutions for the insane governed by local authorities, State and Pro- 
vincial statutes, with heavy penalties for their violation, should require 
them to be constructed, organized, and conducted, substantially as the 
State and Provincial hospitals or asylums are usually appointed and 
maintained; and should especially require them to receive, whenever 
the friends may desire it, the insane ot the favoied classes in respect to 
propert}7, either as pay patients, or as tree patients, supported, like all 
others, from the common fund ot the municipality. One ot these courses 
is pursued by all the State institutions, and there is no one teature ot 
their organization that is as effective as this in preventing their manage- 
ment from falling below a liberal, curative standard, fire poor will 
generally be well taken care ot when they receive such treatment as the 
middle classes in respect to fortune are willing to pay for, or are satis- 
fied with without payment, except indirectly as taxpayers. Ihe rich 
will generally be sent to the corporate or private institutions, all the in- 
mates of which are independent, and can more conveniently receive in 
them such indulgences as their habits and tastes require, and their means 
allow, than they can in large institutions, most or all of the inmates of 
which are a public charge. The second proposition, in theory at least, 
solves the question before the Section. The reception and care by every 
public hospital for the insane of all persons belonging to the vicinage— 
that is, within the hospital district—who are affected with insanity pro- 
per, includes, of course, the reception of those whose insanity is chronic, 
and this is believed to be the best ot all the provisions tor their care 
which have been, or are, or possibly can be made, 01 which have been 
suggested or advocated. . 
The movement ot the insane, under this will be simply as fbl- 
lows: The recently insane are promptly placed in district hospitals, and 
there receive the treatment most conducive to their comfort and re- 
covery. About one-halt ot them recover, and return to their homes and 
employmerrts, or die, in the course of the year that follows their admis- 
sion; the other halt remain where they are without additional expense 
for transportation, and continue to receive care and treatment adapted to 
the condition of each case. Those who still give promise of improve- 
ment, are treated with that end in view, and occasionally reward perse- NICHOLS, 
vering efforts in their behalf by entire recovery of reason; those who 
continue to be actively maniacal, or melancholic, or who exhibit suicidal, 
homicidal, or other specially dangerous propensities, and the paroxysmal 
cases, whether simple or epileptic, receive the care that secures to each 
case the highest degree of comfort and safety of which it is susceptible, 
and that is as necessary now as in the acute stage of the disease. A few, 
perhaps ten per cent., of the annual additions to the chronic members 
of the hospital family, pass early into the mechanical, but not always 
unhappy, life of passive dements, whose bodily habits are regulated, 
and whose comforts are ministered to, by the order and appliances 
of the institution, while they engage, with more or less interest in 
its character and results, in such labor as they are capable of, in the 
wards, kitchens, laundry, and stables, and in the gardens and fields, 
when the sun is not too hot for their weak brains, nor the air too cold 
for their feeble circulations. The subjects of chronic insanity render 
considerable assistance in the wards occupied in part by the recent cases, 
and somewhat reduce the number of attendants that need to be em- 
ployed ; while the labor of the insane is mostly performed by the chronic 
patients, the recovery of those who have been recently affected is occa- 
sionally much promoted by industrial exercise, and they will here and 
there fall into a party of regular workers with more facility than they 
will work either by themselves, or in company with others whose cases 
are entirely of their own class. The habitual employment of a large 
number of patients is calculated to suggest and justify a variety of occu- 
pations, among which the recently affected may find those adapted to 
their respective capacities. The insane may be much benefited by labor, 
and may also be greatly injured by it: compulsory labor would cause 
the rapid and cruel sacrifice of many of the insane, both of the acute 
and chronic classes. The condition of the brain and the probable effects 
of labor upon it, should be carefully considered before each patient is 
put to work, and the effects of his work as carefully watched. The 
medical judgment that prescribes and regulates the labor of the insane, 
should be as able and critical as that which prescribes the drugs that are 
administered to them; and a medical staff accustomed to consider the 
conditions under which a large number of subjects of both recent and 
chronic insanity may labor without detriment, if not with advantage, 
will become more acute and just in its discriminations, and less liable 
to fall into injurious errors, than a staff of less experience in this par- 
ticular. The extreme vicissitudes of the American climate, with its 
fierce summer-heats and depressing winter-colds, seem to admit of less 
labor by the insane in the open air than the more equable climate of 
Europe. If the disease be more active here than there, as many repre- 
sent, our insane cannot advantageously work as much, either in-doors or 
out, as theirs, and yet, if such a sense of the importance of labor as a 
sanitary measure in treating the insane, especially of the working classes, 
prevailed here as appears to prevail abroad, the systematic employment of 
our patients would probably become a constant feature in the adminis- 
tration of our hospitals, with an improvement in the health, content- 
ment, quietude, cheerfulness, and happiness of their inmates. 
The scheme of providing for the insane of all classes in institutions 
situated at or near the centres of limited districts, renders it practicable 
for the kindred of the chronic patients to visit them occasionally, and, 
in addition to the immediate happiness which such visits confer, opens 
the way to the return of a portion of the subjects of passive, settled de- PROVISION FOR SUBJECTS OF CIIROTsIC INbANITY. 
1135 
mentia to the care and support of their families The practice of fur- 
loDghino- patients, which obtains among the English asylums, has been 
resortecfto, to a limited extent, in this country and the Provinces. I 
it should here become an approved measure, either of treatment or of 
relief of over-crowded institutions, it will be practicable and frequently 
resorted to only under the district system. A patient’s return on furlough 
to his home one or two hundred miles from the hospital, must in prac- 
tice prove equivalent to a final discharge, both from the custody and from 
the oversight of the institution. The subjects of chrome insanity, to 
whom the”habits of the hospital have become a second natm-e are effi- 
cient aids in maintaining its discipline. Most of the 
admitted one by one, unconsciously imitate the companions w th whom 
they are thrown, and readily fall into the order of the hospital without 
friction, and without special instruction or exercise of authority which 
"‘in America^he'ffisaneof every degree of culture and refinement, and 
of imiorance and rudeness, as well as of every nationality, are received 
into all our institutions. The character of the institution into which a 
, . , • ~..0i i\lvr determined by bis means, or those of his near 
Mends who'may aid him in his extremity. Each class has its conditions 
Of happiness; The first for every class, is society after its kind; after 
that the cultivated demand articles of taste and delicacy, which are an 
that, tLe t ignorant; the ignorant demand the substantial con- 
amons oi 1 j , refined. After insanity has been under 
irtatanebfor a jw,“those cases that are complicated with paralysis and 
Sr indubitable evidences of organic cerebral disease, may be classed 
with the cases of four or more years’ duration, while cases which exhibit 
™ evidences of organic disease may still be classed among the hopeful, 
no evidences oi £ , but beyond the rule, which should be 
and should be ti tnat the violent and turbulent should be entirely 
inflexibly adhered aU ra]eß of classification in Ame- 
separated from te f j should be'regarded as generalizations which 
ncan institutions ai , * distribution'of the inmates of each establish- 
afford much aid in a proper distiiomion oi . ff 
meat but from which there must be constant departures in every enort 
mem, uui nun vvu i +ne utmost a deviation of which nidi- 
t? secure the highest comfort and ~ i<JB should bo 
vidual cases aie suscep i * ,emselves but it would be an unneces- 
in one or more wards by tnemscivca, uu 
-IrX o subject a persoir of refined sensibilities whose paroxysms 
Sifht and infrequent, to the constant observation ot the painful scenes 
: y.'.. .■ 
times a most unfid ass experience, that such a critical classifi- 
obvious, and this is I® ®Bmoro satisfactory details in the treatment of 
cation can be came itv than in the exclusive treatment of 
the collected insane of a community, rnau 
either class, or ot a single* Editions of the best provision for the 
In estimating _ . spould be borne in mind that this is pre- 
subjects of chronic insanity, ■ phenomena as recent insanitv • 
cJy fire same diseaseleases of“palEe 
dementCand m the prospect of restoration. It follows that the active 1136 
NICHOLS 
forms of chronic, mental disease require precisely the same treatment as 
the recent. The protection of society and of the individual, and the 
mitigation of the pains and privations of disease, are as much demanded 
in the case of the chronic maniac, whether his mania be constant, recur- 
rent, periodical, or epileptic, as in that of the recent; and it stands to 
leason that a medical staff, constantly accustomed to treat recent insanity 
with the expectation of curing it, is likely to be better prepared, both by 
knowledge and habit, to treat chronic disease for its alleviation, than 
one whose professional efforts in the exclusive treatment of chronic dis- 
ease are very rarely rewarded by a full restoration. 
Ihe theoietical grounds of the rule that all public institutions should 
leceive the subjects of both recent and chronic insanity, are sustained by 
the crucial test of experience. Nearly every institution for the insane in 
Christendom is to-day occupied by cases of every variety, duration, and 
manifestation; from the last admitted, in which the outbreak occurred 
but a short time ago, to the most hopeless case of fatuity. The exceptions 
are a very few—not, I think, as many as half a dozen altogether—which 
aie occupied exclusively by chronic and presumptively incurable inmates; 
I know of none which receives only recent cases and discharges them as 
soon as they become chronic. The presence of recent and chronic cases in 
all institutions is, of course, due in part to the retention of cases which were 
admitted when recent, and which have passed to the chronic state; but 
it is by:no means wholly due to a circumstance so natural and purpose- 
less. Not only was the subject of the care and treatment of the victims 
of chronic insanity fully discussed, both in Great Britain and on the 
continent of Europe, long before the question became an urgent one in 
this country, but, after trying various experiments in separating, to a 
greater or less degree and in various ways, the acute from the chronic 
cases, the Europeans have all, I understand, come back to what in Eng- 
land is called the public-asylum, and here the State-asylum, or hospital, 
system. In fact, if the public institutions for the insane in the United 
States and the Provinces of the Dominion were to be distinguished by 
the character of their inmates in the respect under consideration, they 
should be styled asylums for the subjects of chronic or incurable insanity, 
and if the recent and chronic cases were to be separated, the most numer- 
ous class (the chronic) would naturally take the present institutions, 
which are much too large for the recent, and the pertinent and pressing 
question of the day would then he. the best provision for the recent or acutely 
insane. Estimates kindly furnished me by 27 superintendents of the 
United States, show that, on an average, 12| per cent, of the cases of 
insanity in 22 States are of less than one year’s duration, and the 
remainder chronic. Five of their superintendents estimate the average 
ratio of recent to chronic cases of insanity in the Provinces of Canada 
to be per cent. As pnly five of the States make full provision for all 
their insane, in institutions having a resident medical head, it may be 
that the ratio of recent to chronic cases, under treatment in them, is a 
little greater than in the whole insane population of those States ; but I 
am more inclined to think that the estimates of recent cases are too high 
and will not be borne out by the results of treatment. The proposition 
is not only sustained by the practice of the institutions of both the old 
and new worlds, but by the authority of the ablest and most experienced 
men in the specialty; among readers of the English language the names 
of Dr. Bucknill and Dr. .Robertson, of England, and Dr. Earle, of this 
country, are best known in this connection. PROVISION FOE SUBJECTS OF CHRONIC INSANITY. 
1137 
Perhaps a full consideration of the plan of providing for the subjects 
of chronic insanity, now as fully set forth as the time allowed me will 
permit should embrace answers to the objections that have been, or may 
be made to it It has been said that the retention of chronic cases in 
the hospitals in which they have been placed, brings no direct relief to 
the wretched lunatics in the county alms-house receptacles. It does not, 
except by arresting all additions to their number, which would certainly 
be a oreat and happy achievement; but the objection is answered by & 
simple declaration of the obvious truth, that it is less expensive and in 
every way more feasible to provide for the alms-house insane in district in- 
stitntions than in any other proper way. It will cost less tor the necessary 
enlargement of buildings and their appointments, and for transportation. 
If a sufficient number of district institutions already exist, they can be 
enlarged both so as to retain all the patients whom they do not cure, 
until they die if their condition require it, and to receive the alms-house 
patients at less expense than would be incurred by providing for them 
either independent central, or district, asylums of a proper kind ; and if 
there are not enough district institutions to make them practically acces- 
sible to all acute cases, they certainly should, for reasons that have been 
given, be provided as rapidly as possible with accommodations for all the 
chronic cases of the vicinage. 
It has been said that the States (I do not recollect that it has been said 
of the1 Canadian Provinces) will not incur the outlay necessary to pro- 
vide institutions with such appointments and management as are deemed 
I cessaryfohece.it cases; but this declaration is shown to be unfounded 
by the activity and liberality which are displayed at this moment by the 
greater number of the leading States, in establishing excellent district 
institutions for all their insane, of both the acute and chrome classes. 
Five States have provided for every ease within their borders not pre- 
ferably provided for by friends, and others will soon have discharged the 
same duty An editorial table in a recent number of the American 
Journal of’lnsanity shows that the total present and prospective capa- 
city* of the institutions for the insane in the United States is for 85,325 
inmates at a cost, according to a table prepared-by Dr, Conrad, of the 
Msrvhuui Hospital of at least $35,000,000, with an annual expenditure, 
a hrtime?hr $5,000,000, This has mainly been 
accomplished in the last half of that century o our national existence 
which has just terminated, scarcely as many as the odd 82a ot the num- 
ber now under treatment having been provided for fifty years ago, lam 
sorry to be compelled to acknowledge that there is not yet sufficient hos- 
pital provision for the insane in the United States, and hat in a few 
instances that which exists is seriously defective in material appointment 
and organization; but I cheerfully submit the work of the first century 
of the Republic in the personal care and legal protection of the insane, 
to the iXmentof our impartial psychological brethren abroad with 
much confidence that it will be deemed to be indicative of a high degree 
of enlightenment and liberality on the part of the American people who 
have sustained it with their means; ot true science and humanity on 
the part of American psychologists; and of genuine Christian benevo- 
lence on the part of the noble men and the philanthropic woman,' who 
have executed it with the best efforts of their heads and hearts. 
As the third fourth, and fifth propositions relate to the means and 
1 Miss D. L. Dix. NICHOLS, 
modes which render the approved and prevailing plan of providing for 
the subjects of chronic insanity practicable and successful, I shall briefly 
consider them together. The propositions of 1851 and 1853, referred to 
in the series of 1866, and quoted in the foot-note to page 1128, express 
in considerable detail the essential conditions, both material and admin- 
istrative, of the successful treatment of the insane, and, being of acknowl- 
edged authority, have prevented many costly errors of ignorance in 
establishing the institutions of the country, and have efficiently promoted 
the general uniformity and excellence of their management. With the 
experience of the quarter of a century during which those propositions, 
40 in number, have been in force, they are, with slight modifications, 
considered as judicious and binding as when they were put forth, except 
that a change of circumstances has rendered it necessary to depart from 
two or three of the rules which use arbitrary numbers in expressing 
their requirements. The increased numbers of the insane to be provided 
for, and the larger ratio of the chronic to the curable inmates of our in- 
stitutions at the present time, as compared with that of twenty-five years 
ago, have rendered it necessary and admissible to treat a much larger 
number of patients in one institution than was then considered proper. 
Like many institutions of government, education, and business, those for 
providing for the insane have grown upon our hands until they have 
become much larger than was anticipated when those propositions were 
framed and adopted. Other things being equal, the evidence of experi- 
ence and authority shows that hospitals having 500 patients are managed 
as advantageously to their inmates, and quite as economically, as those 
having half that number; and there is nothing in experience, nor, to my 
mind, in theory to show that hospitals containing a still larger number 
of inmates, “ embracing,” in the language of the fifth proposition of the 
series of 1866, “ the usual proportions of curable and incurable insane 
in a particular community” are not equally well managed. Of course it 
is necessary, and, I believe, conducive to the welfare of patients and the 
advancement of the specialty, that the ratio of staff-physicians should 
not only be proportionate to the number and character of the patients, 
but that the physicians should be charged with more authority and 
responsibility than they usually possessed twenty-five or more years ago. 
That they should be men of ability, liberal education, and sound princi- 
ples, no one will deny. It does not appear to me that the number of 
assistant physicians required in large institutions for the insane can be 
determined by a rule of universal applicability, but I think that a pro- 
portion of one to one hundred cases of active disease, whether acute or 
chronic, and one to two hundred chronic cases that are ordinarily quiet 
and orderly, will, on the one hand, afford no opportunity for the rust 
and vices of idleness, and will, on the other, be sufficient for the per- 
formance of every useful professional office in the medical and moral 
treatment of the patients, with time for the relaxation necessary to the 
maintenance of cheerful health, and for professional and general im- 
provement. 
The prevalent overcrowding of institutions for the insane, is highly pre- 
judicial to the welfare of their inmates. Hot only should this be avoided by 
the provision of ample room for the number of cases under treatment, but 
the facilities of classification or ward separation possessed by institutions 
which receive all the insane of a community, should considerably exceed 
those ordinarily provided, in order that, in addition to the usual classi- 
fication, based,mainly on conduct and the activity of disease, there should PROVISION FOR SUBJECTS OF CHRONIC INSANITY. 
be sub-classes of epileptics, of dipsomaniacs, of regularly working patients, 
and of patients who are too demented, or who, though able, are too indo- 
lent, to work each of these classes requiring some special provision and 
treatment. 
In enlaro-ino- district institutions, in addition to extending the original 
structure as far as it will admit, I think that one 01 more detached build- 
ings or wards may be desirable in effecting all useful purposes of subdi- 
vision. I certainly see no objection to them for the use of the quiet 
classes of agricultural patients, if not placed too far from the main struc- 
ture, if the topography of the grounds favor the erection of such wards, 
and if it be thought otherwise desirable; but I should always consider 
it an indispensable condition of good management, that the assistant 
physician having immediate charge of the inmates of a block or group 
of blocks, should have such a residence that he could not only conveni- 
ently see his patients often, but that he could be readily consulted at all 
hours of the day and night. In some cases, the fitness of accommodations 
might be most economically and conveniently secured by the erection of 
new and improved buildings on the same grounds with old and imperfect 
ones and the devotion of the former to the recent cases and their suitable 
associates among the chronic, and of the latter to the most hopeless 
cases or to those belonging to the collateral classification which I have 
recommended. . „„„ „ , 
When a district institution contains as many as 600 patients of both 
sexes and the number is likely to considerably increase, a second com- 
plete set of hospital buildings should be provided in the same neighbor- 
hood and if practicable, on continuous gi ounds, and the sexes separated 
by retaining one in the old buildings and placing the other in the new. 
The buildings for each sex should be separately inclosed, and not much 
less than half a mile distant from each other, unless a hill or wood should 
nresent a natural barrier to the view and hearing of one from the other. 
The two sets of buildings being in the same neighborhood, patients of 
both sexes can at the same time be accompanied to and from them by 
the same friends or officers, and the same relatives can visit patients of 
both sexes by one journey, which will not unfrequently be both a conve- 
nience and a saving of expense. The employment of each sex will con- 
veniently and economically supplement that of the othei. The men will 
raise vegetables, milk,etc., for both establishments, and the women may 
do the washing, mending, etc., for the men as well as for themselves. 
The separate care of each sex will render admissible many relaxations ot 
the restraints to personal liberty that prudence requires when both sexes 
occupy connecting wings of the same continuous structure. After the 
separation, the superintendent may remain in charge of both establish- 
ments with an adjunct in immediate charge of each, or there may be an 
independent superintendent of each, under the same board ot manage- 
ment, as circumstances may render most expedient. 
All public buildings, particularly those belonging to a government ot 
the power and dignity of a State or Province, should present just claims 
to architectural fitness and taste. Edifices occupied by the msaneshould 
be at least neat and cheerful in their appearance; and their construction 
of durable materials in the most enduring manner will prove most econo- 
mical in the end. Cost should be held subordinate to every essential sani- 
tary provision, as drainage, ventilation, the ot light, heat, and 
water and abundant room and means of classihcation; and just in propor- 
tion as such provisions are subordinated to necessary cost in the construe- 1140 
NICHOLS, 
tion and fitting up of buildings for the insane, do these become custodial 
receptacles which deny to their inmates the benefits of hospital treatment. 
There is, however, some incongruity in providing highly ornamental and 
costly structures mainly for the treatment of the insane poor, most of whom 
have little or no aesthetic capacity to appreciate and be benefited by the 
outlay; and it may be feared that the taste and ambition of legislatures 
that at one period authorizes the high embellishment of hospital struc- 
tures at considerable cost, will at another be accused of extravagance, and 
that, in the strifes of political parties, such expenditures will be made the 
pretext, if not the reason, for withholding appropriations for the most 
necessary purposes. Happily, the first cost of the essential provisions for 
the most humane and beneficial treatment of the insane of the dependent 
classes, has now been determined by a wide and varied experience, and is 
found to be much less than has been sometimes expended for the purpose, 
and not to exceed the means of any State. What the States and Provinces 
have already accomplished in this direction, and most of it in the short 
period of less than fifty years, while they have been at the same time 
not only providing their capitols, court-houses, penitentiaries, and other 
buildings that directly appertain to the necessary functions of govern- 
ment, and also making considerable outlays for institutions for the blind, 
for the deaf and dumb, and for feeble-minded youth, affords as positive 
a guaranty as anything that lies in the future can, that at no distant day 
all of them will adequately care for all their insane poor, as well as no 
little excuse for what appears to impatient benevolence and sometimes 
unpractical science, to be inexcusable tardiness in the discharge of their 
imperative duty. 
Discussion on Dr. Fichols’s Paper. 
After the reading of the preceding paper, Dr. Isaac Ray, of Philadelphia, 
said:—The increase of insanity among us has led to ranch inquiry as to the 
best means of caring for its subjects, who are mostly of the indigent class, with 
the greatest degree of economy compatible with a proper regard to their com- 
fort and cure. One of the conclusions arrived at by many intelligent men, 
some of them superintendents of our hospitals for the insane, is that the larger 
our hospitals, the more cheaply they may be built and maintained. This con- 
clusion 1 have always regarded as unsound, and the more the experiment has 
been tried, the more it has confirmed me in this opinion. True, an institution 
for 200 patients would, undoubtedly, cost less, proportionately, than one for 40 
or 50 patients, other things being equal. But the rule is not absolute. There 
comes a point where the economical result is reversed, so that the larger the 
hospital, the more expensive it will prove. Indeed, it would be hard to show 
how increase in size can be followed by decrease in expense. A well organized 
hospital-staff should consist of a superintendent, two assistant physicians, a 
steward, matron, and a force of attendants equal to one to every five or ten 
patients. A farmer, and more or fewer assistants, will be needed for outside 
work. Not less than this is required in a hospital of 300 patients. Conse- 
quently, a hospital for 600 must require double the number of assistant-phy- 
sicians, and double the number of attendants, and of indoor and outdoor ser- 
vants. The matron and steward will each require a helper. Where or how the 
cost of maintenance is diminished, is not very obvious. True, the cost of one 
superintendent is supposed to be saved, but, unquestionably, the larger the estab- 
lishment the larger would be the salary of the superintendent, and as more 
care and responsibility would be thrown on the assistants, their compensation 
would naturally be increased. So that little, if anything, could be saved in PROVISION FOE SUBJECTS OF CHRONIC INSANITY. 
1141 
that direction. Besides, I believe, it is generally understood among those who 
have had some experience in the financial history of institutions requiring the 
expenditure of more or less money, that the practice of economy is much 
affected by the amount of money disbursed. The smaller it is, the more fru- 
gal!,, it is Spent In the daily handling of large sums, there comes, as a 
result of such familiarity, a sort of contempt for small sums not likely to pro- 
duce the strictest economy. This is human nature, and implies no lack ot 
honesty or sagacity. Though not very familiar with the reports of our hos- 
pitals, of late years, yet I have the impression that our largest hospitals show 
no decided advantage over the smaller, in the cost ot maintenance. Any little 
difference in their favor may be, very likely, the result of other causes. Ac- 
cording to the report of the Willard Hospital, for the year 1874, he average 
cost wSs $3.17 per week, if I recollect rightly, which is little less than it is in 
some of our smaller State hospitals. And yet it is supposed that in the former 
the patients are all of the kind that can be properly maintained at the least 
expense. And this figure is likely to he increased m future years, by the 
repairs and renewals, always a formidable item ... the expenditures, and none 
the less, certainly, where the buildings are cheaply constructed, and all the 
appointments of a makeshift kind. , 
Nor do T sec how the expense of construction can be diminished by the plan 
much favored just now, of having the hospital consist of several buildings, 
separate and independent, scattered over the premises, instead of a single 
structure receiving all the patients under its roof.. Ihe idea that anything is 
gained by this mode of construction is such an obvious fallacy that one hardly 
knows how to meet it. It certainly has always been supposed that ... build- 
in ° the less you have of wall and roof, the less will he the first cost; and if 
tlmt lie so it is self-evident that 30 or 30 patients can he more cheaply pro- 
vided for in a hall, in the usual way, than in a building designed only for them 
Nor does it need any special proof to show that the expense ot warming and 
ventilating several detached buildings must be far greater than would be needed 
fo a Sinofe one of equal capacity. The fact is obvious at sight. In short, 
the clamor against “ palatial” structures, to use the popular phrase is little 
better than claptrap, thoughtlessly used by people supremely ignorant of the 
cost of building at the present day, as well as of the peculiar requirements of 
, . : „ ° * Ac the result of mv own observation and expen- 
enceTaiV convLed that four hospitals for 300 patients each, can be both 
built and maintained at a less cost than one for 1300 patients, equal provision 
being made in both cases for the kind of care to winch the insane, even m the 
lowest grades of the disease, are eutitlec. rtnap mqmmntli 
I doubt however, whether it is possible to have, in these mammoth estab- 
lishments certain qualities of administration indispensable to their highest 
purposes! The animating spirit, the close and t3 To!’ 
euidinv correcting every movement, and essential loom highest idea ot hos- 
ptal management, will be but feebly under■such conditions The 
Pent”but an ’atom in the great mass aroundh™, attributes of 
humanity, sane and insane, 1,1 Tw s | c done, against the establish- 
Contending as I now do, »"d “ ap’pl°valto Dl, Nicbols,s 
paper0 with Exception, however, I heartily concur in all his conclusions 
prT..„Mas s. :: z:: 
all appieciatc the va ue jt witb whieh Ido not agree entirely. On 
just heard read. Thei - { views differ from those expressed 
one point, however, I must confess mat my linsnitik fv„- 
bv mv excellent friend, and that is, in regard .0 the best size toi Uosp tals loi 
theTnsane We all know that this is a point on which there has, of late years 
at least been a difference of opinion in the Association of Medical bn per- 
fn ten dents 6As it now stands, indeed, it is the only one of our many pro- 
posmous that has not received au unanimous, or very nearly unanimous, 1142 
NICHOLS, 
approval by the members. I still believe that the original proposition was 
right. I believe that the size then recommended is really better than any 
other, but I am also fully aware of all the arguments that can be brought to 
justify much larger hospitals, especially those of expediency and even possi- 
bility. It is fully shown by reliable statistics, as I believe, that the people of 
the State will derive more benefit from several small hospitals in different 
parts of the State, than from one large one at a central point; and I think that 
it will also be found that the former can be provided with quite as small an 
expenditure of money, and can be carried on at no greater cost per patient. 
Dr. Nichols has recommended the plan, which has now been fully tested, and 
which, even by the first decision of the Association, allows as many as 500 
patients being collected in one vicinity ; and this is by having separate hospi- 
tals for the sexes. This plan I feel that I have a right to say is no longer an 
experiment. A trial of sixteen years under my own observation has shown 
that, in every respect, it is a most valuable arrangement, having many advan- 
tages and no disadvantages. It has also received unqualified approbation from 
many other distinguished psychologists in addition to Dr. Nichols. I am 
aware that it has been said that, while I argue in favor of hospitals for 250 
patients, practically, I have been providing one to accommodate twice that 
number. This, however, is a mistake. The Pennsylvania Hospital for the 
Insane, at Philadelphia, is really made up of two entirely distinct hospitals, 
one for each sex, and it has been so, as already said, for more than sixteen 
years. Both hospitals have the same board of managers, and, for reasons not 
necessary to detail here, have always had the same physician-in-chief and 
superintendent. It is anticipated, however, that ultimately each will have its 
own separate superintendent, and that the only connection between them will 
be the board of managers. 
Now, what we have done, is exactly what I would propose for any hospital. 
First build your hospital for 250 patients. This will commonly be occupied 
by both sexes. When this is filled, or nearly so, build another for a similar 
number of patients. Separate the sexes; have distinct organizations—all on 
the same tract of land, but with entirely separate pleasure-grounds. There 
may be the same water-works, gas-works, bakery, machine-shop, and other 
common arrangements, that will add to the economy of the institution. This 
provides for 500 patients in one locality, and yet conforms to the original 
proposition ot the Association. Ido not propose entering into any extended 
discussion ot the reasons why I believe that these smaller hospitals have ad- 
vantages, but there is one that 1 cannot avoid referring to, and that is the per- 
sonal intercourse which a superintendent is able to give to his patients, Avhen 
their number is not so great as to prevent his paying daily, or very nearly daily, 
visits to each. I believe this to be one of the most important of all his duties, 
and one which generally, if he is rightly constituted for his position, no one can 
do for him. It is true that an assistant may be superior to his chief in this 
respect, but this is not to be anticipated, and if it is so, the assistant ought to 
have charge of a hospital himself. Two hundred and fifty patients, or about 
that number, are as many as any superintendent can visit daily, with tolerable 
satisfaction to himself and to them. 
Now, Ido not wish to be misunderstood in this matter. I still think, as the 
Association at first thought, that this size of 250 is the very best, but I do not 
mean to say that no other is admissible. lam well aware how much easier it 
is to get an appropriation for the extension of a hospital, than for the building 
of anew one. What I mean to say is this:—Build your hospitals, indifferent 
parts of a State, of a capacity for 250 patients, and in sufficient numbers to 
accommodate all your insane, if you can do so. If you cannot do this, and 
yet can build single hospitals for 500, 700, or even 1000 patients at one point, 
by all means do so. The hospitals you must have at all,hazards. If you 
cannot get what I regard as the best arrangement, come as near to it as you 
can, let the size be what it may. PROVISION FOR SUBJECTS OF CHRONIC INSANITY. 
1143 
The President, Dr. John P. Gray, of Utica, said : I should object to put- 
ting buildings half a mile apart, if for no other reason because such an 
arrangement would render it difficult, if not impossible for the superintendent 
to consult constantly with his subordinate officers I was chairman of the 
commission which located the Willard Asylum. We found the point on the 
lake the most desirable place for the main hospital building; the building now 
called the “ branch,” and more than half a mile away, was then erected ; it was 
the old State Agr cultural College, and was subsequently remodelled to receive 
patients But there is a resident physician in the “ branch,” as there are in 
other separate buildings, since constructed and these Phy81™” 
tical nurnoses exercise the power and control of resident supei mtendents, tor 
the communication between these distant structures and the matn hospital- 
bmlrHno- i* hv tplpffranh Although that is an institution for the subjects ot 
ch on.” insanity there are five medical men, a superintendent and four assist- 
ctnonic ms y, d they are needed. Though as a commissioner 
on the lake, I did nSt like the feature of 
having buildings half a mile or more apart. In this instance it seemed a neces- 
81tAsto° the othefquMtion, as to the number to be accommodated in a single 
U - 
ZuUthe each have a resident physician. In Engl 
at Wakefield, the West-Riding A y on the qualifications of assistant 
physicians 1 nk it important to have assistants who have had hospital 
experience' I should object to taking young men just out of a medical col- 
experience, isi rience and putting them in such responsible 
Dr KU-kbride's remarks as to qualifications would apply with double 
force in an asylum where the buildings were separated. I N D EX. 
Abdomen, penetrating wounds of, 6.A 
Acid, salicylic, 506 
Adams, morbus coxarius, 599 
subcutaneous division of thigh-bone 624, 629 
Address on American medical literature. -.3 
hygiene and preventive medicine, 21 
medical biography, 91 
chemistry and toxicology, 4y 
- jurisprudence, 167 
ataff nf U. S. army, 286 
medicine and medical progress in the United States, 1 
mental hygiene, 205 
obstetrics, 138 
progress of medical education, 265 
surgery, 73 
of welcome, xxxiii . , 
Agnew, C. R., Diseases of conjunctiva, 902 et seq. 
, D. H., morbus coxarius, 600 
Alcohol as food and medicine, 452 
Allen, mechanism of joints, 510, 51 , • • 
Altitudes, high, influence of, on phthisis, 38 
Anaemia, pernicious progressive, 432 
Anaesthetic, nitrous oxide as an, 642 
Analgesic effects of rapid breathing, _ . 
Anatomy, pathological, investigations in, 
Anchylosis of hip-joint, 624 
Aneurism, treatment of, 545 
Aneurismal disease of orbit, 912 
111 life on nervous diseases, 375 
Artificial drum-membrane, 974 
Ashhurst, treatment of aneurism, 5 <2, < 
Aspiration, 862 . „ 
Astringents in diseases of conjunctiva, 893 
Atlee, J. L., fibroid tumors of uterus, 8.3 
L., fibroid tumors of uterus, 808, 826 
Aural disease’ early treatment in, 947 
from bathing, etc., 1008 
vertigo, 1000 
Ayres, croup and diphtheria, 065 
Baldwin, influence of high altitudes on phthisis, 421 
, quarantine, 1069 
Barker, labor in narrow pelves, 793 
Barnes, convulsions in children, <99 
fibroid tumors of uterus, 823, 8.6 
introductory remarks, <6l 
labor in narrow pelves, <93, 
non-puerperal hemorrhages of womb, 775 
ovariotomy by enucleation, 806 
Bartholow, croup and diphtheria, diseases 366 377 
influence of modern life on nervous diseases, odd, oi 
. typho-malarial fever, 338 
Bathing, a cause of auraldisease, 1008 
Bibliography of medical jurisprudence, 192 1146 
INDEX 
Biography, medical, address on, 91 
Biology, Section on, 467 
Bladder, stone in, 609 
in Finland, 662 
Blake, tests for hearing of school-children, etc., 992, 999 
Blood, microscopy of, 467 
Bowditch, address on hygiene, etc., 21 
— influence of modern life on nervous diseases, 375 
Brain, microscopic study of, 1083 
Breathing, rapid, analgesic effects of, 642 
Bkodie, morbus coxarius, 601 
Buck, early treatment in diseases of ear, 947 
Buenos Ayres, vital statistics of, 1029 
Bulkley, eczema and psoriasis, 691 
treatment of syphilis, 738 et seq. 
unity or duality of venereal sores, 716 
variation in type, etc., of skin diseases, 682 et seq. 
Bumstbad, virus of venereal sores, its unity or duality, 708, 715, 716 
Burnett, artificial drum-membrane, 987 
aural vertigo and variable hearing, 1000 
hearing of school children, 999 
tests for hearing, 958 
Burns, non-puerperal hemorrhages of womb, 775 
Byford, labor in narrow pelves, 793 
non-puerperal hemorrhages of womb, 762, 776 
puerperal fever, 856 
Calculous diseases, 609 
Campbell, J. A., non-puerperal hemorrhages of womb, 774 
■ , H. F., morbus coxarius, 598 
Oanniff, antiseptic surgery, 530, 531 
Carpenter, antiseptic surgery, 533 
morbus coxarius, 601 
Carter, diseases of conjunctiva, 904 
progressive myopia, 941 
Caustics in diseases of conjunctiva, 893 
Centennial medical commission, vii 
Chaille, address on medical jurisprudence, 167 
microscopy of blood, 487 
Chemistry, medical, address on, 49 
Children, convulsions in, 796 
partially deaf, instruction of, 992 
school, tests for hearing of, 992 
Cholera, quarantine for, 1059* 
Commission, centennial, vii 
Congenital pulsating exophthalmos, 921 
Congress, minutes of the, xxxvii 
officers of the, xi 
Conjunctiva, caustics and astringents in diseases of, 893 
Conus, 923 
Convulsions from high temperature in children, 796 
Corneal diseases, 942 
Ooxalgia. See Morbus coxarius. 
Crime, responsibility of the insane for, 1097 
Croup, pseudo-membranous, 341 
Cupples, morbus coxarius, 599 
Cysts, ovarian, 859 
Dalton, excretory function of liver, 601 
mechanism of joints, 514 
prevention of fungous growths, 508, 509 
Davis, address on progress of medical education, 265 
alcohol as food and medicine, 461 
influence of modern life on nervous diseases, 375 
typho-malarial fever, 339 
Deaf children, instruction of, 992 
and dumb, education of, 1004 INDEX 
1147 
Denison, influence of high altitudes on phthisis, 387 
Denmark, venereal disease in, 745 
Dermatology, Section on, 665 
Didama, microscopy of blood, 486, 487 
Diphtheria and pseudo-membranous croup, 341 
Disease-germs, 1011 
Diving, a cause of aural disease, 1008 
Drum-membrane, artificial, 974 
Drysdale, treatment of syphilis, <4l 
Duality of syphilis, 708 . . 
Duffy, influence of high altitudes on phthisis, 420 
Dugas, penetrating wounds of abdomen, 631 
Duhring, leprosy, 721 
treatment of syphilis, <4O 
variation in type, etc., of skin diseases, 682 et seq. 
Dulles, simple ulcer of stomach, 424 
Dumb, education of deaf and, 1004 
Dunlap, fibroid tumors of uterus, 8-4 
Ear, disease of, from bathing, etc., 1008 
early treatment in, 947 
Section on, 947 
middle, inflammation of, 988 
Eczema and psoriasis, 691 
Education of deaf and dumb, 1004 
medical, address on, 265 
of partially deaf children, 992 
Electrolysis for ovarian cysts, 859 
Enders, leprosy in Sandwich Islands, 71/ 
Engelstedl variation in type_, etc., of skin diseases, 683, 684 
venerea] disease in Denmark, <4o 
Enucleation, ovariotomy by, 801 
Epilepsy, etiology of, 378 . , 
Estlander, stone in bladder, in Finland, 662 
temperature of osteosarcoma, bob 
typho-malarial fever, 340 
Etiology of epilepsy, 378 
Eustachian tube, inflammation ot, 988 
Eve, address on surgery, 73 
Excision of lower jaw, 605 
Excretory function of liver, 489 
Exophthalmia, pulsating, 912, 921 
Eye, Section on diseases of, 893 
Femur, subcutaneous division of, 624 
Fever, puerperal, 829 
typho-malarial, 305 
yellow, quarantine in, 1059 
Fibroid tumors of uterus, 808 
Fjnland, stone in bladder in, 66-. 
Fitch paracentesis, aspiration and transfusion, 86-. 
Flint' address on medicine and medical progress, 1 
Jr excretory function of liver, 489, 002 
Fungous growths in solutions for hypodermic use, 506 
Geographical distribution of calculous disorders, 609 
Germs, disease, 1011 . 
Gestation, uterine hemorrhage 
Gibbons, croup and diphtheria, 363 
influence of high altitudes on phthisis, 422 
_ modern life on nervous diseases, 3 <4 
simple ulcer of stomach, 431 
Goodell, mechanism of labor in narrow pelves, 777, 793, 795 
noil-puerperal hemorrhages of womb, < <3 
puerperal fever, 855 
Gordon non-puerperal hemorrhages of womb, 7<4 _ 
Gouley, excision of lower jaw for phosphorus necrosis, 605 1148 
INDEX 
Grant, antiseptic surgery, 533 
morbus coxarius, 600 
Gravid uterus, retroversion of, 890 
Gray, address on mental hygiene, 205 
microscopy of brain, 1096 
provision for subjects of chronic insanity, 1143 
responsibility of the insane, 1109 
Green, J., diseases of conjunctiva, 903 
, progressive myopia, 940 
, T., influence of modern life on nervous diseases, 373, 377 
Gross, address of welcome, xxxiii 
closing remarks, xlix 
morbus coxarius, 597, 600, 602 
Hamilton, O. 0., croup and diphtheria, 365 
, F. H., antiseptic surgery, 532 
Hare, croup and diphtheria, 363 
influence of high altitudes on phthisis, 423 
simple ulcer of stomach, 430 
Harlan, congenital pulsating exophthalmos, 921 
diseases of conjunctiva, 903 
Hartshorns, quarantine, 1070, 1071 
Hearing, tests for, 958, 992 
variable, 1000 
Hextzmann, treatment of seborrhoea, 723 
— syphilis, 739, 740 
unity or duality of venereal sores, 716 
Hemorrhage, uterine, in gestation, 870 
non-puerperal, 762 
Herniotomy, opening the sac in, 634 
Hewson, antiseptic surgery, 530 
nitrous oxide as an ansesthetic, and analgesic effect of rapid breathing, 642 
High temperature, convulsions from, 796 
Hingston, morbus coxarius, 598, 603, 604 
Hip-disease. See Morbus coxarius. 
Hip-joint, anchylosis of, 624 
Histology, investigations in, 503 
Hodder, non-puerperal hemorrhage of womb, 773 
Hodge, fibroid tumors of uterus, 825 
Hodgen, antiseptic surgery, 518, 531 
Holmes, convulsions from high temperature in children, 796, 800 
Howard, croup and diphtheria, 364 
influence of modern life on nervous diseases, 375 
— pernicious progressive ansemia, 432 
Hubbard, puerperal fever, 857 
Hughes, simulation of insanity by the insane, 1110 
Hunt, alcohol as food and medicine, 452 
quarantine, 1071 
relations of pharmacist to medical profession, 1075 
Hutchinson, centennial medical commission, vii 
Hutchison, excision of lower jaw, 608 
Hyde, antiseptic surgery, 534 
excision of lower jaw, 608 
opening sac in herniotomy, 634 
Hygiene, address on. 21 
— mental, address on, 205 
Hypodermic injection, fungous growths in solutions for, 506 
Inflammation of Eustachian tube and middle ear, 988 
Insane, responsibility of, 1097 
simulation of insanity by, 1110 
Insanity, chronic, mode of providing for subjects of, 1127 
Instruction of deaf and dumb, 1004 
partially deaf children, 992 
Instruments, obstetrical, 827 
Inversion of uterus, chronic, 873 INDEX. 
1149 
Jaw, lower, excision of, 605 
Johnson, influence of high altitudes on phthisis, 422 
Johnston, microscopy of blood, 467, 486 et seq. 
Joints, mechanism of, 510 
Jones, artificial drum-membrane, 987 _ 
modes of treating inflammation of Eustachian tube and middle ear, 988 
Joynes, microscopy of blood, 488 _ 
Jurisprudence, medical, address on, 16 i 
bibliography of, 192 
Kempster, microscopic study of brain, 1083 
Kerr, quarantine, 1071 
Keyes, treatment of syphilis, <26, t39, <4O 
unity or duality of venereal sores, 715, 716 
Kimball, fibroid tumors of uterus, 824 
ovariotomy by enucleation, 806 
Kinloch, antiseptic surgery, 533 
Kirkbride, provision for subjects of chronic insanity, 1141 
Knapp, tumors of optic nerve, 905 
Labor, mechanism of, 777 
Lazarewitch, obstetrical instruments, o.j< 
Lebert, simple ulcer of 
Leprosy in Sandwich Islands, 71 < 
Lister, antiseptic surgery, 535, 541 et seq. 
excision of lower jaw, 608 
introductory remarks, 517 
morbus coxarius, 594, 601 et seq. 
treatment of aneurism, 5 <3 
Literature, medical, address on, 223 
Liver, excretory function of, 489 
Loring. progressive myopia and conus, 923, 940, 941 
Lusk, labor in narrow pelves, 793 
puerperal fever, 829, 858 
McGuire, morbus coxarius, 601 
Maddin, croup and diphtheria, 364 
influence of modern life on nervous diseases, 3 <4 
Mason, simple ulcer of stomach, 431 
Mastin, calculous disorders, 609 
Maxilla, inferior, excision of, 605 
Mears, puerperal fever, 857 
Mechanism of joints, 510 
labor, 777 
Medical biography, address on, 91 
chemistry, address on, 49 
education, address on, 265 
jurisprudence, address on, 167 
bibliography of, 192 
literature, address on, 223 
profession, relations of pharmacist to, 1075 
staff of U. S. army, address on, 286 
Medicine and medical progress, address on, 1 
preventive, address on, 21 
Section on, 305 
Membrana tympani, artificial, t i 4 
Mental diseases, Section on, 1083 
... hygiene, address on, 205 
Microscopic study of brain, 1083 
Microscopy of blood, 467 
Middle ear, inflammation of, 988 
Miner, ovariotomy by enucleation, 801, 807 
Minutes of the Congress, xxxvii 
Modern life, influence of, on nervous diseases, 356 
Moore, morbus coxarius, 598 
subcutaneous division of femur, 630 1150 
INDEX 
Morbus coxarius, 575 
Myopia, progressive, 923 
Narrow pelves, mechanism of labor in, 777 
Necrosis, phosphorus, 605 
Neftel, etiology of epilepsy, 378 
influence of modern life on nervous diseases, 374 
Nerve, optic, tumors of, 905 
Nervous diseases, influence of modern life on, 366 
Nichols, mode of providing for subjects of chronic insanity, 1127 
Nitrous-oxide gas as an anaesthetic, 642 
Non-puerperal hemorrhage of womb, 762 
Obstetrical instruments, 827 
Obstetrics, address on, 138 
Section on, 761 
Officers of the Congress, xi 
Sections, xiii 
O’Hara, simple ulcer of stomach, 431 
Oldright, croup and diphtheria, 364 
treatment of syphilis, 739 
Opening the sac in herniotomy, 634 
Ophthalmology, Section on, 893 
Optic nerve, tumors of, 905 
Orbital aneurismal disease, 912 
Osteosarcoma, temperature of, 658 
Osteotomy, subcutaneous, 624 
Otis, treatment of aneurism, 572 
Otology, Section on, 947 
Ovarian cysts, electrolysis for, 859 
Ovariotomy by enucleation, 801 
Paracentesis, aspiration, and transfusion, 862 
Parvin, address on obstetrics, 138 
non-puerperal hemorrhage of the womb, 775 
ovariotomy by enucleation, 807 
Pathological anatomy, investigations in, 462 
Peaslee, fibroid tumors of uterus, 824 
ovariotomy by enucleation, 806 
Pelves, narrow, mechanism of labor in, 777 
Penetrating wounds of abdomen, 631 
Pepper, croup and diphtheria, 362 
typho-malarial fever, 339, 340 
Pernicious progressive anaemia, 432 
Peru, Yerrugas, a disease peculiar to, 685 
Pharmacist, relations of, to medical profession, 1075 
Pharmacopoeia, universal, 1072 
Phosphorus necrosis, 605 
Phthisis, influence of high altitudes on, 387 
Pooley, antiseptic surgery, 530 
——-- diseases of conjunctiva, 904 
morbus coxarius, 601 
treatment of aneurism, 571 
Porter, unity or duality of venereal sores, 715 
Post, morbus coxarius, 597, 603 
subcutaneous division of femur, 629 
treatment of aneurism, 572 
Pseudo-membranous croup, 341 
Psoriasis and eczema, 691 
Puerperal fever, 829 
Pulsating exophthalmia, 912, 921 
Puncture of gravid uterus, 890 
Quarantine, 1059 
Rapid breathing, analgesic effects of, 642 
Rawson, vital statistics of Buenos Ayres, 1029 INDEX 
1151 
Rat, microscopy of brain, 1096 
provision for subjects of cbronic insanity, 1140 
responsibility of the insane, 1091 
• simulation of insanity by the insane, 1125 
Refraction, defects of, and myopia, 923 
Refractive lesions and corneal diseases, 942 
Responsibility of the insane, 1097 
Retroversion of gravid uterus, 890 
Richardson, J. G., excretory function of liver, 502 
fungous growths in solutions for hypodermic use, 50b, 000, ouy 
microscopy of blood, 486 et seq. 
T. G., morbus coxarius, 599 
subcutaneous division of femur, 630 
Ridge, alcohol as food and medicine, 461 
Risley, diseases of conjunctiva, 900 
progressive myopia, 941 
Rochester, convulsions in children, <99^ 
non-puerperal hemorrhage of womb, 774 
retroversion of gravid uterus, 890 
Rosebrugh, non-puerperal hemorrhage ot womb, 773 
Rudnew, investigations in histology, 503 
pathological anatomy, 4b2 
prevention of fungous growths in solutions for hypodermic use, 509 
Sac, opening the, in herniotomy, 634 
Salicylic acid, 506 
Sandwich Islands, leprosy in, 717 
Sanitary science, Section on, 1011 
Satterthwaite, antiseptic surgery, 542, 543 
disease germs, 1011 
Sayre, morbus coxarius, 575, 600 et seq. 
subcutaneous division of femur, 629 
School-children, tests for hearing of, 992 
Schools for deaf and dumb, 1004 
Scott, influence of modern life on nervous diseases, 6to 
’ simple ulcer of stomach, 430 
typho-malarial fever, 339 
Seborrhoea, 723 
Section on biology, 467 
dermatology, 665 
medicine, 305 
mental diseases, 1083 
obstetrics, 761 
ophthalmology, 893 
otology, 947 
sanitary science, 1011 
surgery, 517 
syphilis, 665 
Sections, officers of the, xiii 
Semeleder, electrolysis for ovarian cysts, 859 
Servais, subcutaneous division of femur, 629 
Shepard, non-puerperal hemorrhage of womb, <74 
Sherman, non-puerperal hemorrhage of womb, / <4 
Simple ulcer of stomach, 424 
Simpson, labor in narrow pelves, <94 
non-puerperal hemorrhage ol womb, i m 
ovariotomy by enucleation, 807 
puerperal fever, 857 
Simulation of insanity by the insane, 1110 
Skin-diseases, variations in type and prevalence of, 660 
Smith. J. L., diphtheria and pseudo-membranous croup, 341 
’ j simple ulcer of stomach, 431 
Speir, treatment of aneurism, 573 
Spencer, artificial 9Bl 
Squibb, universal pharmacopoeia, 1072 
Staphyloma, posterior, 923 
Statistics, vital, of Buenos Ayres, 1029 1152 
Stevens, corneal diseases and refractive lesions, 942 
Stilus, simple ulcer of stomach, 430 
Stomach, simple ulcer of, 424 
Stone in bladder, 609 
in Finland, 662 
Strawbridge, diseases of conjunctiva, 903 
Stuart, influence of high altitudes on phthisis, 422 
Subcutaneous division of thigh-bone, 624 
Sub-periosteal excision of lower jaw, 605 
Surgery, address on, 73 
antiseptic, 518, 535 
Section on, 517 
Swimming, a cause of aural disease, 1008 
Syphilis in Denmark, 745 
treatment of, 726, 741 
unity or duality of, 708 
Syphilography, Section on, 665 
Taylor, treatment of syphilis, 739, 740 
unity or duality of venereal sores, 715, 716 
Temperature, high, convulsions from, 796 
- of osteosarcoma, 658 
Tests for hearing, 958, 992 
Thigh-bone, subcutaneous division of, 624 
Thomson, diseases of conjunctiva, 904 
progressive myopia, 940, 941 
Todd, non-puerperal hemorrhage of womb, 775 
Toner, address on medical biography, 91 
Toxicology, address on, 49 
Transfusion, 862 
Trenholme, non-puerperal hemorrhage of womb, 774 
— puerperal fever, 857 
—— uterine hemorrhage in gestation, 870 
Tufnell, treatment of aneurism, 571, 574 
Tumors of optic nerve, 905 
uterus, fibroid, 808 
lurnbull, bathing, swimming, and diving, as causes of aural disease. 1008 
education of deaf and dumb, 1004 
Typho-malarial fever, 305 
Tyson, microscopy of blood, 487 
Ulcer, simple, of stomach, 424 
Unity or duality of venereal sores, 708 
Universal pharmacopoeia, 1072 
Uterus, chronic inversion of, 873 
——— fibroid tumors of, 808 
gravid, retroversion of, 890 
hemorrhage from, in gestation, 870 
non-puerperal, 762 
Van Buren, aneurism, 545 
- antiseptic surgery, 541 
Vanderpoel, quarantine, 1070, 1071 
Van Harlingen, variation in type, etc., of skin diseases, 684 
Variable hearing, 1000 
Venereal disease in Denmark, 745 
sores, virus of, its unity or duality, 708 
Verrugas, 685 
Vertigo, aural, 100 
Vital statistics of Buenos Ayres, 1029 
Vosburgh, non-puerperal hemorrhage of womb, 775 
Walker, responsibility of the insane, 1109 
Ward, verrugas, 685 
Weir, antiseptic surgery, 534 
Welcome, address of, xxsiii 
INDEX INDEX. 
1153 
I variation in type and prevalence of skin-diseases, 660, 681, 684 
j. p chronic inversion of uterus, 873 
1 ’ovariotomy by enucleation, 806, 807 
puerperal fever, 857 
Wilder, mechanism of joints, 514 
Williams, E., diseases of conjunctiva, 903, 904 ,• qi9 
orbital aneurismal disease and pulsating exophthaimia, 9i- 
~ H,P and astringents in diseases of conjunctiva, 893, 902, 903 
progressive myopia, 941 
Womb. See Uterus. Q 0Q~ 
Woodward, address on medical staff of U. b. army, 286 
croup and diphtheria, 363 
tvpho-malarial fever, 305, 308, 340 
Woodworth, quarantine, 1059 
Wormley. address on medical chemistry, e*c., 49 
Wounds of abdomen, 631 
Yandell, address on American medical literature, 223 
Yellow fever, quarantine in. 1059 
Yeomans, puerperal fever, 855 
simple ulcer of stomach, 430 
Zavarikini, investigations in histology, 503 
T H K EN D.