BELLEVUE AND CHARITY HOSPITAL 
REPORTS. 
1 8 7 0. 
JJATUBA 
ARTE 
NEW YORK: 
D. APPLETON ANT) COMPANY. 
90, 92 & 94 GRAND STREET. 
1870. Entered, according to Act of Consrress, in the year 1869, by 
D. APPLETON & CO., 
In the Clerk's Office of the District Court of the United States for the 
Southern District of New York. CONTENTS. 
I. 
ON AMPUTATION OF THE CERVIX UTERI IN CERTAIN FORMS 
OF PROCIDENTIA, AND REMARKS ON THE COMPLETE EVER- 
SION OF THE CERVIX UTERI. By Isaac E. Taylor, M.D., . . 1 
II. 
ON THE ANALYTICAL STUDY OF THE PULMONARY PHYSICAL 
SIGNS FURNISHED BY AUSCULTATION AND PERCUSSION. 
By Austin Flint, M. D., 69 
III. 
ON ENTIRE EXCISION OF THE OS CALCIS. By F. A. Burrall, Jr., 
M. D., 91 
IV. 
ON THE,SERIOUS CONSEQUENCES WHICH RESULT FROM THE 
NEGLECT OF SLIGHT INJURIES OF THE ANKLE-JOINT; 
ILLUSTRATED BY CASES. By Lewis A. Sayre, M. D., . .107 
V. 
A METHOD OF DRESSING FRACTURED CLAVICLE. By Lewis A. 
Sayre, M. D., 129 
VI. 
ON THE DIAGNOSTIC CHARACTERS, MECHANISM, AND PATHO- 
LOGICAL SIGNIFICANCE OF THE MITRAL DIRECT, OR OB- 
STRUCTIVE CARDIAC MURMUR, AND ON THE OCCURRENCE 
OF A TRICUSPID DIRECT MURMUR. By Austin Flint, M. D., . 135 IV 
CONTENTS. 
VII. 
ON THE MODE OF OBTAINING THE VENOUS HUM, AND THE 
VALUE OF THIS PHYSICAL SIGN. By Austin Flint, M.D., . . 143 
VIII. 
CASES ILLUSTRATING STRANGULATED ABDOMINAL HERNIA, 
WITH OTHER ABDOMINAL HERNIA, NOT STRANGULATED, OF 
UNUSUAL CHARACTER, Etc., Etc., IN ALL, SEVENTY-THREE 
EXAMPLES ; ACCOMPANIED WITH PRACTICAL REMARKS. By 
Frank Hastings Hamilton, M. D., 147 
IX. 
A CLINICAL REPORT BASED ON AN ANALYSIS OF ONE HUN- 
DRED AND TWO CASES OF BRIGHT'S DISEASES OF THE.KID- 
NEY. By Austin Flint, M. D., . ' . 227 
AMPUTATIONS PERFORMED AT BELLEVUE HOSPITAL. Compiled 
by F. J. Metcalfe, 309 
XI. 
REPORT OF CASES OF ANAESTHESIA AT THE BELLEVUE HOS- 
PITAL, WITH THE USE OF A NEW INHALING APPARATUS. 
By D. H. Goodwillie, M D., D. D. S., 317 
XII. 
REPORT OF THE PATHOLOGICAL DEPARTMENT OF BELLEVUE 
HOSPITAL. By J. W. Soutiiack, Jr., M. D., E. G. Janeway, M. D., 
and Francis Delafield, M. D., 323 
XIII. 
ON SOME OF THE EFFECTS OF EXCESSIVE INTELLECTUAL EX- 
ERTION. By William A. Hammond, M. D., 379 
XIV. 
THE HISTORY OF NINE CASES OF OVARIOTOMY. By T. Gail- 
lard Thomas, M. D., 391 BELLEVUE HOSPITAL. 
Bellevue Hospital occupies a position on the East Biver 
which has long been famous for its beauty and healthfulness. 
As early as 1786 we find it mentioned among the favorite 
resorts of persons seeking pleasure and relaxation from busi- 
ness. 
In his " Picture of New York, or the Traveller's Guide 
through the Commercial Metropolis of the United States," first 
edition, 1807, Dr. Samuel L. Mitchel thus describes Bellevue 
Hospital among the benevolent institutions of New York : " On 
the shore of the East River, about three miles from the City 
Hall, is a delightful spot, of which our celebrated country- 
man, Lindley Murray, was once the proprietor and resident. It 
has been purchased by the Common Council for an occasional 
infirmary; whither, during the prevalence of sickness in the 
city, it is thought advisable to remove those who languished. 
A more wholesome air is found here, as well as accommoda- 
tions for the sick and the convalescent. The selection of such 
a spot for the reception of the inhabitants who are suffering 
the violent assaults of the fever, redounds greatly to the feelings 
and humanity of the Common Council. In common seasons 
there are no sick persons here. This hospital is opened only 
upon extraordinary occasions." 
The early history of the hospital, and the progressive 
changes in its management down to the year 1857, were very 
accurately detailed in an address delivered on the opening of 
the new wing of Bellevue Hospital, at the request of the VI 
BELLEVUE HOSPITAL. 
Medical Board, by B. W. McCready, M. D. We quote from 
this address the following interesting historical facts : 
" Up to a very recent period, the history of the charity hos- 
pital of this city is confounded with that of the almshouse; 
the sick were received under the same roof with those who 
were unable to provide for their own necessities, and the wants 
of both were cared for by the same officers. According to in- 
formation furnished me by Mr. David T. Valentine, the excel- 
lent clerk of the Common Council, and the industrious chroni- 
cler of by-gone times in New Amsterdam, as far back as the 
year 1699, when the population of the city did not exceed six 
thousand souls, the poor received partial relief in their own 
houses, or in lodgings provided for them by the vestry. About 
fifteen years later, an almshouse was erected on the spot 
Where the City Hall now stands, and where the poor were 
maintained, partly out of what was then termed the minister's 
fund, partly by a small tax upon the inhabitants, and by vol- 
untary contributions. After the War of the Revolution had 
broken out, and previous to the occupation of the city by the 
British, the poor were removed, first to Westchester County 
and afterward to Poughkeepsie. On the conclusion of peace, 
they again returned to the city, where additions wTere made to 
the former buildings to accommodate their augmented num- 
bers. The rapid increase of the population, and the immi- 
gration which poured in from abroad soon, rendered additional 
accommodation necessary; a new almshouse was accordingly 
erected in the rear of the former one, constituting the range 
of build in o-s fronting on Chambers Street, and since known 
as the New City Hall; these were burned dowm about two 
years since. The new building was opened for the reception 
of patients in the year 1795 ; the same causes that had given 
rise to the previous changes were still at work, and in fifteen 
years' time it became necessary to make arrangements for the 
enlarged accommodation of those who were thrown upon the 
charities of the city. At that time, the grounds now occupied 
by the hospital, three miles distant from the city, were destitute 
of buildings; the neighborhood hilly, varied in surface, and 
well wooded; the shore bold ; the river, unconfined by wharves 
and bulkheads, ran two hundred feet nearer in shore than it BELLEVUE HOSPITAL. 
VII 
now does. Well might the wanderer from the distant city, as 
he saw the bank of the East River, trending away in a grace- 
full sweep toward the north, with Blackwell's Island, still 
sufficiently wooded, shutting in the view, and the low shores 
of Long Island, as yet undeformed by factories and buildings 
in his front-well, I say, might he name the place Bellevue ! 
"It was this site which was now pitched upon as suitable 
for the eleemosynary institutions of New York. Between 
twenty-five and thirty acres were purchased or taken by com- 
missioners from the Kipp and Cruger estates. The first stone 
of the building which constitutes the present hospital was 
laid on the 1st of August, 1811. During the War of 1812-'15, 
with an enemy's fleet blockading the harbor, and an enemy's 
army at one time threatening a descent upon the city, the 
work progressed slowly but steadily; finally, in the beginning 
of 1816, the new buildings were opened for the reception of 
their inmates; they consisted of the present hospital, three 
hundred and twenty-five feet in length, fifty-five in depth and 
three stories in height, with two projecting wings, which was 
designed as an almshouse, and of a large edifice, some hun- 
dred feet in the rear, which was occupied as a penitentiary. 
The stone which was employed in the buildings was quarried 
upon the grounds, and their whole cost was, as the record in- 
forms us, four hundred and eighteen thousand seven hundred 
and ninety-four dollars and thirty-four cents. 
" The hospital proper was not as yet separated from the 
almshouse and the penitentiary, but in each of those build- 
ings wards were set apart for the accommodation of those 
suffering from illness or injury. The medical supervision of 
the establishment was committed to a visiting or consulting 
physician, who visited it as often as he deemed necessary, while 
the immediate attendance upon the sick was intrusted to one 
or two young physicians who resided in the establishment; 
thus matters continued until early in the spring of 1825. 
" At that time, owing to the neglect of proper sanitary meas- 
ures, a malignant typhus or jail fever broke out in the peniten- 
tiary ; the pestilence made rapid progress ; the visiting physi- 
cian, Dr. Charles Drake, contracted the fever and was a long 
time confined to his house in the city; the two young resident VIII 
BELLEVUE HOSPITAL. 
physicians both sickened; the disease spread to the turnkeys 
and officers of the house, and general alarm was excited. Un- 
der these circumstances, Drs. Jos. Bailey, Jos. M. Smith, and 
Isaac Wood, were appointed a committe to visit the peniten- 
tiary and report upon its condition. They were received by 
one of the young men, Dr. Belden, who left his bed for the 
last time to meet them; he died a few days afterward. They 
found the prison in a dreadful condition, filthy, neglected, 
without medical attendance. On reporting to Mr. Elisha W. 
King, the chairman of the committee of the Common Coun- 
cil, he requested the doctors to take the medical charge of the 
establishment, and to do what was necessary for its renovation. 
Dr. Bailey at once, from prudential considerations, declined, 
and the task was undertaken by Drs. Smith and Wood. It 
was necessary for the penitentiary to be cleared out, but there 
was a difficulty in the way of this measure. The prisoners 
were committed for crime, and there was no power in the 
Common Council to authorize their removal from the peni- 
tentiary. Application was at once made to Albany, and an 
act hurried through the Legislature, authorizing the temporary 
removal of the prisoners. The building lately occupied as 
the House of Refuge, but originally erected, on the recom- 
mendation of Dr. David Ilosack, as a fever hospital, was then 
nearly finished. It was hastily fitted up, and the prisoners, 
washed, cleansed, and new clothed, were one by one trans- 
ported to it; no want of ventilation there, for the rooms 
were still unceiled; some of the windows boarded up, some 
imperfectly glazed ; air found ready admittance through 
many a crevice, while guard was regularly mounted over the 
prisoners, to prevent their running away when convalescent. 
In a month the pestilence was at an end. Over sixty prisoners 
were attacked by it, after Drs. Smith and Wood took charge 
of them ; of these only five died, but the keepers, the turnkeys, 
the nurses, and the medical assistants, fell victims in far larger 
proportions, and for a long time dropping cases occurred 
through the city, which could be traced to the jail fever of 
the penitentiary. 
" This occurrence led to a change in the medical depart- 
ment of the almshouse, and Dr. Isaac Wood, who, on the res- BELLEVUE HOSPITAL. 
IX 
ignation of Dr. Drake, served during the remainder of the 
year as visiting or consulting physician, was, in January, 
1826, appointed resident physician. With Dr. Wood's ap- 
pointment commenced the permanent separation of the hos- 
pital from the almshouse; indeed, the number of the sick 
poor had now so increased as to demand a separate establish- 
ment. The fever hospital, finished and properly fitted up, 
was appropriated exclusively to those requiring medical or 
surgical treatment. For seven years, from January, 1826, to 
the same month in 1833, Dr. Wood ably, and to the satisfac- 
tion of the authorities and the public, discharged the duties of 
his office. lie then resigned, and was succeeded by Dr. Ste- 
venson, a gentleman of liberal education and large attainment, 
but ignorant of hospital duty. Dr. S. served but a year, and 
then gave place to a gentleman whom we all know and esteem 
-Dr. Benj. Ogden. In 1837 Dr. Ogden was removed on po- 
litical grounds, and Dr. Van Ilovenberg was resident physician 
for two years. In 1839 Dr. Van Hovenburg, having been re- 
moved, was again succeeded by Dr. Ogden, who finally re- 
signed his office in 1840. The next seven years saw a rapid 
change of physicians; the office having become a prize for po- 
litical partisans, every fluctuation of party-power brought with 
it a change of residents. Old abuses, some of them incident 
to the character of many of the inmates of the establishment, 
where the details of the administration were chiefly intrusted 
to young men, repressed with a strong hand during the firm 
and enlightened administrations of Drs. Wood and Ogden, 
CT CT 7 
broke out with fresh virulence. Licentiousness, disorder, and 
filth, reached a disgraceful height. While stating the facts, let 
us not blame too harshly the various residents; for the most 
part, without experience of hospital duty, they found them- 
selves at the head of an immense establishment, the govern- 
ment of which was too much for one person, even of the high- 
est administrative and professional ability. Under them were 
placed the young men, advanced students, or newly-graduated 
physicians, who obtained their appointments by paying a fee 
to the resident. The latter became bewildered by the weight 
and magnitude of their duties, and, after perhaps an ineffectual 
struggle, acquiesced in a state of things they were powerless X 
BELLEVUE HOSPITAL. 
to prevent, or, if they continued to struggle on, the disorder 
was too deeply rooted to be extirpated during the short time 
they continued in office. A thorough change in the mode of 
governing the establishment was needed, and it came at a time 
when the epidemic occurrence of typhus fever raised the exist- 
ing evils of the establishment to a culminating height. A 
committee of the Common Council, consisting of James D. 
Oliver, Washington Smith, and George II. Purser, to whom 
the subject of the reorganization of the medical department of 
the public charities was referred, called to their aid a number 
of prominent medical men, and with their assistance drew up 
a plan for its future government. With the exception that 
the office for resident physician was retained, this is the plan 
which is still in force, and with it a new era commences in 
the history of our institution. In 1849 the office of resident 
physician was abolished by the Board of Governors of the 
almshouse, to whom the control of the establishment had 
passed, and the administration of the medical department 
given over entirely to the Medical Board. A few words will 
complete the sketch I have attempted of the history of our in- 
stitution. On the completion of the penitentiary on Black- 
well's Island, the convicts were transferred from the building 
in the rear of the present edifice, and this last was occupied as 
a hospital. In 1848 the almshouse was removed to the build- 
ing erected for it on the island, and the hospital took its place; 
the extensive grounds of Bellevue were cut up, and the larger 
portion sold. The old penitentiary and fever hospital can now 
scarce be recognized, and in a few years no trace of them will 
remain; let us hope that the hospital may here be permanent; 
a more convenient, beautiful, and salubrious site could scarcely 
be obtained. 
" The same causes which have led to such repeated changes 
in the location of our charitable establishments, to such re- 
peated calls for their enlargement, are still in operation. As 
our population increases, vice and destitution increase in a 
much greater ratio. For several years back the hospital has 
been at times so crowded that it has been necessary annually 
to open the garrets for the accommodation of patients ; dark, 
low, unceiled, ill-ventilated, stifling in summer, freezing cold BELLEVUE HOSPITAL. 
XI 
in winter, they were never intended for habitation, and the 
measure was only had recourse to when forced upon us by 
necessity. But the Governors have felt that we have no right 
to poison our patients by confined air, or injure them by un- 
necessary exposure; that economy ceases to be a virtue wdien 
it leads to needless suffering and loss of life; that the tax- 
payers of our city, heavily as they may be burdened, would 
sustain them in an expenditure necessary for the well-being of 
the sick poor. A new wing has been provided, plain, but well 
adapted to the purposes which it is to subserve, with admirable 
arrangements for the comfort and cleanliness of the patients. 
Another year will behold the complete renovation of the old 
building: Croton water, gas, and proper heating apparatus 
will be introduced, and the addition of another story will give 
us ample room for the classification and treatment of our 
patients; thus the spread of puerperal fever, erysipelas, and 
typhus, will be stayed, and the mortality and average duration 
of the illness of the patients be diminished. 
" And let us here observe, New York is peculiarly situated 
in regard to hospital accommodation. Within a comparatively 
short period, from the size of a provincial town, she has grown 
to the proportions of a metropolis; her population, in the time 
allotted to the life of man, has swollen from thirty thousand to 
eight hundred thousand, and she has had, within a compara- 
tively short time, to provide institutions and public buildings 
which, in other countries, have been the growth of centuries. 
She has far less hospital accommodation than any European 
city approaching her in size. There, hospitals have been the 
growth for centuries of the union of private charity with the 
fostering care of government. In 1840, over fifteen million 
francs, or three million dollars, were expended by the ad- 
ministration of the hospitals of Paris, and a large portion of 
this sum was derived from the revenue of real estate belonging 
to the hospitals, and from bequests by charitable individuals. 
Dublin has eight considerable hospitals, some of them richly 
endowed by private charity, and yet this year the Government 
of Great Britain aids them with a grant of sixteen thousand 
pounds, or eighty thousand dollars. In London, Guy, the 
founder of Guy's Hospital, after spending one hundred thou- XII 
BELLEVUE HOSPITAL. 
sand dollars in erecting the building, bequeathed it over a mil- 
lion dollars. Here our rich men have not yet had time to die 
and endow hospitals, and yet the need for them exists and must 
be met; the sick poor cry aloud to us to aid them, or they 
perish; and whatever, in other respects, may be our short- 
comings, as a New-Yorker, I am proud to say that here such 
an appeal has never been made in vain. Let the public be 
convinced of its truth, and it will demand that it be answered. 
This necessity for increased hospital accommodation in the city 
has indeed been felt for some time, and the additions to the 
City Hospital, St. Vincent's Hospital, that of the Jews, and 
the noble building of St. Luke's, have been products of its 
manifestation. These last may, and probably will, like the City 
Hospital, become the germs of magnificent institutions. They 
will absorb a portion of the destitution which increases with 
our wealth and population; but we cannot wait until the 
death or suffering of thousands awakens private charity from 
its slumbers. The need was upon us, was felt now, and the 
Governors of the Almshouse have met it. 
" On first entering on their duties at Bellevue, the Medical 
Board at once aimed at rendering the institution serviceable 
for the clinical teaching of medicine ; they believed that they 
would thus elevate the character of the institution ; make it 
an honor to be connected with it; secure the best attainable 
professional services for its inmates, and partly repay the pub- 
lic for the cost of its maintenance, by improving the education 
of the rising generation of medical men. These views have 
since undergone no change; on the contrary, every year 
strengthens and confirms them. Last winter three hundred 
students were present at one time, to witness an operation per- 
formed by one of the visiting surgeons, in the theatre of the 
hospital. Could such an audience have been drawn together 
by mediocrity ? or, if drawn together by fortuitous circum- 
stances, would mediocrity and ignorance have dared to face it ? 
Would they not blush in the presence of those who, to a great 
extent, are able to appreciate their acts? Would they not 
tremble and shrink under the indignant criticism they would 
excite ? Things are not done here in a corner, and the veil of 
silence and oblivion drawn over our mistakes. Discussion, BELLEVUE HOSPITAL. 
XIII 
inquiry, and remarks are invited, challenged, and we must be 
prepared to meet the criticism we provoke. If not impelled 
by a higher motive, a sacred regard for that most precious of 
all precious things-human life-a regard that underlies the 
character of every true physician-would not the care of their 
own interests and reputation force upon them the most sedu- 
lous attention to their patients ? 
" Medicine cannot be properly taught by books and col- 
legiate lectures alone. To recognize disease we must be 
familiar with its aspect. The student may be crammed with 
all the knowledge of the books, and yet, if he has had no 
clinical teaching, when dismissed with his diploma to practise, 
he will have to acquire experience at the cost of suffering to 
his patient, and terrible anxiety to himself. Such experience 
can only be acquired within the walls of a large hospital, and 
Bellevue has already become the great clinical school of the 
city. Daily the visiting physicians and surgeons are accom- 
panied by as many students as can profitably avail themselves 
of their instructions ; and we doubt not the instructions thus 
received will be found a source of comfort and relief in many 
a far-off* country spot, where the young physician, with no one 
near to aid him, is forced to rely solely on his own exertions. 
" In nominating the young men, who, under the visiting 
physicians and surgeons, have the immediate care of the 
patients, it has been customary, in most hospitals, for the 
officers to use their right of nomination in rotation, thus secur- 
ing the most desirable situations for their own private students, 
or obtaining a fee for the favor they conferred. It was at 
once determined, by the Medical Board, to do away with all 
such privileges for themselves, to throw the places open to 
general competition, and to select as their candidates those 
who, on trial, prove most worthy. Such has been our in- 
variable practice. No questions are asked as to where a 
young man was born ; from what State he came, or from what 
college he graduated. All are received upon one common 
footing; all are examined by the same committee, and, after 
the examination, the only question mooted is the relative merit 
of the candidates; that this course is the most conducive to 
the interests of the patients there can be no doubt; we believe XIV 
BELLEVUE HOSPITAL. 
it to be equally conducive to the interests of the young men 
themselves. They know the terms upon which they are to be 
received, that they must stand upon their merits alone, and 
many a young man has been, and will be, incited to the more 
strenuous prosecution of his studies, by the hope of entering 
Bellevue Hospital. To this rule we owe the efficiency of our 
medical staff. Nowhere will be found a more intelligent, bet 
ter informed, or more capable set of young men, and from 
among them we look for those who are to be the future pride 
and honor of our profession. 
" So far, gentlemen, as to our views and expectations; but 
what has been the effect of the changes in the Medical De- 
partment on those who are most deeply concerned-on the 
destitute sick who have been committed to our management ? 
For twenty years previous to the change, the average annual 
mortality of the institution was twenty per cent. ; since that 
change, in 1848, the average was reduced to sixteen per cent.; 
in 1849, to thirteen; since that, last year, the medical man- 
agement has been exclusively under the supervision of the 
visiting physicians and surgeons-and, notwithstanding that 
the number of patients is nearly double what it was in 1847, 
the mortality has been diminished to an average of ten per 
cent. In the preceding six years, thirty-five thousand and 
eighty-eight have been under treatment in the hospital. Now, 
gentlemen, look at this matter in what light you may, scru- 
tinize it as you please, make every allowance and deduction 
that the most ingenious criticism will enable you to make, and 
yet the great fact stands out-nearly six hundred lives saved 
per annum ! Nearly six hundred human beings, who would 
otherwise have been consigned to an untimely tomb, preserved 
for the enjoyments, the trials, and the duties of life ' What a 
mass of misery and suffering prevented! Nay, if we believe 
what is indubitable, that faults of omission are almost equally 
criminal with faults of commission, that when a human being, 
whose life might have been saved, is suffered to die, the 
responsibility must rest somewhere, either with individuals or 
with the community, what a mass of crime is prevented ! In 
six years, three thousand five hundred lives saved-three 
thousand five hundred murders prevented-is not that some- BELLEVUE HOSPITAL. 
XV 
thing of which all who have been connected with the present 
organization of the hospital, whether it be the members of the 
Common Council who originated it, or the Board of Govern- 
ors who perfected it and carried it out, or the medical men 
who have been their instruments-is not that something in 
which we can all rejoice-something regarding which we can 
feel with pride that w'e have deserved well of the community ? 
" With enlarged space, with improved ventilation, may we 
not hope that a still further saving of human life may be 
effected ?-that, with the additional facilities wisely and kindly 
afforded us by the Board of Governors, the number of students 
who seek practical instruction at our hospital may be in- 
creased ?-that from it the blessings of sound, practical med- 
ical instruction may be scattered broadcast through the State 
and the country; and that Bellevue, preeminent as it is in 
extent, and in the beauty and salubrity of its site, may be 
equally preeminent in the successful cultivation of medical 
science, and in the relief of human suffering ? " 
The hospital continued under the management of the Gov- 
ernors until the year 1860. During the period from 1857 to 
1860, the improvements in its construction, in its appoint- 
ments, and in its management, were steadily prosecuted; the 
wards were rearranged and better ventilated; the accessory 
buildings were enlarged and improved; the nurses were se- 
lected with greater care; and all the necessities of a large 
hospital were still further perfected. The advantages of the 
hospital for medical instruction were liberally developed, and 
every needed opportunity was given to subordinate this im- 
mense storehouse of clinical and pathological facts to the in- 
terests of practical medicine, surgery, and obstetrics. At the 
close of the term of service of the Governors, this hospital had 
become the habitual resort of the students attending the va- 
rious medical schools of the city, and was fairly recognized by 
the medical profession as the legitimate field for clinical study 
and observation. 
On the 17th of April, 1860, the Legislature passed a law 
organizing the department, and conferring upon the Comp- 
troller of New York the power of appointing four Commis- 
sioners of Public Charities and Corrections, whose terms of of- XVI 
BELLEVUE HOSPITAL. 
lice should be six years. The commissioners appointed were 
Simeon Draper, Esq., Moses II. Grinnell, Esq., Isaac Bell, 
Esq., and James B. Nicholson, Esq., and on the 21st day 
of April, 1860, they organized by the election of Mr. Draper 
as president, and Mr. Bell as secretary. Mr. Draper, who 
had previously been a member of the Board of Governors 
and had long taken an active interest in those institutions, 
entered upon the work of reorganization with great zeal and 
energy, and was ably seconded by the other members of the 
commission. The reforms instituted were of the most radical 
kind, giving to every branch of the service the greatest econ- 
omy and efficiency. Mr. Draper remained connected with 
the department until nearly the close of his official term of 
office, when he withdrew to accept the appointment of Col- 
lector of the port of New York. Although he was not again 
connected with the commission, his personal interest in these 
charitable institutions ceased only with his death in 1866. 
We cannot pay a more fitting tribute to the memory of 
Mr. Draper, than by placing on record in this volume, the 
preparation and publication of which he several years since en- 
couraged, the following extract from the address of the Gov- 
ernors of the Almshouse on his retirement from the presiden- 
cy of that body in 1856 : " For more than seven years, irrespec- 
tively of domestic and personal claims upon his leisure from or- 
dinary business, and, to some minds, the far stronger claims 
of weariness that asks some respite, regardless of weather, 
whether storm or sunshine, during the most pestilential, as 
well as the most healthy seasons, Governor Draper, with 
the watchfulness and regularity of a military sentinel, has 
never failed, always once, and frequently twice a week, to 
visit those outposts of crime and suffering, the various depart- 
ments of our official care, in which he has ever taken so kindly 
an interest. lie has superintended them all so faithfully and 
closely, that as the result he is not more known by the inmates 
than beloved. To the children he is an object of especial at- 
tachment. The poor, miserable, abandoned child-the worse 
than orphan outcast, whose parents have been to it a curse 
rather than a blessing-has found in him a thoughtful protec- 
tor ; a guardian possessing a heart as well as a head." BELLEVUE HOSPITAL. 
XVII 
On the expiration of the term of service of the first Board of 
Commissioners in April, 1865, Mr. Draper and Mr. Grinnell 
retired from the commission, and Mr. Bell and Mr. Nicholson 
were reappointed, together with James Bowen, Esq., and Owen 
W. Brennan, Esq., who form the present Commission of Pub- 
lic Charities and Corrections. 
The following statement, from the annual report for the 
year 1868, exhibits the capacity of the hospital, and the results 
of treatment of those who enter its wards : 
The number of patients remaining in hospital, January 1, 1868, was.. 691 
The number of admissions during the year was 5,800 
The number of births during the year was 594 
Total number of patients treated during the year 7,085 
The number of patients discharged, cured, or relieved during the 
year was 5,597 
The number of deaths during the year was 795 
6,392 
Total number of patients remaining in hospital under treatment, De- 
cember 31, 1868 693 
PHYSICIANS AND SURGEONS OF BELLEVUE HOSPITAL FROM 1847 TO 1870. 
Name and Position. 
Date of Ap- 
poinlment. 
Date of Death or 
Resignation. 
Valentine Mott,1 M. D., Surgeon, 
1847 
Died, 1865 
John W. Francis,2 M. D., Physician, 
1847 
" 1861 
James R. Manly,3 M. D., Physician, 
1847 
" 1851 
Alexander II. Stevens,4 M. D., Surgeon,.. .. 
1847 
" 1869 
Willard Parker,5 M. D., Surgeon 
1847 
Resigned, 1853 
James R. Wood, M. D., Surgeon, 
1847 
Wm. II. Van Buren,6 M. D., Surgeon, 
1847 
" 1853 
John T. Metcalfe,7 M. D., Physician, 
1847 
" 1859 
John 0. Stone, M. D., Surgeon, 
1847 
" 1854 
F. Campbell Stevens, M. D., Surgeon, 
1847 
" 1848 
S. R. Childs, M. D., Surgeon, 
1847 
" 1850 
A. G. Elliot, M. D., Physician, 
1847 
" 1849 
Alonzo Clark, M. D., Physician, 
1847 
1 Consulting Surgeon, 1847-1865. 2 Consulting Physician, 1847-1861. 
3 Consulting Physician, 1847-1851. 4 Consulting Surgeon, 1847-1869. 
6 Associate Surgeon, 1856-1868. Consulting Surgeon, 1868. 
6 Consulting Surgeon, 1868. 7 Consulting Physician, 1868. XVIII 
BELLEVUE HOSPITAL 
Name and Position. 
Date of Ap- 
pointment. 
Date of Death or 
Resignation. 
C. R. Gilman, AI. D., Physician, 
1847 
Resigned, 1850 
Stephen Harris, AI. D., Physician, 
1847 
" 1848 
S. Conant Foster, AI. D., Physician, 
1847 
" 1853 
B. W. AlcCready, AI. D., Physician, 
1847 
A. Vach6, AI. D., Surgeon, 
1848 
" 1848 
Isaac Green, AI. D., Surgeon, 
1849 
Died, 1854 
Thomas F. Cock, AI. D., Physician, 
1850 
Resigned, 1855 
A. B. Robeson, AI. D., Physician, 
1850 
Died, 1853 
Charles D. Smith, AI. D., Surgeon, 
1850 
Resigned, 1859 
Isaac Wood,1 AI. D., Consulting Physician,.., 
1851 
Died, 1868 
James C. Forrester, AI. D., Physician, 
1853 
" 1854 
John J. Crane, AI. D., Surgeon, 
1853 
Lewis A. Sayre, AI. D., Surgeon, 
1853 
Isaac E. Taylor, AI. D., Physician, 
1853 
George T. Elliot, AI. D., Physician, 
1854 
John A. Lidell, AI. D., Surgeon 
1854 
Resigned, 1859 
Stephen Smith, AI. D., Surgeon, 
1854 
B. Fordyce Barker, AI. D., Physician, 
1855 
John W. S. Gouley, AI. D., Surgeon, 
1859 
Alexander B. Alott, AI. D., Surgeon, 
1859 
Charles T. Aleir, AI. D., Surgeon, 
1859 
Died, 1863 
William H. Church, AI. D., Surgeon, 
1859 
" 1866 
Alfred 0. Loomis, AI. D., Physician, 
1859 
John W. Green, AI. D., Physician, 
1859 
Resigned, 1869 
Theodore G. Thomas, AI. D., Physician, 
1860 
Austin Flint, AI. D., Physician, 
1861 
Frank H. Hamilton, AI. D., Surgeon, 
1861 
Henry B. Sands, AI. D., Surgeon, 
1866 
Thomas AI. Alarkoe, AI. D., Surgeon, 
1868 
Austin Flint, Jr., AI. D., Physician, 
1869 
1 Consulting Physician, 1851-1868. Internal on. 
Cervix Everted. 
External oa. 
b'romNatureby R.Kohler. 
Cervix Re-evertedu BELLEVUE AND CHARITY HOSPITAL REPORTS. 
I.-PROCIDENTIA UTERI. 
On Amputation of the Cervix Uteri in certain forms cf 
Procidentia, and remarks on the Complete Eversion of the 
Cervix Uteri. By Isaac E. Taylor, M. D., Emeritus 
Professor of Obstetrics and the Diseases of Women and 
Children in the Bellevue Hospital Medical College, At- 
tending Physician to Bellevue and the Charity Hospital, 
Consulting Physician to the State Woman's Hospital, etc. 
" Prolapsus uteri " and " procidentia uteri" are the terms 
generally employed to indicate the descent of the uterus from 
its normal position in the pelvis; 
This displacement is ordinarily divided into three degrees: 
1. A settling down of the uterus, as if from relaxation. 
In this case the uterus descends toward the lower part of the 
pelvis, shortening the vagina in proportion as it tills the 
upper portion of its cavity, which it distends and pushes be- 
fore it. 
2. The same prolapsus, or descent, is characterized by 
the presence of the os tincse at the vulva. The uterus rests 
on the internal surface of the perinmum, and tills the vagina, 
the upper half of which becomes folded within itself, like the 
linger of a glove, with its top turned inward (Gardien). The 
uterus thus situated takes the direction of the axis of the out- 
let of the pelvis, that is, of the vagina. 
3. In complete prolapsus, or procidentia, the womb has 2 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
escaped from the vulva, or os externum. It has now passed 
the inferior strait, or hangs between the thighs, covered by 
the vagina. The vagina is invaginated, or turned wholly in- 
side out, and embraces not merely the uterus, and its appen- 
dages, but also the bladder, part of the rectum, and some 
portion of the intestine (Kerkringius, Duges, Saviard). It 
may contain not merely the uterus, but frequently the ova- 
ries, with large portions of the round and broad ligaments, 
portions of the small intestines, the bladder, and rectum 
(Hodge). 
It is upon this last, or third degree, I propose offering some 
practical observations in the following paper: 
The preceding divisions, and the opinions relating to them, 
which I have given, are from the highest obstetrical authori- 
ties, both abroad and in our own country. They have been 
the recognized views of the medical profession for a very long 
period. Their correctness, however, has been called in ques- 
tion within the last few (ten) years by M. Huguier.1 
An elaborate memoir was afterward presented by M. 
Huguier to the Academie de Medecine, in Paris, March 8, 
1859, " sur les allongements hypertropkiques du col de Tute- 
rus, dans les affections designees sur les noms de descente de 
precipitation de cet organe, et sur leur traitement^ par la 
resection en V amputation de la totalite du col suivant la 
variete de la maladies2 
In this memoir M. Huguier maintains that the ordinarily- 
received opinion is erroneous, and denies emphatically that the 
appearance of the os uteri at the vulva, or of a greater or less 
portion of the uterus itself'beyond the external organs of genera- 
tion, is the result of a displacement of the organ, or a general 
lowering, or that it is a true and complete prolapsus en totalite. 
He holds that this can be shown to depend on inaccurate obser- 
vations. He contends that when the uterus appears externally, 
and even when the vagina is completely inverted, and the uterus 
appears to be entirely prolapsed between the thighs, this con- 
dition is not due to the fact that the organ has been generally 
1 Gazette Ueldomadaire of 1858. 
' M6moires Academie de Alddecine, tome 33. AMPUTATION OF THE CERVIX UTERI. 
3 
lower in the level, and had completely left the pelvic cavity, 
but rather to the partial or general hypertrophic elongation 
of the supra-vaginal portion of the cervix. The best proof he 
alleges that can be given of this is, that in almost all the 
cases the fundus of the uterus continues habitually in its 
normal situation, sometimes a little higher, sometimes a little 
lower, but it always remains in the cavity of the pelvis. In 
one case it floated in the cavity of the abdomen. If wTe ex- 
amine the tumor with care, and measure its cavity by means 
of the hysterotome, or any other appropriate instrument, the 
elongation is easily detected. We can also equally assure our- 
selves of the presence of the body of the organ in the pelvis 
by careful palpation of the tumor externally; and sometimes 
by abdominal palpation, or by the rectal touch, we may feel 
the fundus or the length of the tumor. 
The two principal lesions and varieties of the longitudinal 
hypertrophy are those which affect the uterine neck above or 
below the insertion of the vagina, and constitute two different 
diseases, although their nature may be the same. 
M. Huguier confines himself, in the second part of his 
monograph, to the consideration of the longitudinal hypertro- 
phy, which simulates, accompanies, or determines the descent 
of the uterus, and not to the eccentric form. These two con- 
ditions, or lesions, demand separate considerations, as the lon- 
gitudinal hypertrophy below the insertion of the vagina is 
not of so much importance. It is easily and simply treated, 
and will not claim our notice at this time. 
The other, the longitudinal hypertrophy of the cervix 
uteri, above the insertion of the vagina, or supra-vaginal por- 
tion, is of more importance, and I desire to invite attention to 
it in this article. 
The proposition and negation of M. Huguier, in opposition 
to the usually received views and opinions, are the result of 
fifteen years' investigation and labor. After having searched 
through the various authors who had written on this subject 
during the last century and a half, he finds no valid proof of 
a complete case of prolapsus uteri, except two observed by 
MM. Morel-Lavallee and Blandin. Huguier knows of no 
others where the characters of the affection have been de- 4 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
scribed in such a manner as to leave no doubt as to its exact 
nature. He therefore denies the frequency of the complete 
prolapsus; maintains that it is rarely seen, and that it has 
generally been confounded with the hypertrophic elongation 
of the superior part of the uterine neck. M. Huguier, to sub- 
stantiate his views, establishes three kinds of proof: 
1. Historic researches. 
2. Pathological anatomy. 
3. Clinical facts. 
Under the first head, reference is made to cases related by 
Saviard, Morgagni, Dance (1829), and Jules Cloquet. Under 
the second head, the magnificent work of Cruveilhier is ap- 
pealed to. All cases where procidentia existed consequent on 
considerable peritoneal effusion, or with very voluminous ova- 
rian cysts, where the pelvic organs are apt to be pushed down- 
ward, are excluded. 
All cases of slight descent of the uterus, described by au- 
thors under the name of semi-prolapsus, and even those 
where the neck and vulvo-uterine canal, partly inverted, pro- 
jected from two to three centimetres (i. e., from three-quarters 
to one inch) from the vulva, were also excluded. 
3. Clinical Facts.-There were sixty-four cases Cl pretended 
complete prolapsus, and of this number only two were in- 
stances of true and complete prolapsus, unaccompanied by 
hypertrophic elongation. 
In a third case, and the only one of that nature, there was 
at once complete prolapsus, retroflexion, and elongation of the 
uterine neck above the insertion of the vagina. 
It cannot be denied that much credit is due to M. Huguier, 
desirous, as he is, of establishing a more modern view respect- 
ing that affection, in presenting to the profession the results 
of his close and careful investigation after such an interval of 
time, and offering, as it does, a new factor in the causes of 
procidentia uteri. But virtually he resuscitated an old opin- 
ion long since expressed. His memoir is very extensive, and 
one of the most beautifully illustrated works that has ever 
been produced on uterine disease. Previous to the publica- 
tion of M. Huguier's memoir in the Gazette Ileljdomadaire^ 
Morgagni, in his forty-fifth letter, indicates the same fact. AMPUTATION OF THE CERVIX UTERI. 
5 
But this fact, it appears, has, in an especial manner, been 
noticed by M. Levret, Journal de Medecine, et Clwrurgle, et 
de Pharmacie^ par Roux (1775), tome xh, p. 352. The essay 
of M. Levret is entitled " Sur un allongement considerable qui 
survient quelque du col de la matrice." 
This paper appears to have been overlooked by M. Hu- 
guier, although he refers to some remarks of M. Levret, who 
differs from him. M. Huguier uses the word "liypertro- 
phique " instead of " considerable " in the title. Levret 
reports four observations, in which there is a correct and 
excellent description of this lesion, and indicates the same 
diagnostic sign as M. Huguier, as new and original. The 
same view and method were adopted by Morgagni, who 
only decided his case by the stylet. 
Levret introduced a whalebone stylet to ascertain the 
exact depth of the uterus, and expresses the opinion that 
none of the old obstetrical authors had known of these cases, 
where the neck of the uterus may sometimes lengthen at this 
spot to acquire five to six inches or more, without the body 
being displaced, and when it was still in the pelvis. As this 
appears to be so very exact and correct a description of this 
lesion of the uterus, referred to by M. Huguier, then Levret 
must be in advance of M. Huguier a full century. The only 
difference, however, between M. Huguier and M. Levret-and 
I think it a very important and material one-is this, that M. 
Huguier considers the hypertrophic elongation as generally 
existing; while M. Levret considers that the longitudinal 
hypertrophy of the uterus is accompanied always by only a 
partial degree of descent of the uterus. 
M. Huguier speaks of the affection as a true hypertrophy. 
M. Levret passes no opinion respecting its pathological char- 
acter, and regards the lesion as only another variety of pro- 
lapsus, and says: " The tumor of which we have spoken is a 
fourth species, composed of an inverted vagina, and the cervix 
of the womb lengthened, without containing the body of this 
organ." 
From this investigation, it appears that M. Huguier is not 
original in presenting this view of the form of disease (so- 
called prolapsus) under consideration. He is entitled to, and 6 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
certainly should claim, the credit and honor of having called 
the attention of the profession anew to the subject. 
He proposes, as a general method of treatment in this 
class of cases, the amputation of the cervix uteri by the re- 
moval of a conical-shaped portion from the hypertrophied 
part, whether this should be a case of elongated or eccentric 
character. For procidentia uteri, this had not, I believe, been 
recommended before, though Lisfranc had, for other diseased 
conditions of the infra-vaginal portion of the cervix, adopted 
the amputation of the cervix uteri. 
This special lesion of the uterus, as a cause and factor in 
producing prolapsus uteri, had only occasionally been recog- 
nized in ancient times. In more modern times it has attracted 
recently some attention. 
In the museum of St. Bartholemew's Hospital, series 32, a 
specimen is referred to by Dr. West, in his work on Diseases 
of Females (pp. 96, 158, 160). Virchow, in the " Geburt- 
shiilfe," vol. ii., p. 205, especially uses the name of " prolapsus 
de la matrice sans descent," or without sinking of the fundus. 
Mayer, of Berlin, refers to some cases of a like nature. 
Cruveilhier, in his " Pathological Anatomy," states that he 
has invariably observed in prolapsus of the womb an elonga- 
tion of that organ, accompanied with great contraction and 
narrowing, which occurs principally at the junction of the 
body with the neck. 
But he also observes that sometimes this elongation exists, 
and at other times the descent of the womb is greatest, evi- 
dently establishing two varieties of prolapsus uteri, one with 
descent of the body, and one without descent of the body, of 
the uterus. In some instances he found the lengthening so 
great that, when seen within the pelvis, the womb appeared 
to occupy its proper position, and, under these circumstances, 
it commenced with the inversion of the vagina. Jules Clo- 
quet figures a case in his " Pathological Anatomy " {surgical, 
translated by Cowperthwait, 1832, and which M. Huguier 
refers to as well as M. Cruveilhier). 
Dr. Heming, the translator of Boivin and Duges's work 
on " Diseases of the Uterus," reports in the Edinburgh Medi- 
cal and Physical Journal, as far back as 1832 (August, vol. AMPUTATION OF THE CERVIX UTERI. 
7 
Ixviii.), that he has seen several cases, and says that it is high- 
ly important to recognize the distinction between this disease 
and simple prolapsus. Sufficient has been adduced to show 
that longitudinal hypertrophy of the supra-vaginal portion of 
the cervix uteri has been recognized by modern authorities. 
But with all this it has not received and claimed that atten- 
tion which it merits, not only in a pathological point of view, 
but as regards the treatment applicable to it. Becquerel, in 
his " Maladies de 1'Uterus," figures, in his plate six, a case 
measuring five and a half inches. The cases of Heming, 
West, and others, were uncomplicated cases of the disease. 
Those of Cruveilhier, Cloquet, and Iluguier, had a fibrous 
tumor or polypus in the body of the uterus. In these cases the 
tumors may justly be considered as one of the causes in 
producing or aiding the hypertrophic growth of the uterus. 
At this time I recall to mind the case of Mrs. V. (1857), 
whose uterus measured seven and a half inches, and which, 
under the treatment that was adopted, was reduced to three 
and a quarter inches after a few months. The patient suc- 
cumbed a few months after this to tuberculous disease, and, on 
post-mortem examination, the uterus w'as found adherent to 
the colon, and a small fibrous tumor existed in the walls of the 
uterus, just where the body joins the cervix. 
With all that we have advanced on this subject respecting 
its history, can we yield assent to the views that M. Huguier 
has promulgated-that the complete exit of the uterus from 
the vulva is so exceedingly rare, while longitudinal hypertro- 
phy of the cervix above the vagina is so generally frequent, 
and the fundus of the uterus habitually near its normal po- 
sition ? 
Scanzoni, Hodffe, and Meigs, do not treat of or make any 
mention of it, and Dr. Sims, in his recent work on " Surgical 
Diseases of Females," merely refers his readers to the work of 
M. Iluguier for further information. It is evident that very 
different views at the present day are entertained by gyne- 
cologists regarding the true meaning of the term procidentia 
uteri. If these views of M. Iluguier are correct, it certainly 
must be apparent that other means should be adopted than 
appliances of various kinds, such as pessaries, or the opera- 8 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
tions of episiorhaphy or elytrorhaphy alone, for the radical 
cure of procidentia nteri; therefore, I think it follows that if 
true hypertrophic elongation of the supra-vaginal portion of 
the cervix uteri exists, they could not individually succeed. 
Grailly Hewitt (1865), in his work on "Diseases of Wo- 
men," remarks that " the proper management of these cases 
must be considered as still open to question, the views of Hu- 
guier not having as yet obtained the sanction of all the best 
authorities on the subject." 
I have spoken, in the commencement of this paper, of the 
three divisions or degrees of prolapsus, which gynecologists 
have usually adopted. Chelius, however, for simplicity of 
arrangement, makes but two divisions, though he recognized 
sometimes the pathological changes in the tissue of the uterus. 
He divided the prolapsus into " complete and incomplete In 
the " complete," the organ projects entirely out of the exter- 
nal parts, and a probe may be introduced into the mouth of 
the womb, not more deeply than two inches. 
Paul Dubois adopts only the two degrees. The complete, 
according to this order, is when the uterus has passed the in- 
ferior strait, and the organ is totally without the pelvis (Chute 
de 1'Uterus, Die., 30 vols.). Scanzoni regards it as complete 
prolapsus when the organ passes the vulva externally, and 
Nonat, Bernutz, and Aran, hold the same view. 
I believe that in this simple arrangement many facts have 
been lost to science. It is no small merit of M. Huguier that 
he recognized a new factor as a pathological cause of prociden- 
tia uteri, and protested with such emphasis against the negli- 
gence of observers. He not only invited but forced mod- 
ern gynecologists and pathological anatomists to recognize the 
truth of his assertions, which they had overlooked. 
The recent descriptions of procidentia uteri have not been 
based on pathological anatomy (it appearing to be almost ig- 
nored), end the physiological and anatomical examinations 
have also been made in an incomplete manner. The different 
forms of this affection have been confounded, and certain dis- 
placements, which did not exist, have been admitted. In the 
practice of some physicians nothing is more common, being an 
every-day occurrence, than the complete falling of the uterus, AMPUTATION OF THE CERVIX UTERI. 
9 
and yet we only occasionally encounter authentic examples in 
the writings of reliable authors. 
The simple division into " complete and incomplete " ap- 
pears to be the most appropriate, whether we recognize the 
pathological changes in the cervix or not. The same division 
answers also, whether we consider this affection as, 1. Idio- 
pathic or primitive, where it has no complications; or, 2. 
Symptomatic, or where it is associated with other lesions. 
This last division, I think, has a practical bearing of much 
importance in treatment. Simple as the division may be, yet 
it has been falsely interpreted in not recognizing exactly the 
relations of the prolapsed part, as complete falling of the womb 
is often spoken of, when the greater portion of the organ, the 
entire body, is still enclosed in the pelvic cavity, and some- 
times raised above the superior strait. This discrepancy arises 
from a difference of opinion as to the precise limits which sep- 
arate the complete from the incomplete. Some admit, as does 
Paul Dubois, that the inferior limit of the pelvic cavity is the 
inferior strait, that is, a line drawn from the lower part of the 
symphysis pubis to the termination of the coccyx, and, when 
the body of the organ passes this limit, the prolapsus is com- 
plete. Others regard the vulval opening at the base, or exte- 
rior, to the labia majora and minora (Hodge). 
Modern researches on the anatomy, physiology, and pa- 
thology of the uterus enable us, I think, to establish a more 
physiological division of this affection, and thus have a more 
just and correct appreciation of its pathological changes. 
The observation of pathological facts demonstrates that the 
falling may be consequent upon enlargement of the body, or 
it may depend entirely upon the cervix. The falling or pro- 
jection of the cervix externally is then but a symptom of a 
disease entirely different from those which produce prolapsus 
of the entire, organ. 
We know that the cervix and body of the uterus present 
decidedly different anatomical structures (Bichet, Guyon, 
Sappey), and physiology teaches that the uterine cavity exhib- 
its completely distinct phenomena from the cervix (Kblliker, 
T. Smith, and others). 
In pathology we notice a separation quite as distinct, and 10 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
the affections which invade the neck in many diseases do not 
trespass on the body of the organ. In the discussion which 
took place in Paris before the Academic de Medecine, April 
5, 1859, on M. Huguier's monograph, M. De Paul affirmed 
that the structure of the cervix differs nothing from that of the 
body. " Do we not find," he says, " the same tissues, the same 
anatomical elements ? What special structure of this portion 
(the supra-vaginal portion) can explain an exact limitation of 
longitudinal hypertrophy? Where and how does M. Huguier 
give a proof of the existence of the hypertrophy of the supra- 
vaginal portion ? " It is very evident that M. De Paul ignores 
this grand and useful and practical law which Nature has es- 
tablished. Proofs, by investigation, have asserted the uterine 
duality, by virtue of which the body and cervix are one. 
With the uterus in its development, its progressive changes, 
through its physiological life, and the mutations which age 
brings with it, there is a kind of perpetual antagonism from 
infancy to old age, not only in its totality but in its separate 
portions. To comprehend the subject, therefore, we feel 
obliged to adopt the simple division which we have stated, 
viz., complete and incomplete, whether simple or complicated, 
idiopathic or symptomatic. 
The cervix uteri itself is divided by M. Sappey and M. 
Guyon into two parts-that portion which embraces the glan- 
dular part, and the space which intervenes between this and 
the body, from one-half to three-quarters of an inch long. 
The cervix comprehends all that portion of the uterus which 
is above as well as below the reflection of the fundus of the 
vagina. The hypertrophy may invade as well the superior as 
the inferior, separately or together, though this M. Huguier 
admits does not occur. For he believes the inferior portion, 
when hypertrophied, is antagonistic to the superior, and vice 
versa. This is not strictly correct, for I have seen two cases, 
one in the Charity Hospital (B. I.), and the other in private 
practice, where not only tlie infra-vaginal portion was elon- 
gated two inches, but the superior also two inches, making 
four inches. M. Verneuil, in the Gazette Hebdomadaire^ 1859, 
reports a case with the same lesions. 
Causes.-The falling of the uterus depends upon a variety AMPUTATION OF THE CERVIX UTERI. 
11 
of causes, very different in tlieir nature and their action. 
They may he divided into those which are external, and those 
which are inherent in the uterus itself. No cause acts with 
more power and effect than accouchement, whether premature 
or complete, and the pathological changes which frequently 
follow it. The more frequently parturition is repeated, the 
more it acts on all the means of suspension of the uterus, and 
the uterus itself, and, subsequently, the general economy. 
If after accouchement a healthy process has not been estab- 
lished, and the uterus not perfectly involuted, but remains 
large and weighty, the physiological softening not only invades 
the uterus itself, but it extends to the ligaments, especially 
the dartoid structure and the pelvic fascia-those which sus- 
tain more perfectly the uterus-and gestation acts also mechan- 
ically in stretching and lengthening these ligaments during the 
whole period of pregnancy. It is well known that when the 
fibrous tissues have once been stretched, and have lost their 
elasticity, they seldom recover their former power of sustaining 
the uterus. They remain relaxed, or they may be lacerated, 
and this is especially true of the lumbo-sacral ligaments. 
The rupture of these ligaments is considered by Boivin and 
Duges as playing an important role in the mechanism of pro- 
cidentia uteri. Nothing is more frequent also than the chronic 
post-puerperal congestion, or chronic inflammation (as it is 
sometimes called), which is apt to occur unless a proper reduc- 
tion of the uterus has taken place. 
Out of one hundred and fourteen cases of procidentia uteri 
which Scanzoni treated, ninety-nine of them were mothers; 
and, out of the sixty-four cases observed by M. Huguier, sixty- 
two were mothers. Some of them had from ten to eleven 
children. These figures, so important at first sight, will, on 
examination, lose their value, for it appears that in these 
patients the commencement of the lengthening was not deter- 
mined, the first symptoms of falling of the uterus not being 
noticed, and sometimes not even the passing of the cervix 
from the vulva. 
All the cases recorded by M. Huguier have been mothers, 
with the exception of two. In general, the patients belonged 
to the class of washerwomen or laundresses, for, out of twenty- 
two observations recorded in his memoir, thirteen were laun- 12 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
dresses (or two-thirds of the number), three journalists, and 
the remainder were distributed as follows: a cook, a nurse, a 
merchant, and an artist. The ages of twenty-one patients were 
as follows: eleven were from forty-live to seventy-one-half 
being forty-five; seven from thirty-three to forty-five; three 
from nineteen to twenty-six. If we take these facts as bearing 
upon the age, avocation, and the pregnancy of the patients, 
and especially the last, they have great significance in their 
relation to the causes producing the hypertrophic condition of 
the uterus. In my own experience they are the chief and 
most constant causes. 
During pregnancy and parturition, the uterus undergoes 
important physiological changes during gestation, not only in 
regard to the body, but the cervix; and afterward occur the 
pathological changes incident to a want of proper reduction of 
the organ to its normal size. 
Occasionally mechanical causes (or chronic idiopathic con- 
gestions) may produce it. We must infer, therefore, that the 
weight of the uterus, by its own gravity, has brought about a 
certain form of lengthening of the supra-vaginal portion of the 
uterus. 
Morgagni has asserted in the case that came under his 
supervision: "It is evident that the uterus, whose fundus was 
somewhat lower down than usual, had been drawn downward 
by the weight of the vagina thus thickened; unless the cervix, 
from the very beginning of the disorder, was of such a laxity 
as to suffer itself to be drawn downward more than the other 
parts, and be distended into that extraordinary length." 
The experience of MM. Bastien and Le Gendre, on the 
cadaver, permits us to form, approximately, the measure of the 
force which is necessary to produce a prolapsus or procidentia 
of the uterus, and to destroy the resistance of the supports of 
the uterus. With a weight of fifteen kilogrammes (or thirty 
lbs.) attached to the cervix, it is brought to a level with the 
orifice of the vulva. Fifty pounds' weight will make it pass 
this orifice one centimetre, or one-third of an inch. 
With a traction of one hundred pounds, the descent con- 
tinued, and reached a distance of one inch and a quarter. In 
experiment No. 9, the uterine cavity, before the traction, AMPUTATION OF THE CERVIX UTERI. 
13 
measured one inch and five-eighths; after the traction, eight 
centimetres, or three inches. If this tractive force from above 
was slow and gradual for some days, the same result was 
arrived at. The fact that the uterus is, after accouchement, 
left enlarged, and requiring from six to eight weeks to be 
restored to a normal size, and to its original structure, is well 
recognized, and, if not properly involuted, may remain so for 
many months, and even years. In such cases, in the body 
of the uterus there is found an enlargement of the pa- 
renchyma of the organ. An attentive examination demon- 
strates the same pathological alterations as occur in chronic 
engorgements of the womb, though the cavity is doubled. 
HALF NATURAL SIZE. 
A. Decidua.-B. Body of the uterus. 
C. Internal orifice of the uterus. 
D. Vagina.-E. Os-tincae. Length of cervix, two and five-eighths inches. 
The cervix partakes of the same condition, but is sometimes 
lengthened during gestation. As this fact has been demon- 14 
BELLEVUE AND CHAEITY HOSPITAL EEPOETS. 
strated (of which the diagram, Fig. 1, is only one of many in- 
stances occurring under my own observation),1 then we can 
plainly perceive how through a physiological process, if not 
modified by the natural laws, a pathological lesion ensues. 
We can thus more satisfactorily account for many of these 
cases of so-called (simulated) procidentia uteri. As a general 
rule, I believe we may assume it as a guide, that the cervix 
uteri, in its supra-vaginal part, measures from one inch to one 
inch and a quarter in the unimpregnated female, while that 
from a female dying soon after parturition, or just before de- 
livery, at full term, measures from one and a half to two 
inches. In seventeen post-mortem examinations, I have ob 
served at full term, or at the very commencement of labor, 
there was one specimen of a cervix uteri of two inches and 
five-eighths in length (see Fig. 1), two of two inches and a half, 
two of two inches and a quarter, and the remaining twelve 
varied from one inch and three-quarters to two inches. 
Boivin and Duges remark that the cervix uteri, during the 
early period of gestation, may be lengthened to two inches, 
but they believe it becomes perfectly obliterated during the 
last month of pregnancy. Filugelli has remarked that the 
cervix uteri may lengthen three inches, during the first months 
of pregnancy, but that it is obliterated at the close. Cazeaux 
denies this view of Boivin and Filugelli, and so do other 
gynecologists, but, as I conceive, on incorrect investigation 
and examinations. 
The remarks of Duges, and Boivin, and Filugelli, are truth- 
ful so far as they go, to the third or fourth month ; and instead 
of the cervix uteri becoming obliterated at the very close of preg- 
nancy, it is the very reverse. The cervix maintains its normal 
length to the end of pregnancy, and is physiologically hyper- 
trophied and softened in breadth. In some instances it is length- 
ened to an extraordinary degree, as the two following cases 
will attest: 
Case I.-(Reported by Dr. George S. Sherman, House 
Physician.)-A patient at the Charity Hospital, in October, 
1867,43 years ot age, was presented to my notice for procidentia 
1 See New York Medical Times, June, 1862; also, Transactions State 
Medical Society, 1865, article Placenta Prawia. AMPUTATION OF THE CERVIX UTERI. 
15 
uteri of three months' duration. She had ceased to menstruate 
six months before, and had been irregular the last six months. 
The uterus was procident from two and a half to three inches. 
She denied being pregnant. There was no distinct areola, 
no vomiting, no nausea. The external abdominal examina- 
tion felt no tumor in the superior strait. 
The appearance of the os-tincse presented nothing that 
could lead me to suspect gestation in this case. The cervix 
externally was thick and large, and the neck long and cylindri- 
cal, being about the size and thickness of the thumb, and 
could be felt extending up the vagina nearly three inches. 
The body of the uterus was not recognized. The rectal and 
vaginal touch gave the same information. 
The sound was introduced, carefully and gently, and the 
uterus measured ten inches. Per rectum the sound could be 
felt in the pelvis, high up through the long, narrow cervical 
tube, and no round globular body was ascertained. The pa- 
tient aborted two days afterward of a foetus three months and 
a half old. 
The same circumstances were also exhibited in the case 
which occurred in the Bellevue Hospital, under Dr. Young's 
and Dr. Stoddard's care. The long cylindrical cervix was 
felt, but the round globular body of the uterus was not rec- 
ognized by the various methods of examination. In this 
case I hesitated to pass the sound at the first examination, 
simply because the only evidence of gestation was the blue- 
ness of the labia of the cervix (not the vagina). The patient 
positively denied having had any intercourse with any man 
in four years. After the birth of her child, she did not have 
her menses for six months. On examining: ag;ain a second 
time, very carefully, on all points, I resolved to introduce the 
sound. The uterus measured eleven inches. Two days after- 
ward, this patient miscarried of a foetus three months and a 
half old. On examination of the neck afterward by Dr. Stod- 
dard and myself, the round globular form of the body of the 
uterus was recognized, with a cervix an inch and a half long, and 
of about the same breadth as is frequently seen after labor. 
In connection with these cases, M. Cazeaux, in his work on 
" Midwifery," relates a case that he saw at his clinique, in 16 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
1849, which he considered a very remarkable case of incom- 
plete prolapsus, during pregnancy-in which the entire neck 
of the uterus projected beyond the external parts. The cavity 
of the neck measured two and three quarter inches in length- 
extending on the sides three and a quarter inches; anteriorly, 
two and a half inches; posteriorly, two and three fourths 
inches. Dr. J. C. Nott, formerly of Mobile, now of this city, 
reports a case, as he supposes, of extraordinary hypertrophy of 
the cervix uteri, during gestation, Oct. No., 1867, American 
Journal of ^Jedical Science. The measurement was externally 
three and a half inches in length, and one and a half inches in 
diameter. 
I am aware the views I have presented on this point are 
in direct contrast to those usually received. They have, how- 
ever, been fully and carefully substantiated, not only by cases 
in the living subject, but by several post-mortem examinations. 
These facts will tend to show, if they do not demonstrate 
clearly, how cases of hypertrophic elongation may occur, and 
how the supra-vaginal portion of the cervix becomes of such 
a considerable length, and of a cylindrical form. 
They will corroborate the opinions of M. Huguier as re- 
gards the elongation of the cervix and the necessity for the 
treatment he proposes, though differing pathologically, yet sus- 
taining the views of Levret and Morgagni, though they gave 
no explanation of the pathology of the disease. 
Morgagni, book iii., letter xlv., page 622, remarks on this 
affection : " On the outside of the labia of the pudenda, which 
was much dilated, a body three or four inches in length was 
prominent. This body was of a cylindrical form, thick, and 
made up of a substance similar to a ligament, and smooth. 
Being surprised at its unusual length, I cut into the vagina, 
and within it I found the cervix uteri contained, having be- 
come very much larger than it naturally is; nor was this to 
be wondered at, since the parietes of the cervix itself, and the 
fundus uteri, were not firm, as they are in their natural state, 
but extremely lax and flaccid." 
Cruveilhier, in relation to this point, observes (Livraison 
xvi., page 2): " The lengthening of the womb can only be 
effected by previous softening, in consequence of which the AMPUTATION OF THE CERVIX UTERI. 
17 
organ becomes in some degree ductile. This softening may 
be, perhaps, purely and simply the result of a slight pull on 
the womb." 
Experience teaches us that no tissues are more ductile and 
distensible than those of the uterus, especially when they have 
undergone the ramoUissement consequent on pregnancy, or in 
some cases of a decided lymphatic constitution. 
Huguier and Kiwisch have classed these kinds of cases under 
hypertrophies. They are not so considered, by others. For it is 
proved by microscopical examination that the structure of the 
hypertrophied uterus after accouchement presents no inflamma- 
tory or heterologous deposits, but the tissue of the organ retains, 
as I have before remarked, its histological character, similar to 
the tissues of the uterus at the ninth month of pregnancy, except 
only that its component muscular fibres were smaller in size. 
No fact is more evident than the eccentric hypertrophy of the 
body of the uterus, and this without the uterus being pro- 
cident or even prolapsed. We meet with these cases es- 
pecially after abortion, where the uterus measures from three 
and a half to four inches, while the os-tincse may be in its nor- 
mal position, from two and a half to two inches and three- 
quarters from the vulva, and occupying its proper axis. 
M. Huguier has dwelt very slightly, in his celebrated me- 
moir, on the causes of this affection. Before considering, there- 
fore, other causes producing it, I will refer to the measure- 
ments of the uterus of M. Huguier in his own cases. These 
were twenty-three in number. In three there were no meas- 
urements. In the remaining twenty the fundus was inside of 
the vulva sixteen times, and four times it was outside: 
1 case the fundus was inside 18 lines, or 1 inch and 
1 " " 16 " 1 inch and 
1 " " 14 " 1 inch and 
6 " " 12 " 1 inch. 
1 " " 10 " f of 1 inch. 
2 " " 9 " f of 1 inch. 
2 " " 8 " £ of 1 inch. 
2 " " 4 " £ of 1 inch. 
16 cases. 
These measurements would be materially altered if the 18 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
perinaeum was relaxed or ruptured, or if the uterus had been 
procident for a number of years. 
In many cases of procidentia uteri, where there is not the 
true longitudinal hypertrophy, the uterus almost always be- 
comes retroverted, and sometimes retroflexed, before it becomes 
procident. 
If we take the measurements of the uterus in M. Huguier's 
cases, as he has given them, with the exception of observations 
11 and 12, we will have, out of twenty cases (as two are con- 
sidered as complete by M. Huguier himself), the following 
result. Out of twenty-two cases, four were outside and eigh- 
teen inside, and are as given below: 
In 1 the uterus was 8 inches in length. 
In 2 " " 
In 4 " 4| " 
In 8 " 4 " 
In 12 " under 4 inches. 
Not only in these twenty-two cases operated upon, but the 
average measurements of the sixty-four cases were, as M. Hu- 
guier himself admits, 12 centimetres, or 4 inches. The meas- 
urement of the two specimens in the Dupuytren Museum was 
only 10 centimetres, or 3^ inches. These measurements of M. 
Huguier do not correspond to the kind of cases he has re- 
ported as true hypertrophic elongation of the cervix uteri 
above the vaginal insertion. For further proof of these re- 
marks I shall refer to the diagrams representing Huguier (Fig. 
5) and Cruveilhier's (Fig. 6) cases. 
The affection is not due solely to the puerperal causes which 
are so frequent and general, but it may exist previous to preg- 
nancy, as the following case will show: 
Case II.-Sarah J , aged 18 years (menstruated at 14), 
admitted to Charity Hospital, November 7, 1865 (reported by 
Dr. T. D. Bradford, House Physician). " A strong, well- 
nourished colored girl, unmarried, and never pregnant. While 
hard at work three years before, lifting, the uterus fell, and 
has remained procident ever since. She suffers intense pain 
in the pelvic region, is incapable of walking but very little, 
and then has to straddle very wide to move along. Amen- 
orrhoea of two months' duration, cervix prolapsed 1^ inches, AMPUTATION OF THE CEEVIX UTEEI. 
19 
very tender and irritable; can scarcely be touched; small os 
tineas The vaginal examination, quietly and carefully made, 
gives the measurement, both anteriorly and posteriorly, 2^ 
inches, and from the os tincae 3f inches. The cervix uteri is 
long, slender, and cylindrical, at this height. The rectal 
touch does not feel the body of the uterus. The abdominal 
examination, from the excessive tenderness of the pelvis and 
hypogastric region, is unable to perceive the fundus. A small, 
thin, metallic sound, introduced gently through the cervix, 
reaches the extent of from four and three-quarters to five 
inches. The sound is then felt over the pubis. There was no 
cystocele or rectocele. 
" Treatment.-Leeches to the vulva, hyoscyamus pills, 2 gr., 
three times a day. The leeching to be repeated two or three 
times. The congested condition overcome December 10th. 
The uterus was of the same length. 
"December V^th.-From three-quarters to one inch of the 
cervix was amputated by the circular method. The patient 
is to be kept quiet in bed, and suppositories of opium given for 
a few days. 
" March ls£-Patient still remains in the hospital, and the 
uterus measures three inches. She can walk easily and with- 
out much pain." 
This patient came into the Charity Hospital again Feb. 1, 
1868, with chronic cellulitis. The uterus measures three 
inches, and the os uteri is one and a half inches from the 
vulva. She again left the hospital, and returned shortly 
afterward, and is now an inmate in the hospital, with the 
uterus as last reported, February, 1868. 
This case might be classed among the congestive variety of 
this form of disease, as suggested by Berniitz, or it might have 
been, as Berniitz would consider it, congenital, the congestion 
occurring afterward. Of the congenital kind, he reports the 
following, the nature of which is proved by the fact that the 
same peculiar formation was actually found in one of the pa- 
tient's sisters, while all the others were sterile : 
" Case III.-M. S. W., aged twenty-five, was admitted 
January 15, 1861, into 'La Pitie.' She began to menstruate 
at fifteen, and continued regular until she was nineteen, when 20 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
she ceased to do so for three months, and was troubled with 
amenorrhoea and sharp pain in the right iliac region. At 
twenty-one years of age she had to lift heavy weights and 
work very hard. This caused great pain in the lower part of 
the body, for which she sought advice, and was told she had 
prolapsus uteri. She left her situation for a lighter one. Still 
the pains continued, and she suffered much whenever she sat 
down. After the inflammation had subsided, a sponge was 
introduced as a pessary, but could not be borne. After a 
while, Gariel's pessary was tried, but with no better result. On 
examination now, the cervix was found to be very low in the 
vagina, and elongated; the fundus occupying its normal po- 
sition. The sound measured about three and one-half inches, 
but did not seem to have reached the fundus. Symptoms of 
peritoneal inflammation having followed the examination, 
leeches, blisters, and poultices were ordered. The inflamma- 
tion gradually subsided, and, on a vaginal examination, the 
uterus was found retroverted. 
" Finding that rest and treatment did no good as regards 
the allongement or lengthening, while all else had improved, 
and the parts quiet, amputation of the cervix was determined 
upon, and performed by M. Maissonneuve, who removed about 
three-quarters of an inch on the 22d of October. 
" November 21<^.-Patient left the hospital in a greatly im- 
proved condition. She married soon after, and was compara- 
tively well when last seen." 
This form of cases M. Bemiitz not only considers as con- 
genital, but also hereditary in some cases. At any rate, the 
elongation was, in both these eases, prior to pregnancy, as it 
was in two of M. Iluguier's cases, and in my own case at the 
Charity Hospital. Tn the first of M. Iluguier's cases, the 
patient menstruated at nineteen and married at twenty-one. 
When she was twenty-four years of age, not having yet been 
pregnant, she felt, after lifting a heavy weight, a sudden sen- 
sation, as though something had given way in the abdomen, 
attended with violent pain in the back. As the acute symp- 
toms abated, the cervix protruded at the vulva. M. Huguier 
found elongation of the uterine cavity, and well-marked pro- 
lapsus. The sudden appearance of the cervix at the vulva is AMPUTATION OF THE CERVIX UTERI. 
21 
explained, if we suppose that supra-vaginal elongation was al- 
ready present, without giving rise to any symptoms,- until the 
strain, by causing prolapsus, revealed the malformation. 
The second patient, after having (Observation XXII.) been 
struck upon the abdomen when sixteen years of age, suffered 
some pain for a time, and soon after the cervix appeared at the 
vulva. We may take it for granted that these few cases show 
that this affection may exist previous to gestation, and that 
this peculiar form of the disease may be overlooked, until the 
accouchement has brought it to light. The congenital elon- 
gation may exist apart from prolapsus, and no morbid symp- 
tom originate therefrom, until some mechanical or other 
causes induce a congestive action, when all the symptoms of 
true and recent prolapsus will become evident. 
I have only a few words to say on rectocele and cysto- 
cele, as causes of, or in aiding, the elongation of the cervix. 
M. Cruveilhier attributes the elongation in these cases to 
the dragging and pulling of the attachments of the bladder 
and rectum. It is not necessary for both to exist, to produce 
it, for true rectocele alone will produce it. Partial cystocele, 
and rectocele, which I have in many cases seen existing to- 
gether, may act in quite an opposite way. They may and do 
become the natural pessary to prevent the farther descent of 
the uterus only an inch from the vulva, or even sometimes as 
high up as the'middle part of the vagina. 
The facts here related show that we may have-1. As 
the most frequent cause, an enlarged non-involuted uterus, 
body and cervix. The cervix, becoming lengthened during 
gestation, and remaining so after delivery, and gradually be- 
coming prolapsed, eventually becomes lengthened by its own 
gravity, and finally elongated to several inches, while the fun- 
dus may remain at the superior strait, if bound down by ad- 
hesions, or a chronic cellulitis, or it will be retroflexed internal- 
ly, or becoming totally procident, with retroflexion externally, 
and with eversion, partial and complete, of the cervix uteri. 
2. The disease may be produced through any cause that 
may induce congestion of the uterus, and treated accordingly. 
3. It may be congenital. 
In the external tumor the uterine neck is found presenting 22 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
different aspects according as the neck is healthy or diseased. 
Sometimes the orifice is so small as scarcely to admit the 
smallest probe. At other times it is, without being in a patho- 
logical state, partially or completely everted through its whole 
length, measuring in some instances from three and a quarter 
to three and a half inches in diameter. Cases of this nature 
have been mistaken and considered as a large hypertrophy of 
the cervix, and have been treated for that disease. This form 
of the cervix has engaged my attention for a number of years, 
and for this reason I will offer a few remarks upon it. 
The partial or complete eversion of the cervix may exist 
previous to procidentia, and then it acts as a prevention of 
prolapsus of the uterus. It is more generally noticed after the 
uterus is procident. This eversion is frequently found in those 
who have had children, though it may be recognized in the 
primipara. In Boivin's case it was congenital. It was noticed 
in a very young woman, brought into the " Maison de Saute " 
in a dying state, with fever, and who died the next day. On 
post-mortem examination the uterus was found internally of a 
bright-red color, the tissue soft, within the body and cervix 
of the uterus. The os uteri was everted so as to present a 
kind of broad, flattened ring around the cervix uteri, in which 
the inferior and vaginal portion of the cervix was retro verted.* 
Scanzoni (page 144, American translation), speaking 
of the pathological anatomy of the uterus in procidentia, 
remarks : " The vaginal portion, ordinarily hypertrophied, 
often hardened, but sometimes also much tumefied and 
softened, shows a discoloration of a bluish red or slate gray. 
Around the orifice it is deprived of its epithelium, and cov- 
ered with erosions and ulcerations more or less deep. Of- 
ten, after a long duration of the disease, there is a true inver- 
sion of the neck. The orifice dilates at first insensibly, and its 
borders form a circle from one inch to one inch and a half in 
diameter, through which the neck is everted in such a manner, 
that the mucous membrane, covered with the glairy mucosity 
peculiar to the neck, forms after death a bluish-red ring around 
the orifice which leads to the cavity of the womb." 
M. Huguier, page 347, in his monograph, remarks: " There 
is a third cause of increase (while speaking of the causes of 
* Boivin and Duges (page 99), Heining's translation. AMPUTATION OF THE CERVIX UTERI. 
23 
eccentric hypertrophy of the infra-vagihal portion of the cervix) 
of the uterine orifice, of which the mechanism is physiologically 
pathological, and entirely without all kinds of traumatism. 
" In certain females who have not had infants, but who have 
suffered for a long time with complete inversion of the vagina, 
the uterus, in consequence of its increase in weight, tends more 
and more to descend, and to precipitate itself outward; but it 
is arrested by the resistance of the vaginal walls, which will 
not yield, nor prolapse any more, and then they exercise a 
traction from the centre to the circumference, or, if you wish, 
from within, outward. The eversion of the vagina causes it to 
reach sometimes the internal surface of the neck." 
Jobert, Huguier remarks, " appears to us to have been 
mistaken when, in a lecture which he gave, while referring to 
this point, he attributes the increase or widening of the infra- 
vaginal portion of the cervix, and the eversion of its edges out- 
ward, to certain muscular fibres of the cervix." Both of these 
authors refer to the inferior or vaginal part of the cervix uteri 
as being everted, and term it extroversion. 
Tyler Smith, in his article on Leucorrhoea {fiedico-chirur- 
gical Transactions, vol. xxxv.), gives a plate of a partial ever- 
sion through congestion of the cervix, to show that ulceration of 
the cervix uteri is mistaken sometimes for a partial eversion of 
the cervix. Boivin and Duges, Scanzoni and Huguier, make the 
diameter of the cervix, when everted, from one inch to one inch 
and a half. This form is very frequent, but the cases I have 
brought forward and referred to, of which representations are 
given, measured from two and a half to three and a half inches, 
precisely double the length of the cervix, and are thus com- 
plete eversions of the cervix uteri. 
The affection is not very infrequent. Klob, in his " Patho- 
logical Anatomy of the Female Sexual Organs " (American 
translation by Kammerer and Dawson, 1868), remarks, under 
the head of Prolapsus Uteri, that " a peculiar condition of the 
cervix uteri is found in the higher degrees of prolapsus uteri. 
As mentioned above, the external orifice in many cases is so 
dilated that the cervical canal may be viewed half way up. In 
some cases the eversion of the cervix may reach such a degree 
that the internal orifice becomes the external one, the entire 
cervical canal being everted. The eversion, however, of the 24 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
latter is never so complete as that of the vagina; the inner 
surface of the cervix may become the inferior one of the tumor 
forming the prolapsus, but it is never rolled out so far as to 
form its external surface." In these cases the mucous mem- 
brane of the canal, when everted, appears as a bluish-gray 
ring encircling the entrance to the uterus. 
I am gratified to adduce the testimony of the authors as 
cited, and especially Klob's corroboration of my views on this 
subject, who gives us the latest pathological view on the sub- 
ject of eversion of the cervix uteri. 
Fig. 2. 
HALF NATURAL SIZE. 
When I presented this subject before some medical associa- 
tions, it was deemed unusual, and even excessively rare, and 
some considered it as impossible. 
The cases under my observation were generally complete 
eversion of the whole cervical canal, and the colored diagram 
will testify to the description as given by Scanzoni and Klob. 
The colored plate (Bridget Mathew's case, Case 8,) represents 
the uterus prolapsed, with the cervix everted, having a partial AMPUTATION OF THE CERVIX UTERI. 
25 
cystocele and rectocele; and the second diagram shows the 
cervix reverted. The third plate (a wood-cut, Fig. 2) shows the 
uterus returned into the vagina, and the natural appearance 
and size of the os uteri. 
The mechanism of eversion is simple, and presents no diffi- 
culty of explanation. In several instances after the reeversion 
had been made, and the uterus returned into the vagina, by 
introducing the speculum, the eversion can be seen gradually 
taking place, as the uterus is again becoming prolapsed along 
the vagina, as the speculum is withdrawn. It will become 
completely everted after the uterus becomes procident. It is 
rolled out in the same manner that the horse's anus is after 
defecation, just before the closure of anus. 
PATHOLOGICAL ANATOMY. 
Case reported by Dr. O'Dwyer, House Physician in Char- 
ity Hospital.-Hannah Beattie, aged forty years (Ireland), 
widow, admitted into fever department of the Charity Hos- 
pital, Blackwell's Island, December 24, 1867. Suffering from 
general peritonitis, and double pleuritis. Says she has suf- 
fered several years with falling of the womb. Has one son 
living, nine years of age. She was admitted in a moribund 
condition, and died on December 25, 1867. On post-mai^tenb 
examination, the uterus was found protruding about two and 
a half to three inches beyond the vulva (see diagram), with the 
following measurements. In contrast with this morbid speci- 
men (Big. 3), which shows the isthmus of the cervix uteri as be- 
ing the part which is elongated, is a copy of M. Guyon's plate 
of the isthmus of the cervix as delineated of the natural size. 
Externally from anterior lip to fundus 5| inches. 
Internally from anterior lip to fundus 5 J inches. 
Length of body from fundus to the commencement of cervix... 2J inches. 
From the commencement of cervix to the os internum (inter- 
mediate part) inch. 
From the internal os to the commencement of everted part of 
cervix * £ inch. 
From the commencement of the eversion to os-tincaa i inch. 
Transverse measurement of everted os 2f inches. 
Antero-posterior 2^ inches. 
Transverse measurement at the isthmus 7 inch. 
Measurements of the specimen. 26 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Fig. 3. 
HALF NATURAL SIZE. 
Fig. 3.-A. B. Intermediate part of the cervix, or isthmus. 
A. Internal orifice of the uterus. C. External orifice everted. D. Posterior 
part of vagina. 
Fig. 4.-Cast of the internal part of the uterus, after M. Guyon, showing the isthmus. 
By the diagram it appears, from the measurement, that the 
glandular part of the cervix is one inch and a quarter in its 
natural length, and from the os internum to the body of the 
uterus-the intermediate part or isthmus of the cervix, which, 
according to the anatomical views of Sappey and Guyon (see 
Fig. 4), is one-third of an inch-has, in this specimen, increased 
to one inch and three-quarters, or twenty-one lines, being six- 
teen or seventeen lines more than natural. 
The body, naturally one inch and a sixth (Sappey's meas- 
urement), has increased to two inches and a quarter, or twen- 
ty-seven lines, nearly double. The specimen presents the lines 
of demarcation of each part of the uterus so perfectly that 
there can be no difficulty in defining them. Wd find the body 
twice its natural length, and the isthmus, or intermediate part, 
increased seven times its length, presenting a long, cylindrical, 
contracted appearance, in contrast to the body or everted AMPUTATION OF THE CERVIX UTERI. 
27 
thickened cervix, infra-vaginal portion. The natural breadth 
of the supra-vaginal portion is preserved through nearly its 
whole length. If we compare the appearance of the cervix 
with Cruveilhier's plate, and the appearance and measure- 
ments with those of Berniitz and Huguier, we will perceive 
that the elongated appearance is solely in the intermediate 
part of the supra-vaginal portion, between the os internum 
and the body. In the case of Berniitz, taking Sappey and 
Guyon's measurements of a normal multipara uterus, it -would 
be two inches. In M. Huguier's case, the longest of all his 
three morbid specimens (Observation XV., plate 5, No. 4), al- 
though there were no distinct lines of demarcation between 
the body and the internal orifice, the isthmus would present 
five inches. 
Fig. 5. 
HALF NATURAL SIZE.-(AFTER HUGUIER.) 
A. Isthmus or intermediate part. 
B. Anterior peritoneal cul-de-sac. 
C. Posterior peritoneal cul-de-sac. 28 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Fig. 6. 
HALF NATURAL SIZE.-(AFTER CRUVEILHIER.) 
A, Isthmus or intermediate part. 
B. Anterior peritoneal cul-de-sac. 
C. Posterior cul-de-sac. 
The uterus, in M. Huguier's case, measured eight inches 
in length, which is very unusual, and seven and a half inches 
internally. The proportions are nearly the same for the isth- 
mus as in the case of M. Berniitz and my own, considering the 
length. In the three morbid specimens which have come under 
my observation, the same appearance of narrowing existed in 
that part of the uterus, and it can be demonstrated that there 
is an elongation of the cervix in the supra-vaginal portion of 
the uterus, or, more truly, in the intermediate part. 
If to the non-shortening of the cervix uteri (as is repre- 
sented in the diagram, during pregnancy, Fig. 1) there is added 
noninvolution, the uterus will descend by its own gravity, and 
become, at first, partially prolapsed, then retroverted, and fre- 
quently retroflexed. 
From its ductile nature, and ramollissement consequent on 
gestation, the cervix gradually becomes more and more elon- 
gated, until the uterus reaches double its natural length, and AMPUTATION OF THE CERVIX UTERI. 
29 
sometimes even to seven, eight, or nine inches. This view is 
corroborated also by the evidence of the two cases I have re- 
ferred to, during pregnancy, when the cervix was lengthened 
to at least five inches in one, and five inches and a half or six 
inches in the other. The body of the uterus could not, by any 
of the measurements which would be admitted, if pregnancy 
existed, at three months and a half be more than four or five 
inches in length or breadth. 
If these views and investigations are correct, they tend to 
a practical solution of the question of the so-called, hypertrophy 
of the superior part of the cervix. 
As a further and additional proof, when the uterus is re- 
turned into the pelvis, as was supposed by Aran, it has dimin- 
ished, to all appearances, even by the use of the sound, to the 
extent of one inch. I have, however, referred before to M. 
Aran's views on this point, and established the fact that the 
womb is not diminished in length, but is simply retroflexed or 
doubled up. If a true organic hypertrophy existed, this would 
or could not occur. I have quoted the opinion of M. Cruveil- 
hier, that the weight of the uterus aided materially in the falling 
of the womb, though M. De Paul considers this cause as second- 
ary, and attributes it to the particular state of the vagina and 
the softening of the tissues. He accounts for the lengthening 
and contraction in this manner: " When a portion of the cer- 
vix escapes from the vulva, the resistance is a kind of constric- 
tion or narrowing exercised by the inferior orifice of the vulva, 
producing a kind of strangling, which becomes an efficient 
cause of a secondary-lengthening of the cervix, which is pro- 
lapsed, and assumes the form of a calabash." 
Now, this form of the uterus will frequently depend upon 
the inferior part of the cervix, whether it is everted or not. 
M. De Paul admits the softening and relaxation of the pelvic 
tissues. The post-mortem investigations of M. Huguier, and 
my own, show that the ligaments are stretched, and some- 
times slightly ruptured in one or more places; the constrictor- 
vaginal muscles were also ruptured; the fibro-dartoid vulva 
ring (so well described by Richet) was also affected; the pe- 
rinaeum diminished in length, and, if not relaxed, was rup- 
tured, and thus the intercrossing of the sphincter ani was de 30 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
stroyed, and the support and prop of the whole pelvic viscera 
gone. There is, therefore, nothing to produce a constriction in 
the cases of those who have had children, or even in those cases 
where a relaxed and debilitated constitution exists. If M. De 
Paul had remembered that the narrowest part of the constric- 
tion is above the sphincter muscle, he would have seen that 
the cause which he alleges producing the contraction cannot 
be accepted. 
It has been asserted by M. Iluguier that the body of the 
uterus seldom or never leaves completely the pelvic cavity. 
The posterior peritoneal cul-de-sac in the specimens I have 
seen is much lower than the anterior, and varies from one inch 
to three or four inches in length. I have also noticed it in a 
few instances so extensive as to cover the whole vulva, pre- 
senting a large oval shape, like an ostrich egg, and having an 
elastic sensation, but not giving a tympanitic sound on percus- 
sion. In fact, it is a true procidentia of the posterior vaginal 
wall. 
The posterior cul-de-sac is, therefore, in this kind of proci- 
dentia uteri, composed principally of the peritonaeum, which 
has been dragged down, and doubled to the extent, externally, 
of from one and a half to two or three inches. The anterior 
layer of the rectum will remain intact in the greater number 
of cases (see plates of M. Cruveilhier, M. Iluguier, and my 
own), unless a diverticulum has been created by hardened 
faeces accumulating in the lower part of the rectum, as exhib- 
ited in M. Cloquet's diagram. 
In all the cases I have noticed, I have found the anterior 
part of the rectum forming a very slight portion of the pro- 
lapsed uterus. This part is the peritonaeum, elongated and 
prolapsed. I know it is considered that the large swelling at 
the posterior part of the procident uterus is filled with por- 
tions of the intestines. Cases have been recorded where the 
tumor was enormous, and the small intestines even have occu- 
pied it (Hodge, Davis, and others). 
M. Cruveilhier, in 1842, previous to the publication of his 
celebrated " Pathological Anatomy," remarked that " the an- 
terior cul-de-sac is so small as not to admit the small intes- 
tines, while the posterior cul-de-sac may admit a very great AMPUTATION OF THE CERVIX UTERI. 
31 
quantity. It is in cases where the tumor formed by the fall- 
ing of the uterus acquired a development so considerable as 
the child's head." M. Cruveilhier, however, afterward, in his 
"Pathological Anatomy" (p. 576), in 1849, says, positively, 
that he has " never encountered this appearance in the cada- 
ver," and asks the question, " How shall we explain this in- 
vagination of the size of a child's head without it (the descent 
of the intestines) ? " 
It is very apparent from the morbid specimens examined 
by MM. Huguier, Berniitz, Cruveilhier, and myself, that there 
is no descent of the anterior part of the rectum; but the 
tumor is formed solely by the peritonaeum, and this con- 
dition, with the softening of the pelvic tissues, sufficiently ex- 
plains it. 
If the anterior part of the rectum has prolapsed, then 
there could not be any retroflexion externally ; if the anterior 
portion of the rectum was not prolapsed, but simply the peri- 
tonaeum, then the body of the uterus, which is generally large 
and retroflexed, and the long slender cervix, will press the 
posterior part of the vagina against the rectum, and prevent 
the rectum or the intestines from coming down. The same 
would be the case if the uterus is prolapsed, and retroflexed 
externally. (See Fig. 7.) 
Diagnosis.-In diagnosis we have to distinguish between 
the true and the simulated prolapsus. The differential diag- 
nosis respecting other diseases I shall exclude. In the in- 
vestigation of these cases we depend in a great measure upon 
the sound. It was the use of the hysterotome that led M. 
Huguier to the discovery of this form of procidentia uteri. 
The sound has, as we have seen, been resorted to before by Mor- 
gagni and Levret. The presence of a part, or the whole uterus, 
may be confounded with or mistaken for tine and simple pro- 
lapsus. In the ordinary or true descent of the womb, the 
depth will be two and a half to two and three-quarter inches. 
In the elongation of the cervix, the sound penetrates twelve, 
fourteen, or even twenty centimetres, i. e., three and a half, 
four and a half, or six inches. 
The sound also permits us to ascertain the direction of the 
axis of the uterus, and its relation to the pelvis; whether the 32 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
fundus remain in the normal position in the pelvis, or above 
the superior strait, and floating in the abdomen; whether the 
body is retroflexed internally, or whether the whole uterus is 
procident and retroflexed. It is requisite that care and cau- 
tion should be exercised in the examination of these cases. 
Aran, as well as others, has suggested that a flexible sound 
should be substituted for the metallic one, or, as some prefer, 
a very slender, flexible metallic sound. The reason alleged 
for its use is, that the structure of the uterus has undergone 
the modification of softening, and the metallic one might per- 
forate the parietes of the uterus. This fear I believe to be 
groundless. The ordinary instrument was found preferable in 
my investigations, and passes without any liability of being 
arrested by, or coming in contact with, any of the folds of the 
mucous membrane in the cervix, or the curvature of the cer- 
vix itself, if retroflexion exists. It is more distinctly felt in 
the cervix uteri by the vaginal-rectal or double touch. 
Force or harsh treatment is to be condemned ; gentleness 
and tact, slight and easy movement of the instrument, will 
succeed. The sensation communicated to the fingers when 
it has reached the fundus is easily recognized. Softening of 
the uterus in excess, in these cases, is not by any means fre- 
quent. It may be, and is in some instances, quite flabby in 
cases a few weeks after gestation, or in those cases, which 
occasionally are seen, called the squatty uterus, and to which 
Dr. Digby invited the attention of the profession a few years 
since, and which are not infrequent. These cases are also 
sometimes observed in young women, and the uterus will then 
measure three and a half to four inches, after amenorrhoea of 
three or four months' duration. 
More generally the tissue of the womb preserves its nat- 
ural firmness. I have not seen, in any of my cases where the 
sound was used, an endometritis or a cellulitis follow, though 
I use it to ascertain the partial inflammation of the body of 
that organ. 
In the 16 cases which have come under my notice, includ- 
ing three post-mortem specimens, of prolapsus or procidentia 
uteri, during the last eight years, the following is the result: AMPUTATION OF THE CERVIX UTERI. 
33 
Of 76 cases, with 29 operations, 26 were successful. 
In 48 cases the uterus was hypertrophied, measuring 3^ to 
41 inches-45 of these were the result of non-involu- 
tion-of this number, there were 8 operations by am- 
putation of the cervix, and 4 with episio-perineoraphy. 
In 8 cases there was retroflexion externally, with the cervix 
in part or wholly everted. In 3, the measurement was 
1^ inches to 2 inches. In 4, from 4£ to 5| inches. 
The 4 cases were operated upon, and the peringeum 
closed. 
In 15 cases, there was true elongation or so-called hyper- 
trophy of the supra-vaginal portion of the cervix, with 
the fundus in the normal position, or the body retro- 
flexed either internally or externally. In these 15 
cases there were 13 operations by amputation and 
perineal closures ; 3 cases were observed in gestation, 1 
at three months, 2 at three months and a half. In 
these cases the uterus measured 9£, 10|, and 11 inches 
in length. 
In 3 cases, there was true simple procidentia, 2^ to 2| 
inches. 
From this investigation, can we believe it is true, as M. 
Huguier has stated, that the rarity of true procidentia uteri 
without any elongation is in the ratio of 1 to 32 ? 
If we count the cases wholly procident-with the 3 cases 
also completely external, with retroflexion, making 6 cases- 
we shall have (including the 3 morbid specimens) the propor- 
tion as 1 to 124, instead of 1 to 32 cases. I believe this 
experience will be found to correspond with the experience 
of those who may have given this disease their attention. M. 
Huguier cites but one case of retroflexion of the uterus ex- 
ternally, out of the 64 cases. Dr. Sims says he has met with 
only a very few cases of this character, and remarks that, " if 
the ' body of the uterus passes out of the pelvis, there is no 
supra-vaginal elongation." This opinion, from my experience, 
is not established. 
Independently of the sound, other means of exploration 
are adopted ; the vaginal and rectal touch is most important. 
The double touch is highly necessary where one Anger is in- 34 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
troduced into the rectum, and the thumb into the vagina, and 
then grasping the cervix. In simple procidentia without 
elongation, the double touch recognizes clearly the fundus 
uteri, and also that no body or substance intervenes between 
the fingers. On the introduction of the sound, the end of it 
will be perceived at the fundus externally. The same method 
of grasping the uterus, when retroflexion exists, will be amply 
sufficient to satisfy our minds in this case. In the supra-vagi- 
nal elongation of the cervix, the vaginal examination recognizes 
the long, cylindrical neck, which is confirmed by the rectal 
touch. The double touch recognizes the same, and the cylin- 
drical tube may be felt and grasped, and moved about in the 
pelvis. If the fundus is in the normal position, it cannot easily 
be felt, unless the sound is used, when it may be found by ex- 
ternal abdominal examination, even with the superior strait, 
or sometimes above it, while the cervix is external. This, 
however, is not by any means according to my experience ; for 
the uterus is generally retroflexed, the cervix being from 1 to 
2 inches external. The vaginal and rectal touch will recognize 
the end of the sound at the fundus of the uterus; and the 
uterus may, sometimes, then be raised to the superior strait, 
provided no peritoneal adhesions exist, or that it is not pre- 
vented by some mechanical cause. Without these investiga- 
tions, the presence of a part, or the whole uterus, may be mis- 
taken for a true elongated hypertrophied cervix. In the 
complete falling, the fundus is on a level with the vulva, or 
just within the labia. It is af this point, I think, we may ex- 
plain how the prolapse occurs in these eases. The simple 
prolapse has been compared to an ordinary hernia. The 
womb represents the intestine, the suspensory ligaments the 
mesentery ; the perinaeum is considered as the abdominal pa- 
rietes, the vulvo-vaginal canal as the ring. When, therefore, 
the suspensory ligaments are relaxed, the uterus pushes in- 
cessantly as a wedge against the perinaeum, glides by it, dilates 
the vagina, and passes out of the vulva. 
If the vagina is very much relaxed, or the perinaeum rup- 
tured, the suspensory ligaments resist for a time, but eventu- 
al! v the uterus, which was retroflexed internally, passes out and 
becomes doubled up or retroflexed externally. In the simple AMPUTATION OF THE CERVIX UTERI. 
35 
prolapse, the reduction of the organ is easy ; congested by too 
long a procidence, it will become painful, and sometimes a 
slight gurgling is heard from the intestines wedged in the pos- 
terior peritoneal cul-de-sac. When the uterus is returned into 
the pelvic cavity, it becomes retroverted. There is difficulty 
sometimes in reducing the uterus with elongation of the cer- 
vix, if of long standing, especially if retroflexed externally; 
and, when returned, it will become doubled up. Should there 
be any sensitiveness of the cervix or the whole uterus, it is bet- 
ter to overcome this irritation before reduction. 
It is evident that the disease or affection first suggested 
by Levret was entirely overlooked or forgotten by nearly 
all gynecologists down to the present time, until it was first 
referred to by Cruveilhier, and ably and fully presented by M. 
Huguier lately, and now demands the attention of the med- 
ical profession. 
Aran considers that this elongation is only apparent, and 
that after he had measured,- in some cases, the same uterus 
attentively before and after the reduction of the prolapsus, it 
was less than when it had been prolapsed. If so, the elonga- 
tion was consequent upon the prolapsus, which may be 
recognized in some cases. Kiwisch has also alluded to the 
same circumstance, and remarks, that, " if the uterus, which 
measured 4^ to 5 inches when the cervix was external, was 
returned, the uterus would only measure 3 inches." The 
observations of Aran and Kiwisch show the ductility of the 
uterus, but the nature of the affection remains the same. They 
have, however, I think, not fully recognized the true nature of 
the case. The uterus becomes retroflexed when fully returned, 
and if it measured from 4 to 5 inches before reduction and 3 
inches after reduction, it will, if the organ is elevated (when 
wholly returned) to the superior strait, measure the same as 
before it was reduced. The falsity of the measurement is 
owing to the curvature at the neck, for it is doubled upon 
itself, retroflexed. The general measurements of M. Huguier's 
cases, out of the sixty-four, according to his own statement, 
were 3f inches. As my attention for many years has 
been given to this subject, I have measured not only the 
procident uterus, but the uteri of those who have had chil- 36 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
dren, and were not complaining of any symptom of prolap- 
sus: 
1. In those women who have been recently confined. 
2. After two or three years' confinement. 
3. After the cessation of the menses. 
4. In many cases for so-called chronic inflammation. 
In a large number of the cases the uterus was found from 
3| to 4 inches-the majority 3^- inches. I believe it will be 
ascertained that this is a more correct estimate of the size of 
the uterus in women who have had infants, than the usually 
recognized standard of 2^ or 2f inches in the living subject. 
The different appearances of the forms of uterus, prolapse 
with descent of the body, and prolapse without sinking of the 
body (Virchow, Huguier), have been dwelt upon under the 
pathological observations, and need not be referred to again. 
Treatment.-In order to the correct and rational surgical 
treatment of procidentia uteri, it is necessary for us to fix on 
the exact nature of the pathological lesions which constitute, or 
which give rise to it. From the preceding reviews of the 
pathology of this affection, it is apparent that we have two 
varieties, namely-simple prolapsus without hypertrophy, 
which is rare, and prolapsus with or without hypertrophy 
and elongation of the supra-vaginal portion. 
To the last variety, our attention is especially directed. 
The cause is inherent in the uterus itself. The increase of its 
length may be in the cervix, or cervix and body together, or 
more generally in the intermediate part or isthmus. All cases 
connected with polypi, ascites, ovarian tumors, or the simple 
prolapse, with or without retroflexion, as I have stated above, 
are excluded in the consideration of the present subject. Gen- 
erally three indications are to be fulfilled in simulated proci- 
dentia uteri: 
1. To replace the uterus in the vagina, and retain it, by 
the T bandages or with the abdominal truss. 
2. To maintain the uterus in its place by tentative means 
or appliances, such as the various forms of pessaries, vaginal 
or intra-uterine. 
3. To maintain the uterus in a permanent manner, or by 
the radical cure. AMPUTATION OF THE CERVIX UTERI. 
37 
It is the third method which I propose to consider, i. e., 
the radical cure. 
Before referring to the surgical treatment which I prefer 
adopting and advocate, I desire to pass in review the different 
methods which have been resorted to, as wrong impressions 
and some confusion exist respecting them, as they are con- 
sidered or spoken of at the present day. 
The operations practised, with the intention of mechanically 
preventing the descent of the womb, are the following: 1. 
Infibulation. 2. Episioraphy. 3. Episio-perineoraphy. 4. 
Elytroraphy, Anterior and Posterior. 5. Elytro-Episiora- 
phy. 6. Amputation of the cervix uteri, with or without a 
removal of the supra-vaginal portion of the cervix, conoidal 
in shape, as recommended by M. Iluguier. 
Infibulation consists in the union of the labia majora. 
Schaeffer, in 1856, practised this method, and was perfectly 
successful. Afterward Klein adopted it, but, instead of using 
one suture for the operation, substituted two. In his case the 
uterine cervix passed through the inferior part of the vulva, 
and was wounded by the suture. The operation did not suc- 
ceed. Aran has lately proposed this operation, and practised 
it four times. In one case, the accident that befell Klein 
happened to Aran-the suture passed through the cervix uteri, 
which had escaped below, and was strangled. The other 
cases did not succeed. This method of relieving prolapsus has 
not been very successful, and cannot be, except by completely 
infibulating the whole vulva. 
2. Episioraphy was first suggested by Fricke, of Ham- 
burg, in 1833, who operated by removing portions of the mucous 
membrane J to 1 inch from the edge of the labia, and carried 
it down to the fraenum, so that a portion of the labia an inch 
in breadth is removed, and the same repeated on the other 
side. The edges are then brought together by ten or twelve 
stitches. This operation was adopted by Velpeau, also by 
Scanzoni, Roux, and by Stoltz. 
3. Episio-perineoraphy. This is a modification of the 
former operation. It is the extension of the incisions on the 
perinseum, so as to give a greater resistance to the parts on 
which the prolapsus acts, and to correct the relaxation of the 38 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
tissues of the perinseum, or to remedy the rupture, if any exist. 
This mixed method has been employed by Stoltz, of Strasburg. 
The credit of introducing it is due to J. Baker Brown, of 
London, who popularized the operation. The success of this 
method of operation, whether for prolapsus uteri in some 
instances, or for ruptured perimemn, or for true vaginal 
rectocele, is, I believe, complete. Where care in denu- 
dation of the mucous membrane has been observed, and the 
parts are nicely adjusted, reunion of the parts, as a general 
rule, is seldom wanting. There is little or no risk in the 
operation. Since J. Baker Brown's method was presented 
to the profession, various modifications in respect to the form 
of the denudation of the mucous membrane, or the kind of 
clamps or bars or the tying of the sutures, with their different 
adjustments, have been made. The exceptional cases are 
those of a syphilitic nature, or strumous diathesis. Geddings, 
Savage, May, Gamgee, Teale, Malgaigne, and others, have 
performed it. Hilton, in 1854, before the operation, preferred 
dividing the sphincter ani; and Oldham, in 1857, adopted the 
same views, with complete success. 
4. Elytroraphy, Anterior or Posterior. Gerardin pro- 
posed to remove a slip from the circumference of the vaginal 
mucous membrane of an inch in diameter near the os uteri, 
when the uterus was external, and afterward to return it into 
the vagina, and allow it to heal up by granulation, and thus 
produce contraction of the vagina at the superior part. The 
name of Elytroraphy was given to this method of opera- 
tion by M. Berard, Jr. There has been much controversy in 
regard to the origin of this operation. Velpeau, in a clinical 
lecture, says: " The first idea of this operation is due to Ge- 
rardin, who described it in a memoir which he presented to 
the Societe de Medecine de Metz or Nancy, which, however, 
was never published. He proposed to contract the vagina, 
and, if necessary, even to obliterate it in women who have 
ceased to menstruate. In his letter to the Academy, he 
says that before 1823 he had proved that the pessary might 
be replaced by and the cure of prolapsed womb radically 
effected by a surgical operation," which is stated above. 
It is, therefore, possible that Marshall Hall might have AMPUTATION OF THE CERVIX UTERI. 
39 
been aware of Gerardin's suggestions before he proposed 
his operation, which was performed by Heining, Novem- 
ber 19, 1831. If Dr. Hall derived any benefit from 
Gerardin's suggestion, his operation was different in its lo- 
cality, and the method of producing a contraction of the 
vagina. The credit is usually conceded to Dr. Hall for his 
method of operation. A mistake exists in the minds of 
the profession, respecting the form or shape of the portion 
he had removed from the mucous membrane of the vagina. 
It is generally spoken of as elliptical. This is not as it is de- 
scribed by Dr. Hall himself, in the London Medical Gazette, 
vol. ix., page 269. He says: " The uterus being protruded as 
much as possible by the efforts of the patient, two parallel 
incisions were made through the mucous membrane from the 
sides of the os uteri, along the course of the protruded vagina 
to the os externum; the portion of this membrane situated 
between these incisions was then removed, leaving a space of 
1^ inches in breadth, and of the entire length of the vagina, 
completely denuded. A suture was then inserted near the os 
uteri. This suture being tightened, the os uteri was pushed 
upward; a second, and a third, and others wTere inserted in 
the same manner, at short intervals, to the os externum." 
From this description it appears that the form of the part of 
mucous membrane removed was of a parallelogram, and not, 
as it has been supposed, elliptical. The case was successful, 
and remained so when examined several years afterward. 
The elliptical shape for denudation belongs to Dr. Ireland, 
of Dublin, who, in November, 1834, operated for procidentia 
uteri. The operation of Dr. Hall was modified by " dissect- 
ing a slip of the mucous membrane from the lateral portion of 
the vagina, about 1^ inches wide, extending the whole length 
of the tumor, from the os uteri to the os externum. The in- 
cisions were parallel, except at the commencement and termi- 
nation of each other, where thej suddenly converged, leaving 
an intermediate portion of the vagina free." Dr. Ireland pre- 
ferred this method, because it was more safe than Dr. Hall's, 
as the operation would be performed between the rectum and 
bladder. Dr. Irving, of Dublin, also adopted this modifica- 
tion in his case in 1834. Both operations were successful. 40 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
In August, 1835, Velpeau modified Drs. Hall and Ire- 
land's operation, and reported to the Academie Royal e de 
Medecine a case in a woman about fifty years of age. lie re- 
moved three strips of mucous membrane from the vagina, one 
anterior and two lateral; each of them was 10 lines, or 4 of 
an inch wide, and the whole length of the vagina. " The 
woman had been cured for two months " when last seen. M. 
Maingault objected to the operation, as it would prevent the 
female from becoming a mother, and would entail serious in- 
convenience in case of accouchement. M. Velpeau, in reply to 
this objection, remarked, that "there existed facts which 
tended to prove that the cicatrices of the vagina will yield suf- 
ficiently to permit the passage of the foetus." 
At the same session of the Academie, M. Berard, Jr., pre- 
sented a woman on whom he had practised the operation of 
Dr. Hall with full success. In the cases of three females oper- 
ated on by him, two had been radically cured.* All these 
cases were treated by the silk suture. 
But, prior to all these cases, Dr. J. F. South, of London, 
as far back as 1832,j- operated for prolapse of the bladder, with 
procidentia uteri, and removed an elliptical portion of the va- 
gina, extending within $ an inch of the os uteri, and down to 
the os externum, using the metallic sutures (platina). The 
operation was not successful the first time, but the second oper- 
ation was. In this instance, the position of the patient to be 
operated upon was standing, with her body bent at right 
angles, with her legs and arms resting upon a table, and the 
pelvis higher than the shoulders. A pewter speculum, slit 
lengthwise, and the edges widened, was introduced into the 
vagina, with the gap in front; the labia held apart by the as- 
sistants, and the perimeum pressed up with the speculum; 
the same method of excising portions of the mucous mem- 
brane as in the first operation. Patient did well this time. 
After an interval of several years, in 1856, Dr. Marion 
Sims operated on a case of procidentia uteri, and, to quote 
his own words " seriously proposed to this lady to make 
a complete vesico-vaginal fistula by removing at once, as 
* Archives Generales de Medecine, tome viii., 2d series, page 515. 
t Chelius's Surgery. Edited by Dr. South. AMPUTATION OF THE CERVIX UTERI. 
41 
it were, a large portion of the base of the bladder, with 
the anterior wall of the vagina. The portion removed 
measured 2^ inches transversely, by 2f inches longitudi- 
nally. The chasm was fearful." He further says, " his 
surprise was equalled only by his delight that he had not 
succeeded in doing what he intended." The portion de- 
nuded, or rather excised, was of an elliptical shape, the same 
as Dr. Ireland's, and having no intermediate healthy tissue. 
Two years afterward, in 1858, Dr. Sims modified his former 
method, and adopted a V shape, leaving the intermediate 
space free between the two slips of mucous membrane 
removed, and not completing the elliptical shape. The 
denuded surfaces were brought together by metallic sutures 
(silver). 
On July 5, 1861, Dr. Roberts, of Dublin, in a case of pro- 
cidentia uteri, modified Hall and Ireland's operation, and 
substituted the triangular shape, " by dissecting a slip of the 
mucous membrane covering the posterior surface of the uterus, 
brought the edges together by metallic sutures, and removed 
a similar piece from the anterior surface, and drew the edges 
together in the same manner, and performed afterward the 
operation for lacerated perinaeum. Patient did well." {Dub- 
lin Journal of Medical Sciences, vol. xxxii.) 
In 1865, Dr. Emmet modified the operation of Dr. Sims 
of the V shape, by making it a triangle, the same form as Dr. 
Roberts's, but with an intermediate space of healthy tissue. 
The triangle shape was suggested to Dr. Emmet, as he recog- 
nized in some of his own patients and those of Dr. Sims, that 
had been operated upon, the uterus was retroverted, and the 
cervix caught in the base of the V shape, suggested by Dr. 
Sims. It appears that the several operations which I have 
referred to, where the silk ligature was used, up to 1835, and 
others, where the 'metallic ligature was adopted, were per- 
fectly successful. My friend, Dr. Sims, however, entertains 
a different view, and says, in his " Clinical Notes on Uterine 
Surgery," " I do not think the operation ever succeeded till 
my own day," and this success is due wholly to metallic 
sutures. 
The operation on the vagina, by caustics, lately resorted to 42 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
in some cases, by Dr. Routh, of London, has not claimed much 
attention from the profession. From this resume of the vari- 
ous operations on the vagina, we find that the principal op- 
erations at the present day, for procidentia uteri, are : 1. Epi- 
sio-perineoraphy; 2. Elytroraphy, anterior or posterior, or 
both at the same time (Dr. Roberts) ; and, 3. Amputation of 
the cervix uteri by different methods. Having already dwelt 
upon the former, my remarks in the few following pages 
will be addressed to the subject of the amputation of 
the cervix uteri for this affection. The cases which M. Hu- 
guier considers as contraindicating the operation are: " too 
large a pelvis; too large a vulval opening; a perinaeum more 
or less relaxed or ruptured; a considerable relaxation of all 
the soft parts that form the floor of the pelvis, or where the 
body of the uterus is completely without the excavation, or re- 
troflexed in such a manner that the fundus of the organ is 
lower than the cervix, and do not permit us to hope for suc- 
cess." The cases which have presented themselves for my con- 
sideration were many of them of long standing, varying from 
one to thirty years, and in whom, according to M. Huguier's 
views, an operation was contraindicated. Some of these cases 
will be represented by diagrams. 
Previous, however, to M. Huguier's suggestions for removal 
of the cervix uteri for procidentia uteri, Professor Chaumet, in 
1845, recommended the following method: 1. Remove a por- 
tion of the vagina, as advised by Dr. Hall and performed by 
Gerardin, Laugier, Professors Velpeau and Berard, Jr.; 2. 
Amputate the whole or part of the cervix uteri. In the case 
operated on by Professor Chaumet, the result was in every 
respect satisfactory: although eight months had elapsed, and 
the woman had been occupied in the most laborious duties, 
she remained cured. 
Lisfranc gave more currency to the propriety of the ampu- 
tation of the cervix uteri for diseases of the uterus than any 
previous surgeon on the Continent, but it was generally for 
large hypertrophy of the infra-vaginal portion of the cervix. 
The opinions of several of the more recent gynecologists, such 
as Beccpierel, Nonat, Hodge, and others, give but little, if any, 
sanction to this method of operation, through mistaken views AMPUTATION OF THE CERVIX UTERI. 
43 
as to its value. As no description of M. Huguier's operation 
lias been given by any American authority, I shall be excused 
for presenting it before I pass to tlie relations of other methods 
for amputation of the cervix uteri, according to the nature of 
the case. 
This operation consists in the removal from the superior 
extremity of the vagina of a portion, or the totalite, of the cer- 
vix from without inward, after having previously separated 
the bladder from the part which is to be removed. This has 
been termed the " conoidal amputation of the cervix uteri." 
The object of the operation is not only to amputate the supra- 
vaginal portion of the cervix, but to remove some, or a consid- 
erable portion, of the supravaginal part, which is the seat of 
the hypertrophy. The difficulties consist in the necessity of 
avoiding the posterior peritoneal folds, and the bladder in 
front, dangers from haemorrhage during or after the operation, 
and the consecutive inflammation, perimetritis. 
Previous to the operation, M. Huguier gives special atten- 
tion to the welfare of his patients, which consists in producing 
an eruption, by croton oil being freely rubbed on the thighs, 
legs, and flanks, and which is done from fifteen to twenty days 
before the operation, for fear of peritoneal inflammation. 
The patient is placed in the usual position for diseases of the 
uterus, on the back, and the procedure of the operation is as 
follows: 
1. " The first step consists in the section of the posterior 
part of the vagina and neck. The danger is the lesion of the 
peritonaeum. To avoid this, the surgeon introduces his index- 
finger of the left hand into the rectum, and places it in contact 
with the anterior part of the intestine. The finger indicates 
to the eye the limit of the recto-vaginal fold of the peritonaeum, 
and serves as a guide during the whole of the operation. In- 
cising on the finger the portion of the vagina which is inserted 
on the neck, during which incision the cervix is seized by an 
assistant with the Museaux forceps in the posterior lip of the 
os tincae; then directing the incision toward the cavity of the 
neck, to avoid the peritonaeum, through the thickness of the 
uterine tissue, obliquely from below upward, and from without 
inward, as far as it has reached the cervical cavity. 44 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
"The second step of the operation consists in.the removal 
of the anterior section of the cervix. The danger to be in- 
curred here is cutting into the bladder. To arrive at this, he 
introduces into this organ a sound, directing it below, toward 
the inferior part of the vesical cul-de-sac, which forms at the 
anterior part of the tumor. It is then given to an assistant. 
The anterior part of the cervix is seized by the Museaux for- 
ceps, and depressed by the assistant. An incision is made 
about four lines from the end of the sound, of a horizontal and 
semi-lunar shape, from the superior convexity, which embraces 
the anterior part of the cervix, and the extremities join those 
of the first incision posteriorly. We then separate, by a care- 
fid dissection, the bladder from the anterior part of the cervix, 
in a space from three-quarters of an inch to an inch at most, 
after which we divide the anterior part of the neck obliquely 
from above, below, and from below upward, reaching the cer- 
vical cavity near the posterior incision. 
" The part removed has the form of a cone of which the 
base is the os tine®. To avoid the haemorrhage which fol- 
lows the operation, it is necessary sometimes to tie the arte- 
ries. To prevent the uterus from ascending after the opera- 
tion, a tenaculum is inserted in the posterior part of the 
cervix. It is with difficulty the arteries can be secured in the 
uterine tissue, as it is so dense and friable that the ligatures 
do not hold the arteries. M. Huguier, for this purpose, has 
invented a procedure to secure them. It is a strong curved 
hook, resembling a fish-hook, at the head of which is a liga- 
ture, and the ligature is then passed over the artery, and tied. 
Besides this means of operating, instead of removing the part 
by the scissors or scalpel, the ecraseur may be employed, as 
was accomplished by Chassaignac in 6 cases. This cannot 
be applied till the anterior and posterior parts are separated; 
even then the conical shape cannot be given to it. The ecra- 
seur is valuable where there is a vascular neck, or a very large 
hypertrophied os uteri. 
" Should the ligatures not succeed in their application, then 
the actual cautery, or the persulphate of iron, to arrest the 
haemorrhage, should be used. The portion excised being re- 
moved, we return the uterus into the pelvis. On the part AMPUTATION OF THE CERVIX UTERI. 
45 
excised, a mesh of lint covered with cerate is placed, and 
this is maintained in position. The cicatrization is complete 
in from 20 to 30 days. The superior extremity of the vagina 
is thus contracted or gathered up, and presents a reddish cica- 
trix, about three-quarters of an inch, at the bottom of which 
we perceive a small transverse opening. The womb dimin- 
ishes, in two or three months, in volume, independent of the 
portion which is removed, reducing the uterus nearly two 
inches in its length." 
M. Huguier does not perform any operation on the peri- 
naeum, as he has given the contraindications for his opera- 
tion ; and the ruptured or relaxed perinseum was one of these 
contraindications. 
I have stated above that the very cases M. Huguier has 
objected to are the kind of cases which have claimed my 
attention, and, therefore, deemed that the operation for episio- 
perineoraphy should be performed. If these cases, as M. 
Huguier considers, contraindicate the operation of amputa- 
tion of the cervix for procidentia uteri, what operation, may I 
ask, would be of any value or benefit to the patient ? Cer- 
tainly, elytroraphy, anterior or posterior, with any of the mod- 
ifications which have been suggested, would not, I think, be 
likely to succeed. In the cases I have described, if the fundus 
reaches, or remains in, the normal position, then the elytro- 
raphic operation would either raise the fundus uteri two or 
three inches above the superior strait, or, if not thus elevated, 
it will assume the retro verted or retroflexed position. This 
occurred in several of the cases of Dr. Sims, and was recog- 
nized by Dr. Emmet, a few years afterward, by the cervix en- 
gaging in the base of the V-shaped pouch which Dr. Sims had 
adopted. Hence, the V shape was modified to a perfect tri- 
angle by having the base made complete. With even this 
alteration, I am impressed with the idea that it will not pre- 
vent the womb from becoming retroverted or retroflexed, if 
there is the elongation of the supra-vaginal portion, as I have 
demonstrated. Possibly, I may be mistaken in regard to the 
kind of cases this operation or method is to be performed 
upon, as there is nothing definitely stated, either by Dr. Sims 
or Emmet, as to what kind of hypertrophy it was. Should 46 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
we judge from what Dr. Emmet says in the concluding re- 
marks he makes in his essay on procidentia uteri, we might 
be enabled to conclude they were not cases of elongation. 
Dr. Emmet says " his method should be resorted to, when the 
uterus has become hypertrophied, and before it has remained 
outside of the vagina for years unreduced ; before the vagina 
has lost entirely its contractile power, through the usual sys- 
tematic course of stretching by pessaries, each from necessity 
being larger than the previous one in use." 
It is more particularly in the exceptional cases, as adduced 
by Huguier, that I have resorted to the operation of amputa- 
tion of the cervix uteri for procidentia uteri. I am so con- 
vinced on this point, that it is difficult to believe, nor do I see 
that, any other form of operation for simulated prolapsus could 
be as successful, unless the special objects, which are to be ob- 
tained from the amputation, ensue : 1st, a modification in the 
size and weight of the uterus; 2d, a decrease of the hyper- 
trophy or elongation-first, by the loss of blood which will 
necessarily follow the operation, sometimes greater, and some- 
times less, and, second, by the suppuration which will take 
place-and 3d, the contraction or lessening of the remaining 
portion of the cervix. 
It is not only in the cases of longitudinal hypertrophy, or 
elongation of the cervix, that the amputation of the cervix 
will be necessary, but in cases sometimes of an eccentric char- 
acter. Dr. Sims incidentally refers to the kind of cases which 
M. Huguier has described, and remarks upon the objects of 
the operation for amputation : " I amputate the cervix only 
when its lower segment is too large, or too long, and projects 
so far into the vagina as to present a mechanical obstacle to 
the retention of the uterus in situ, when replaced " (p. 302). 
In other words, he only operates for hypertrophy or elongation 
of the infra-vaginal portion of the cervix. 
Dr. Sims, in a short paper on " Amputation of the Cer- 
vix Uteri " [Transactions Med. Society, State of New York, 
1861), after performing the operation of M. Huguier, by re- 
moving a conical portion of the cervix, for great engorgement 
and hypertrophy of the cervix with granular os uteri, re- 
marks : " This mode of operation should not be imitated, for AMPUTATION OF THE CERVIX UTERI. 
47 
the cicatrization of the wound almost obliterated the cervical 
canal." 
In regard to the treatment of these cases by amputation 
of the cervix uteri, for their radical cure, or for the greater 
comfort of the patient, I have been guided by the nature of 
the case requiring the operation : 
1. If there was a uterus with a procidentia, with elongation, 
having a short anterior and posterior infra-vaginal portion, 
with no eversion or decided hypertrophy of the cervix, Hu- 
guier's operation was adopted, by removing a conical portion 
of the cervix, though in a different manner from that of M. 
Huguier, which will be referred to shortly. 
2. When there was infra-vaginal hypertrophy, more than 
ordinary with elongation, the simple circular amputation was 
resorted to, sometimes by the scalpel, sometimes by the ecra- 
seur (double chain or the twisted wire), but more generally 
by the scissors. Previously, however, to using the ecraseur, 
the mucous membrane was divided completely around the 
cervix, to prevent the drawing in of the mucous membrane 
into the chain of the instrument, and thus avoiding the possi- 
bility of lacerating the peritonaeum. 
3. When the cervix was everted in part or in totalite, I 
then performed the operation which is described in case 4, and 
illustrated in the diagram accompanying it. (Fig. 7.) 
4. Should the anterior and posterior labia of the cervix be 
somewhat elongated and hypertrophied, even with eversion, 
or without eversion, and the body of the uterus large, I have 
performed what I shall call the " double-flap operation " (see 
Case 4, Am. G.). In this operation, there will be but lit- 
tle, if any, contraction of the cervical canal. It leaves the ap- 
pearance of the cervix as nearly natural as it could well be (see 
Fig. 11). After the operation, episio-perineoraphy is per- 
formed, for a more perfect restoration of the uterus internally, 
and for a more successful issue. 
Dr. Sims, in the ordinary hypertrophy of the infra-vaginal 
portion of the cervix, excises the cervix by first slitting it 
laterally, nearly to the junction of the mucous membrane of 
the vagina with the neck, and then separates the anterior lip 
first, and afterward the posterior half; then he brings the mu- 48 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
cons membrane of the vagina, which covers its anterior part, 
to join the posterior part, and unites them by three or four 
metallic sutures, to produce union by the first intention. I 
do not perceive that there is any more guarantee in this mod- 
ification or method from contraction of the cervical canal 
than by the simple circular amputation. " In all three of the 
cases " he had operated on by this new method, he says, 
" menstruation has been easy since the operation, although the 
os was smaller than natural; but in each case I enlarged the 
opening a little by slight incisions." 
The perineal operation might be objected to after the am- 
putation of the cervix, because it may be supposed that, after 
the removal of the cervix, the uterus will ascend in the pel- 
vis more nearly to its natural position. This is not true re- 
specting the cases I have referred to, but it remains in the 
pelvis for a short time, until it becomes more reduced in size 
and length; it then begins to take its natural position. I 
believe that the perineal operation is absolutely necessary ; 
for, if it does not positively cure the dilatation of the rectum, 
or prevent the procidence of the recto-vaginal wall from be- 
coming prolapsed, it will, in time, return to a more natural 
condition. 
The dilatation of the posterior part of the vagina, or the 
rectum, is not the principal complaint, but only takes place 
from mechanical causes, in consequence of the loss of support 
in the pelvic floor. When this support is again supplied, the 
prolapse of this portion of the vagina, or rectum, will grad- 
ually disappear, or, at any rate, is so much lessened as to be of 
no practical inconvenience. In some cases, where I have had 
an opportunity of examining after the lapse of some years, and 
in one case, which I saw in March, 1868, there was not any 
portion which was found external. The protrusion is not 
likely to be reproduced unless the womb should become again 
affected. I have had two instances, where the patients have 
removed the clamp suture, and then I have substituted the 
cobbler's stitch for the usual suture, which will be described. 
I have performed the operation for episio-perineoraphy a great 
many times for different purposes, and in very few instances 
has the operation failed. The failure has been in consequence AMPUTATION OF THE CERVIX UTERI. 
49 
of a syphilitic hypertrophy of the parts grafted on a syphilitic 
constitution. From experience, and the very nature of most 
of these operations, as referred to, and the character of the 
affection, it is not to be expected that success will result in all. 
There must be failures, and there will be failures. Yet suc- 
cess will be obtained in a very large number of cases. The 
operation, by amputation of the cervix, as resorted to by M. 
Iluguier, appears to be rather a formidable one, on account of 
his removing so large a conical portion from the cervix, as he 
dissects the bladder and the rectum from their attachments to 
the uterus, and especially where the lower and upper branches 
of the uterine arteries course. It is for this reason that severe 
haemorrhage may follow, or a perimetritis occur. I do not 
think it necessary to resort to so extensive a removal of the 
cervix as M. Huguier, nor coidd it be extended farther up the 
cervical canal than the glandular part, as the portion above 
this is so very narrow, as I have shown. 
With the different methods I have followed, according to 
the nature of the case, I do not believe there is any fear of 
such a severe haemorrhage, nor risk of a perimetritis or cellu- 
litis, as I have never met with them, and I think the opera- 
tion perfectly simple and safe. I have not considered it re- 
quisite to prepare the patient for the operation, as M. Huguier 
suggests. In fact, with rest for a day or two, and the bowels 
evacuated previously to the operation, is all that is necessary. 
After the operation, the part excised is treated by water or 
sedative applications during the day occasionally, and the T 
bandage. In a few hours, or a day or two, the uterus recedes 
into the vagina, and sometimes at once, and gradually begins 
to diminish in length, and in the course of a few days will 
ascend to the natural axis in the pelvis, measuring 2^ inches. 
After this occurs, the operation of closing the peringeum is 
resorted to in two or three weeks, the uterus retaining its 
natural position. 
Case IV.-Complete procidentia uteri of ten years, mith re- 
troflexion externally ; elongation of the supra-vaginal por- 
tion ; complete eversion of the infra-vaginal portion • com- 
plete rupture of the perinceum ; amputation of the cervix 50 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
uteri. Double-flap operation. Failure of the clamp su- 
ture for the perinaeum. Successful restoration of the pe- 
rinoeum by the cobbler's stitch. Reported by Dr. Everett, 
House-Physician. 
Ann G , aged twenty-eight years, was admitted into 
Bellevue Hospital October 7, 1864, for procidentia uteri. Is 
the mother of two children; the first was born at full term, 
the second was a miscarriage, at five or six months. She has 
suffered from procidentia since the birth of her first child, ten 
years ago. On examining the vulva, the uterus was procident, 
Fig. 7. T 
TWO-THIRDS NATURAL SIZE. 
A. Internal orifice. B. Internal part of the cervix uteri. C. External orifice or os tinea. 
D. Fundus uteri. 
with complete retroflexion externally. The cervix was dis- 
covered very large, and totally everted, measuring three and a 
half inches in diameter, presenting a bluish-red appearance; the 
large globular substance hanging down was recognized as the AMPUTATION OF THE CERVIX UTERI. 
51 
fundus and body of the uterus. The rectal touch could feel 
nothing of a uterus in the pelvic cavity, and the sound intro- 
duced into the bladder could be felt when the end was turned 
to the rectum. The sound introduced into the uterus gave a 
measurement of 5^ inches, while in the retroflexed condition 
externally. When the uterus was replaced in the pelvic cavity, 
and the sound passed into the uterus, the length was six 
inches, and the fundus could be felt at the superior strait. 
There was only a slight cystocele; but no rectocele of any 
moment, for the fundus occupied the posterior cul-de-sac ex- 
ternally. As no tentative treatment, either by the various kinds 
of pessaries would be of any permanent value-or even the 
elytroraphic operation - the only resource left, I believed, 
was the amputation of the cervix uteri, and the restoration of 
the perinseum. 
After the patient had been in the hospital a month, Novem- 
ber, 1864, the double-flap operation, as I have termed it, was 
performed in the presence of a large number of medical gen- 
tlemen and students. The first step was to return the body 
of the uterus into the pelvic cavity, the cervix remaining ex- 
ternal ; next, to reinvert the cervix uteri; then divide the right 
and left side of the cervix laterally, half to three-quarters of an 
inch above the union of the vaginal cul-de-sac. After this, 
transfix the posterior labia of the cervix, commencing at the 
summit of the division just made laterally, at about two-thirds 
of the thickness of the labia, then cutting through the whole 
length of the posterior half of the cervix. The anterior labia 
was transfixed and divided in the same manner; then remov- 
ing the posterior upper portion upward and inward in toto ; 
afterward the anterior lower part from above downward, leav- 
ing the one-third of the thickness of the anterior and posterior 
labia, having a mucous membrane externally. Thus we re- 
move three-fourths of the cervix above the insertion of the va- 
ginal mucous membrane after the separation of the two-thirds 
of the cervix uteri in its thickness, and half to three-quarters of 
an inch above the insertion of the vaginal mucous membrane 
the anterior labium is doubled up, and the end of the labium 
reached to the point of the cervix that was separated, and two 
sutures (metallic, iron or silver) are inserted on each side, and 52 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
tied. The posterior is done in a like manner by two sutures 
on each side. Then the labia which have been doubled up, 
and united by sutures, are brought in apposition, by two more 
sutures on each side, and also by one suture in front, to pre- 
vent the parts from gaping, and making it more secure. The 
lateral portions of the cervix are in close union, at the edges, 
and the two external mucous surfaces of the infra-vaginal por- 
tion of the cervix, the anterior and posterior, are in apposition. 
Union by the first intention takes place, and the artificial os tineas 
is now covered by a mucous membrane for three-quarters of an 
Fig. 8. 
APPEARANCE AFTER OPERATION-HALF NATURAL SIZE. 
inch in the cervix, and no perfect closure of the cervix can oc- 
cur. The cervix was allowed, after the operation, to remain ex- 
ternal, and water dressing solely adopted, three or four times a 
day, the patient removed to her bed, and pills of hyoscyamus 
or aqueous ext. of opium 1 gr. three times a day. The catheter 
to be used every four or five hours. No untoward circum- AMPUTATION OF THE CERVIX UTERI. 
53 
stances occurred, the inflammation was of a light character, and 
the sutures were removed on the fifth day, except the one 
directly in front closing the labia. The operation of episio- 
perineoraphy was then performed after the uterus was re- 
turned into the pelvis, by the ordinary clamp suture, only 
adopting the parallelogram shape for the removal of the mu- 
cous membrane, when the vulva is expanded four inches in 
length, or two inches on each side, and one and a half inches 
breadth. Patient returned to bed; water dressing; T band- 
ages ; catheter used as usual, and opium or hyoscyamus pills 
given. 
Every thing was progressing favorably; but on the fourth 
morning the patient removed the clamps. On examination 
the peringeum appeared closed perfectly, but my fears were, as 
the union was only recent, the adhesions would give way, and 
the uterus become again procident. The uterus measured 
four inches; the patient left the hospital the next day. In 
July, 1865, eight months afterward, Ann G. returned to the 
hospital for a second operation on the perinaeum, the uterus 
being prolapsed in part, and measuring four and a half inches 
in length, and retroverted. The perinaeum quite gone, and 
appeared as it did at the first examination. The same opera- 
tion for the perinaeum was resorted to, and the same circum- 
stances occurred as previously. She removed the sutures on 
the fourth day. She was then dismissed from the hospital. 
In February, 1866, seven months afterward, while I was 
on duty at the Charity Hospital, she begged to be admitted, 
and promised faithfully to adhere to every order or direction. 
As she was au fait in removing the suture by the former 
method of treatment for the perinaeum, I proposed another and 
a different method, which I have called the cobbler's stitch. 
I felt confident she could not remove this suture. 
The patient was placed in the usual dorsal position. After 
chloroform had been administered, and the extremities of the 
patient sustained by assistants, the right and left labia were 
denuded by scissors, after the portion of the mucous membrane 
was marked out of a parallelogram shape, two inches in length 
on each side, and one inch and three-quarters in breadth. (The 
uterus had not increased any more in length, but the cervix re- 54 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
mained partially external.) The largest number of silver wire, 
a foot in length, having a large curved needle (see diagram) 
attached to each end, was used. The suture was introduced 
at the lower part of the perinaeum, close to the anus, carried 
deeply into the labia on the left side, one inch from the edge 
of the labia, then through the right labia from within, out- 
ward, and emerged the same distance from the edge of the 
labia. The right labia was then pierced from one-quarter to 
one-third of an inch higher up on the same side, and passed 
through to the left labia; then the left labia was entered by 
the suture, in the same place the needle emerged from, and 
thus every quarter or one-third of an inch the suture was intro- 
duced from left to right, and from right to left, until it had 
reached the commencement of the part that was denuded, 
making from four to six times. After the parts were suffi- 
ciently dry (though it is not necessary to wait for this), the 
labia were then drawn together, like the cobbler's stitch, 
not too tightly, but sufficiently so to bring the parts in 
close apposition. The wire was then tied in front, and four 
or five small sutures applied on the edge of the labia; water 
dressing and T bandages moderately applied, and the usual 
treatment adopted after operations of this nature. This suture 
Fig. 9. 
cobbler's stitch. 
the patient did not comprehend, nor could she possibly re- 
move it. The sutures were removed on the tenth day. AMPUTATION OF THE CERVIX UTERI. 
55 
Fig. 10. 
No untoward circumstances transpired to remove them 
before. At the time of removal the parts were somewhat 
oedematous, and the stitches slightly embedded. The water 
dressings were properly attended to every day, and inflamma- 
tion was thus prevented. On examination the perinaeum was 
solid and well established, the uterus higher up. The patient 
was retained in the hospital for six weeks, and the perinaeum 
continued perfect, the uterus measuring from three to three 
and.a quarter inches in length. The diagram gives the ap- 
pearance of the cervix uteri at that time. The representation 
was taken by my artist, M. Kohler. 
AFTER OPERATION. 
Fig. 11. 
Remarks.-The principal data of this case were recorded 
by my House-Physician, Dr. Everett. I was induced to resort 
NATURAL SIZE. 56 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
to what I have called the double-flap operation on the cervix 
uteri for elongation of the supra-vaginal portion of cervix 
uteri, with eversion of the cervix. I thought by this method 
we should avoid the peritonaeum, posteriorly, and the bladder, 
anteriorly, if it should descend too low. 
2. The derivative action might be ample enough to remove 
the elono-ation, as the cervix had been reached above the vam- 
nal cid-de-sac. 3. That the contraction (if there was any) of the 
cervical canal would not be so great when the two external 
mucous surfaces were brought in contact. 4. That the chances 
of pregnancy were much greater than by the other methods. 
I have now operated by this method in four or five instances 
with success, and I see no reason why it should not be re- 
sorted to, where the proper cases present. The haemorrhage 
is not as free as it is by M. Huguier's operation. Sometimes 
there is very little haemorrhage, and no vessels require to be 
secured. I have not seen as much in operations of this form, 
as I have sometimes for simple division of the cervix in dys- 
menorrhoea or for sterility. I have made trial of the cobbler's 
stitch on several occasions, which answers very well, and the 
operation in some cases can be accomplished in from ten to 
fifteen minutes. The appearance of the perinaeum is as perfect 
as it possibly can be. 
Case V.-Procidentia Uteri of ten years'1 duration ; Elonga- 
tion of the supra-vaginal portion of the Cervix ; Circular 
Amputation', Cure. 
Sarah Jarvis, aged forty-six years, November 2, 1867, pre- 
sented herself as a patient of the Bureau for Medical and Sur- 
gical Relief of the Out-door Poor, Bellevue Hospital. At 
eighteen years had typhus fever, since which time her menses 
have never been regular; has had frequent haemorrhage, some- 
times two or three times a month, which -was probably owing 
to small vesicular polypi in the cervix. Her first child, and 
only one, was born when she was thirty-five years old, and 
after she had been married five years. She was delivered 
by forceps. Patient excessively dropsical at the time; she 
occasionally suffers from pain in the left side, for which she 
has been treated by various remedies. AMPUTATION OF THE CERVIX UTERI. 
57 
On examination the uterus was found procident two inches ; 
cervix not large; a small polypus in the cervical canal. By 
the vaginal touch the cervix was recognized as being elon- 
gated, cord-like, and extending up the vagina from one and a 
half to two inches. Per rectum the same condition was ascer- 
tained. The sound passed five inches and a half to the fun- 
dus uteri. The body was retroflexed. No cystocele, but an 
hypertrophic condition of the anterior part of the vagina, near 
the urethra. No rectocele. Perinseum perfect and firm. Op- 
eration, December 8, 1866. Dr. Taylor, in the presence of 
Dr. W. T. Lusk, and Dr. S. T. Hubbard, at the residence of 
the patient, amputated one inch and a half of the cervix, by 
means of the curved scissors. The neck first being slit lat- 
erally above the vaginal cul-de-sac half an inch, the mucous 
membrane divided around the cervix. The wire-chain ecra- 
seur was first tried, but the wire broke, in exercising, from 
pressure. 
There was very free haemorrhage from an arterial vessel on 
the left side of the cervix, for which, first torsion, and then the 
actual cautery was used; and afterward the persulphate of 
iron. The uterus was replaced in the vagina after the haemor- 
rhage had ceased. The vagina was then tamponed, as I usu- 
ally do in all cases for uterine haemorrhage, by the surgical 
bandage, one and a half to two inches wide, and packing the 
vagina completely. It is perfectly simple, promptly intro- 
duced, and as promptly removed. The next morning the 
tampon was removed. No haemorrhage. Patient to retain 
the bed for two or three weeks. Catheter used as usual. Sed- 
ative treatment, and the tepid-water injection for vagina every 
day. In two weeks the measurement of the uterus gave from 
two and three-fourths to three inches. The uterus had attained 
its normal axis and position in the pelvis. November 14,1867, 
nearly one year afterward, Dr. Lusk reports, " Patient called 
to-day at the Bureau, and says she has been quite well ever 
since." Uterus natural size, two and a half inches; os uteri 
not contracted too much; os tincse slightly abraded. This 
case is reported by Dr. W. T. Lusk, my attending physician, 
to the Bureau. 
Remarks.-In this case the circular amputation was 58 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
adopted. There was more haemorrhage than ordinary. I do 
not think it is necessary to adopt the removal of a conical 
portion of the cervix, as laid down by M. Huguier. The 
form or method I have adopted is in conformity to the nature 
of the case. The important and principal object to be 
obtained from the operation is the derivative effect by the 
removal of a portion of the cervix, and thus a modification in 
the size and weight, a decrease in its elongation, with or with- 
out hypertrophy, by the loss of blood, and next by the suppu- 
rative process which follows-sometimes more or less-and the 
parts to heal up by granulation, occupying about four to five 
weeks. 
The decrease of the affected portion is well illustrated, as 
is so often noticed in the removal of a large pedicle in the 
case of fbro-cellular or fibrous polypi, although the whole of 
the base of a pedicle, when large, may occupy some months 
for its removal. The vitality and the weight of the part are 
interrupted, in these cases of procidentia uteri, by the removal 
of a portion of the cervix, and a new process instituted for its 
return to the natural size. It is not to be asserted that the 
operation will always succeed; nor has the operation for the 
removal of a large pediculated polypi, or a large tonsil. There 
is a tendency to return in some cases of this nature. 
Case VI.-Procidentia Uteri, twelve years' duration ; Elon- 
gation of the supra-vaginal portion ; Body of the Uterus 
retroflexed internally, Cervix externally ; Amputation 
of the cervix, by the removal of a conical portion of the 
neck • Episio-perineoraphy • Cure. Reported by Dr. 
Everett. 
Hannah M., married, aged forty, Ireland, was admitted 
iuto Bellevue Hospital November 2, 1864. Has had six chil- 
dren. Had two miscarriages since the birth of the last child. 
Uterus prolapsed twelve years. She first noticed the tumor 
after the birth of her first child, which happened before a phy- 
sician could attend her. It occasioned her very little trouble 
until about two years ago, since which time it has been get- 
ting worse, and pains her considerably at times. Her menses 
have been regular, except for the last two or three months. AMPUTATION OF THE CERVIX UTERI. 
59 
By inspection the uterus appears prolapsed about two and a 
half inches, and the perinaeum entirely gone. The sound gives 
the length of the uterus as five and a half inches. By the 
vaginal and rectal examination, the long cord-like feel of the 
cervix is perceptive, and the sound can be felt through the 
body of the uterus, which lies in the cavity of the sacrum. 
There was only partial cystocele and no rectocele. 
November \5th.-The amputation of the cervix was per- 
formed in the following manner: The cervix was divided 
laterally one-half to three-quarters of an inch above the vaginal 
cul-de-sac on each side. The anterior and posterior portions 
of the cervix were then removed; the anterior, by dividing it 
downward obliquely and inward to the cervical canal, and 
the posterior upward obliquely and inward, thus a small 
conical portion of the cervix was removed. Ihemorrhage wras 
moderate. After the haemorrhage had ceased, a pledget of 
cotton was applied, and the surgical bandage, as formerly 
used in other cases, introduced as a tampon. The next day 
the tampon was removed^ and the vagina washed out with 
tepid water. Vaginal injections of tepid water every day. 
Pills of opii, 1 gr., three times a day. On the sixth day episio- 
perineoraphy was performed, and the clamp suture adopted 
with the modification of closing the clamps, by Dr. Lane's 
method. Water dressing; catheterism every day, and seda- 
tive treatment. Sutures removed on the fourth morning, and 
the patient retained in bed for ten days more, when she was 
allowed to get up. Uterus did not prolapse, and measured 
only three and a half inches. The body lying in the sacrum 
when reclining, but assumed the natural position when erect. 
She remained in the hospital until December 25th, when she 
was discharged cured. The perinaeum firm and solid. 
Remarks.-In this case I adopted the modification of unit- 
ing the clamps after Dr. James R. Lane's method for ruptured 
perinaeum or vaginal rectocele. Dr. Lane used the ivory bar 
instead of the lead one. The bar intended for the right side 
is ready, threaded with two pieces of metallic wire (iron or 
silver), as represented (see Fig. 12), each piece of wire being 
looped through the two adjacent holes. This is held by an as- 
sistant. The needle, after it has been passed across or through 60 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
both labia, commencing at the lowest part, is then threaded 
with the lower one of the four ends of wire, and withdrawn- 
the same proceeding is adopted for the other ends. The wires 
s Fig. 12. 
are then passed through the second bar, and, being drawn 
tight, the whole is firmly secured by tying or twisting the 
ends together, first of the two lower, and then the two upper. 
Fig. 13. 
AFTER OPERATION. 
The method of applying the sutures is simple and easy, and as 
easily and simply removed, by only dividing the two sutures. 
It is necessary in many cases of this character of prociden- AMPUTATION OF THE CERVIX UTERI. 
61 
tia uteri to have firm support, during the early progress of the 
treatment, by the clamp suture, as the interrupted suture alone 
will not meet the nature of the case. I have preferred, in all 
the operations on the perinseum, the needle as exhibited in 
Fig. 13, instead of Mr. Lane's, and I sometimes introduce the 
four needles before threading them, and then drawing them 
through at once. I perceive that Dr. Hayes Agnew, of Phila- 
delphia, uses a modification of Mr. Lane's needle, by substitut- 
ing a movable joint. 
Case VII.-Procidentia Uteri, four Years' Standing ; Elon- 
gation of the supra-vaginal Portion of the Cervix Uteri; 
Elytroraphy twice, afterward circular Amputation of 
the Cervix • Episio-perineoraphy. Reported by Dr. 
Everett, House-Physician. 
Mary B., aged 26, domestic, native of the United States, 
has had 6 children; 14 years of age when she was first con- 
fined. At that time she had twins. Four years ago last March, 
1864, while carrying a tub of water, she w'as suddenly seized 
with a severe pain in the lower part of the abdomen, and soon 
after the uterus prolapsed through the vulva. She commenced 
flooding, and lost a large quantity of blood, when she came 
into Bellevue Hospital. In the following autumn, Dr. 
Emmet, at the suggestion of Dr. Elliot, performed Dr. Sims's 
operation on the anterior part of the vagina-anterior ely- 
troraphy. Five weeks afterward she was discharged as 
well, and continued so till April, 1865, when she returned to 
the hospital the same as formerly, when Dr. Elliot performed 
the same kind of operation ; but, after a few weeks, the uterus 
prolapsed again. 
In November, 1866, Dr. Taylor amputated the cervix 
uteri (simple circular operation). The uterus measured 4J 
inches. After removing 1| inch from the cervix, the uterus 
was returned into the pelvis, as soon as the haemorrhage had 
ceased. T-bandage applied ; catheterism 2 or 3 times a day ; 
vaginal injections of tepid water; opium pills, 1 gr., 3 times 
a day ; and rest for 2 or 3 weeks. After four weeks, she re- 
quested to be discharged, as she considered herself well. The 
uterus attained its normal position and axis in the pelvis. No 62 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
operation for the perinaeum was then adopted. Seven months 
afterward, she was seen in the hospital visiting a friend. At 
that time, the uterus retained its normal position, and she con- 
tinued regular every month, and was in better health than for 
several years. 
While on duty at the Charity Hospital, Blackwell's Island, 
in February, 1868, Mary B. entered the hospital a day or two 
before, and complained of her former difficulty respecting the 
womb. On inspection, the uterus was prolapsed 1^ inches, 
slightly sensitive to the touch, and measured 4 inches. In 
the operation for amputation, 14 months ago, I did not per- 
form the perineal operation, as I supposed the perinaeum, in 
her case, might be sufficient (although a short one) to retain 
the uterus if the cervix was removed. I was, however, mis- 
taken. This patient was very hysterical. 
February 25, 1868.-I performed the operation of closing 
the perinaeum before the class, adopting the clamp-suture 
(Lane's method) of tying the wire. Sutures removed, March 
1st, by my house-physician, Dr. Ralph Mead. Perinaeum 
closed firmly. 
ALarch -Every thing progressing finely. 
j\Larch -Perinaeum long, firm, and solid; cervix of 
uterus, high up, 2| inches ; measurement, 3 inches. Says she 
feels very well. 
April -Saw Mary B. The uterus measured 2f 
inches, and the cervix was 2| inches from the vulva. In the 
erect position, the uterus -was in its normal position. The 
perinaeum continued firm and solid. The class was present at 
the time of examination, and some of the students and the 
house-staff were permitted to verify the natural relation of the 
uterus to the pelvis, and the size of the uterus. 
Remarks.-The partial failure of this case, which was from 
1 year to 14 months after the operation, wTas owing, as I be- 
lieve, to the want of my not forming a new perinaeum, longer 
than the natural one. It tends to illustrate the opinion I en- 
tertain, that, when the cervix is amputated even by any of 
the methods I have referred to, the operation may not be com- 
pletely successful, unless the perinaeum is repaired, if lacerated, 
or if relaxed, and wide, and gaping, and worn away. It be- AMPUTATION OF THE CERVIX UTERI. 
63 
comes, I may say, almost a positive necessity, if the uterus 
has been completely or incompletely prolapsed. I did not con- 
sider the case of Mary B. as a perfect case of elongation of the 
supra-vaginal portion of the cervix, though the examination 
in February, 1868, gave us the cylindrical cervix, although 
not long. It is adduced to show that, in some cases, the 
amputation of the cervix will not succeed perfectly as an 
operation alone, without the remodelling of the perinaeum, 
which is a great and important part of the treatment. It 
shows also that the operation on the anterior part of the vagi- 
na, as proposed by Hall and completed by Heming and others, 
is subject to the same failure. 
Case VIII.-Procidentia Uteri • complete Eversion of the 
Cervix Uteri of twenty Years' Continuance, Removal 
of triangular Portions of the Cervix Uteri', Cure. 
Bridget Mathews, admitted into Bellevue Hospital, No- 
vember, 1866 ; has had several children ; complains of severe 
dragging sensation in the groins, and has had her menses very 
freely of late. On examination, the uterus was found pro- 
lapsed nearly 2 inches; the cervix was completely everted, 
Fig. 14. 
A B. Triangular portion to be removed. 
C D. External os uteri. 
NATURAL SIZE. 
presenting a red bluish appearance (see colored plate), with, a 
slight discharge of mucous secretion; there was an abrasion 64 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
near the os uteri. There was a cystocele and vaginal recto- 
cele, both of a moderate extent. The uterus measured 
inches in depth, and the rectal touch could feel the fundus of 
the uterus just within the labia, also the end of the sound 
through the body. 
The operation performed was, removing a triangular por- 
tion from the cervix on each side, of an inch long (see Fig. 14), 
and then closing the cervix by two metallic sutures intro- 
duced on each side, and one in front (see Fig. 15). On the 
third morning the sutures were removed, the uterus returned 
into the pelvis, and the operation of episio-perineoraphy 
performed. The clamp-suture was adopted. On the sixth 
day the sutures were removed, and the perinaeum found 
perfect. Ten days afterward, the uterus was normal in po- 
sition, and presented a natural appearance (see Fig. 16). The 
same treatment adopted as in the former case-water dress- 
Fig. 15. 
Fig. 16. 
AFTER OPERATION. 
NATURAL SIZE TWO MONTHS 
AFTERWARD. 
ings, and injections, catheterism, and sedative treatment to re- 
strain the action of the bowels. Previous to the bowels being 
moved by a cathartic, I have always preferred an enema 
should be given, before the deep sutures are removed. 
Case IX.-Complete Procidentia Uteri ; complete Retroflexion 
externally • complete Eversion Uteri; Procidentia of 
twenty-five Years' Duration ; lacerated Perineum ; no 
Treatment. 
Patient admitted into Charity Hospital, May, 1865 ; aged 
73 years. The uterus measured 1| inches ; from the internal AMPUTATION OF THE CERVIX UTERI. 
65 
orifice, 1| inches; when reeverted, 2 inches; slight cystocele 
and rectocele (see diagram). 
Fig. 17. 
TWO-THIRDS NATURAL SIZE. 
A. Os internum. B. Os externum. C. Fundus uteri. Procidentia 25 years. 
Remarks.-This case is presented to show the eversion 
that is manifested in cases where the uterus presents its normal 
length, yet retroflexed externally. 
CONCLUSIONS. 
1. That the opinion of M. Huguier-that the affection 
designated under the names of prolapsus or procidentia of the 
uterus, and which appears to be completely out of the pelvis, 
and is exterior to the vulva, is rare-is correct, though not as 
frequent as M. Huguier supposed, being in the proportion, 
according to my own investigations, as 1 to 12^, instead of 1 
to 32 of M. Huguier. 66 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
2. That there exists very seldom a true hypertrophic elon- 
gation or pathological change of structure of the supra-vaginal 
portion of the cervix ; but that there is an elongation which, 
in a great many cases, varies from 1 to 4, 5, and 6 inches, 
though usually 4| to 5. 
3. That the elongation is principally in the isthmus or in- 
termediate part of the supra-vaginal portion of the cervix, and 
that this elongation is aided and sustained by the gravity of 
the cervix consequent, in a great measure, on the changes 
which have occurred during gestation or parturition. 
4. That the assertion of M. Huguier-that the fundus of 
the uterus remains in the pelvic cavity as high as the superior 
strait, or superior part of the symphisis pubis generally-is not 
verified; but that the fundus or body of the uterus is usually 
found retrover ted or retroflexed, with the cervix in part ex- 
ternal, or, as it is not infrequent, the uterus is procident, and 
retroflexed in toto externally. 
5. That the infra-vaginal portion of the cervix is some- 
times hypertrophied; but that it is in many instances a true 
and complete eversion of this part, measuring from 21 to Sw- 
indles. 
6. That it is not necessary to remove as large a conical 
part of the cervix as described by M. Huguier ; but the simple 
circular method will, in some cases, suffice, though, in other 
cases, the adoption of the other methods, as proposed, may be 
resorted to, according to the nature of the case. 
7. That the only operation which fulfils the principal and 
correct indications in this affection, for the radical cure of this 
affection, is the amputation of the cervix uteri. 
8. That the contraindications of M. Huguier, which have 
been referred to, do not forbid the operation, but require it. 
9. That, to obtain a more perfect success in the treat- 
ment, the operation of episio-perineoraphy should be per- 
formed. 
I have given a transcript of my own experience, and a 
record of a few cases I have treated in procidentia uteri with 
elongation, whether, accompanied or not with hypertrophy. 
I have only added this mite on the altar of our profession, in 
comparison with the large gifts of others. AMPUTATION OF THE CERVIX UTERI. 
67 
If I supposed that the correctness and accuracy of the 
views and opinions I have advanced were beyond all ques- 
tion ; or, on the contrary, that their entire falsity would be 
asserted, I would not have ventured on the preparation and 
publication of this article. I believe the profession are at 
issue as to the facts and as to the interpretation of them in 
these cases. I trust the experience and investigations, as 
recorded, may not be viewed as entirely useless and profit- 
less, but that both the facts and interpretations may be sub- 
jected to the test of scrutiny and inquiry. It is proper and 
just to ascertain as far as possible where an error has been 
committed in the observations, and, on the other hand, where 
wrong impressions have been adduced from right observa- 
tions. I shall presume on the favorable consideration of 
those whose opinions I may have differed from. I hope that 
those who occupy their time and attention in laboring for the 
welfare and comfort of suffering women, who are compelled 
to undergo, perhaps for years, the inconvenience and distress 
consequent upon a 'uterine hernia, will contribute their own 
experience, in order to aid and benefit them. II.-PULMONARY PHYSICAL SIGNS. 
O71 the Analytical Study of the Pulmonary Physical Signs 
furnished lyy Auscrdtation and Percussion. Py Austin 
Flint, M. D., one of the attending Physicians to Bellevue 
Hospital, and Professor of the Principles and Practice of 
Medicine in the Bellevue Hospital Medical College. 
The completeness of auscultation and percussion, as 
branches of medical knowledge, requires-1. That all the 
physical signs which these methods of examination are capa- 
ble of furnishing, shall have been ascertained; 2. That the 
significance of the signs representing the various abnormal 
physical conditions which are incident to different diseases, 
shall have been fully determined, and; 3. That the differ- 
ential characters, by means of which the signs severally may 
be recognized and discriminated from each other, shall have 
been rendered as distinct, simple, and reliable as possible. 
These three requirements fulfilled, auscultation and percus- 
sion have reached the limits of their development and im- 
provement, as branches of knowledge; and then, to secure 
their utmost practical efficiency in diagnosis, it remains for 
physicians to acquire all that is known, together with the 
exercise of the judgment and skill to be derived from practice 
and experience. 
Of the three requirements just stated, our existing knowl- 
edge, as regards the first, may probably be considered suffi- 
cient for its fulfilment. This statement is made with reference 
to the pulmonary signs. It is hardly to be expected that 
many, if any, new signs are yet to be ascertained. The em- 
ployment of auscultation and percussion during nearly halt 
a century has revealed all the acoustic phenomena which 
these methods are capable of detecting; additional new 
sounds of importance are not likely to be discovered. At the 70 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
present time, all that remains for completeness is the definitive 
and permanent settlement of the question how far are diver- 
sities in acoustic phenomena or sounds to be considered as giv- 
ing rise to distinct signs ; or, in other words, to what extent may 
distinct signs embrace diversities of sounds ? If all abnormal 
sounds were to be regarded as so many distinct signs, wholly 
on account of their acoustic differences, the number of smiis 
would be very great, for the diversities of sound are exceed- 
ingly numerous. For example, the dry rales produced within 
the bronchial tubes offer such diversities, that, guided by the 
latter alone, it would be easy to make a large list of signs. 
Taking, however, into account the physical conditions repre- 
sented, and the diagnostic significance, it has been found 
practicable to so combine the diversities of sound, that all the 
dry bronchial rales may be embraced in two distinct signs, 
namely, the sibilant and sonorous. It is highly important 
not to multiply the signs to a needless extent, but, on the con- 
trary, to reduce their number as far as may be practicable 
without detriment to physical diagnosis. It should be a 
source of much encouragement to one entering upon the study 
of auscultation and percussion, to know how few are the 
signs which comprehend all the practical information to be 
derived from these methods. The number of signs need not 
exceed thirty. Regarded as a language, the vocabulary only 
embraces thirty words. 
The second of the requirements for the completeness of 
these branches of knowledge, namely, the significance of the 
signs as regards the morbid physical conditions which they 
severally represent, may also be considered to be nearly ful- 
filled. The meaning of each of the important signs has been 
determined; that is, when any of the signs are present, it is 
positively known that certain definite morbid physical con- 
ditions must exist. This is not saying that the existing 
disease is at once declared by the presence of certain signs. 
The signs, in themselves, represent only physical conditions, 
and a physical condition which gives rise to certain signs may 
be common to different diseases. Thus, solidification of lung 
occurs in pneumonia, in tuberculosis, and in pleurisy with 
large effusion. The signs of solidification are the same in each 
o o PULMONARY PHYSICAL SIGNS. 
71 
of these affections, and the diagnosis is to be made by the com- 
bination of signs and the associated circumstances in each 
case. So, the subcrepitant rale occurs in capillary bronchitis, 
in pneumonia, in bronchorrhagia, and in oedema of the lungs. 
As a physical sign, it is the same in each of these affections; 
but the other signs found in combination and the associate 
circumstances enable the diagnostician to determine in indi- 
vidual cases which one of these different affections exists. 
On entering upon the study of auscultation and percus- 
sion, it should be clearly understood that the signs represent, 
severally, not different diseases, but different morbid physical 
conditions. Having ascertained the latter, it remains to de- 
termine, in particular cases, the diseases to which they are 
incident. 
The statement that the significance of each of the impor- 
tant signs has been determined, does not imply competency 
to explain fully the manner in which all the signs are pro- 
duced. The physical principles involved in the production of 
certain of the signs are not settled to the satisfaction of all 
minds; there is room here for discussion and difference of 
opinion. But it is a fact not to be lost sight of in the study 
of auscultation and percussion, that our existing knowledge 
of the significance, and thereby of the diagnostic value of 
the signs, depends, not on our ability to explain the mechan- 
ism of their production, but solely on their constant associa- 
tion with certain morbid physical conditions, as determined 
by direct observation. Desirable as it may be to settle all 
doubtful points concerning the rationale of the signs, it is not 
essential to do so, and hence, regarding the subject in a 
practical point of view, I have not included this among the 
requirements for the completeness of our knowledge of aus- 
cultation and percussion. 
The third of the three requirements for the completeness 
of auscultation and percussion, as branches of medical knowl- 
edge, is, " That the differential characters, by means of which 
the signs severally may be recognized and discriminated from 
each other, shall have been rendered as distinct, simple, and 
reliable as possible." The chief object of this paper is to offer 
considerations relating to this last requirement. What are 72 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
the true sources of the differential characters of the different 
signs ? What are the differential characters as derived from 
their true sources, and are they distinct, simple, and reliable? 
These questions lead to the foundation of the practical availa- 
bility and efficiency of auscultation and percussion as applied 
to diagnosis. Assuming that all the physical signs to be ob- 
tained by these methods, together with their significance, have 
been correctly determined, it is obvious that the application 
of this knowledge at the bedside will be more or less success- 
ful in proportion as tlie signs are to be recognized and discrim- 
inated from each other with facility and accuracy. It is quite 
needless to dwell upon the importance of the foregoing ques- 
tions, and I shall, therefore, at once proceed to the considera- 
tions which they suggest. 
What are the true sources of the differential characters 
of the different signs ? 
The signs furnished by auscultation and percussion, except- 
ing those in which all sound is suppressed, are sounds, and a 
natural division of them is into-1. Signs which are abnormal 
modifications of the normal sounds pertaining to respiration 
and the voice; and, 2. Signs which are adventitious or alto- 
gether morbid sounds, and which may be added either to the 
normal sounds or to their abnormal modifications. The second 
class of signs may be embraced under the name bales. Practi- 
cally the latter are less important than the signs belonging in the 
first class, and their differential characters are more easily and 
clearly defined ; indeed, the difficult and nice points involved 
in the recognition and discrimination of the different signs 
relate chiefly to the abnormal modifications of normal sounds. 
Now, in seeking an answer to the question as to the true 
sources of the differential characters of acoustic signs, and es- 
pecially of those last referred to, let us inquire under what 
different aspects may they be studied with reference to their 
recognition and discrimination. 
One aspect is their analogies to sounds other than those 
emanating from the chest. This is the aspect under which 
the signs were naturally at first considered. In determining 
the different signs, Laennec was led to compare them with fa- PULMONARY PHYSICAL SIGNS. 
73 
miliar sounds to which they bore more or less resemblance, 
But the analogies to extra-thoracic sounds are limited and un- 
satisfactory. The respiratory and vocal morbid sounds are so 
peculiar that it is difficult to give an adequate idea of them by 
comparison with other sounds. While comparisons are admis- 
sible as far as they are available for illustration, here is not 
the true source of the differential characters of the different 
signs. 
In another aspect the sounds are considered with reference 
to the impressions which they at once convey of the existence 
of certain morbid physical conditions. Certain sounds are 
considered as a priori denoting certain morbid physical con- 
ditions. Thus, it is not uncommon to say of a cavernous res- 
piration, that it is a sound as if air entered a cavity. Nothing 
can be more fallacious than this as a source of the differential 
characters of the different signs. In determining the signs, 
Laennec did not escape errors from this source. It would be 
impossible to derive definite and reliable differential charac- 
ters from the ideas which the sounds in themselves might 
convey. The impressions made on different minds by the 
same sounds differ, and any approach to precision or accuracy 
is rendered impossible by the scope allowed to the imagina- 
tion and to preconvictions. 
In a third aspect the signs are studied with reference to 
elements into which all sounds, wherever produced, are alike 
resolvable. What are the various sensible points of difference 
in musical and other sounds ? The most striking and impor- 
tant relate to intensity, pitch, and quality. Sounds differ in 
being relatively louder or weaker, higher or lower, and in a 
multitude of peculiarities embraced under the name timbre 
or quality. To form an idea of the diversities as regards the 
last-named point of difference, viz., in quality, it is only neces- 
sary to call to mind the fact that among thousands of human 
beings the voice of each person is distinguished by some pecu- 
liarity. The innumerable shades of variation in the human 
voice, which are independent of differences in intensity and 
pitch, relate to quality of sound. Of the three points of dif- 
ference which have been named, those relating to pitch and 
quality are by far the more available in the recognition and 74 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
discrimination of the more important of the signs furnished by 
auscultation and percussion. Points of difference other than 
these three are the duration of the sounds and their proximity 
to or distance from the ear. These last-named points, al- 
though relatively less important, are by no means unimpor- 
tant. In these several points of difference are the true sources 
of the differential characters of the different signs. To deter- 
mine the differential characters of the signs as derived from 
differences relating to intensity, pitch, quality, and duration, 
together with proximity to or distance from the ear, is the 
object which distinguishes the analytical study of the signs 
furnished by auscultation and percussion. A clear apprehen- 
sion of these several points of difference in sounds, and an ed- 
ucation of the ear, by practice, to appreciate them with facility 
and accuracy, are essential, by way of preparation, for enter- 
ing on this analytical study. 
What are the differential characters as derived from their 
true sources, and are they distinct, simple, and reliable ? 
A clear apprehension of the several points of difference 
among sounds, especially of those points expressed by the 
terms intensity, pitch, and quality, having been obtained, the 
first step in the analytical study of the signs furnished by per- 
cussion and auscultation, is to acquire and become familiar, 
practically, with the characters, derived from these sources, 
which belong to the normal sounds. The normal resonance 
on percussion, or the normal vesicular resonance, the normal 
respiratory or vesicular murmur, the normal vocal resonance, 
and the normal sound produced by the whispered voice-these 
are the healthy signs; and they are to be analyzed with refer- 
ence to characters derived from intensity, pitch, quality, and 
duration of sound. In the writer's experience, one of the 
greatest difficulties in the way of successful teaching in this 
department of medical practice often arises from inability to 
secure for this first step an adequate amount of time and labor. 
Many cannot be made to appreciate sufficiently the necessity 
of giving ample attention to the healthy signs, before entering 
upon the study of the signs of disease. In this fact is to be 
found the explanation of failure, in many instances, to acquire PULMONARY PHYSICAL SIGNS. 
75 
a satisfactory knowledge of auscultation and percussion. 
The healthy chest should, first of all, be studied carefully 
and patiently, with reference to the characters of the healthy 
signs, the diversities as regards these characters in dif- 
ferent persons within the limits of health, the points of dis- 
parity between the two sides of the chest in corresponding 
situations, and the differences in different regions on the same 
side of tiie chest. A thorough practical acquaintance with 
the healthy chest, in the several aspects just named, is not only 
indispensable as the first step in acquiring a knowledge of the 
signs of disease, but it secures an amount of practice which 
greatly facilitates subsequent progress. I shall content myself 
here with simply an enumeration of the characters of the 
healthy signs. 
The normal resonance on percussion has an intensity 
which varies much in different healthy persons, and varies, 
of course, in different regions on either side of the chest. 
The pitch is low, as compared with the pitch of the signs 
of disease; it is lower than that of any of the latter. The 
quality is sui generis ; it cannot be described, nor can an 
accurate idea of it be conveyed by any analogy to a resonance 
produced otherwise than by percussion over healthy lung. As 
the peculiar quality is due to the air which yields the reso- 
nance being contained in the air-vesicles, it may be distin- 
guished as vesicular ; and the sign is often called the normal 
vesicular resonance. It is an important fact, in its practical 
bearing on diagnosis, in certain cases of tuberculosis, that the 
normal resonance is somewhat less intense, the pitch higher, 
and the vesicular quality less marked on the right than on the 
left side of the chest anteriorly at the summit. 
The normal respiratory or vesicular murmur has the fol- 
lowing characters: The inspiratory sound is of variable inten- 
sity in different persons, and in different portions of the chest 
in the same person. It is low in pitch ; its quality is sui gene- 
ris, and the term vesicular is also used to denote the quality 
of this sound, as well as the quality of the normal vesicular 
resonance on percussion. Its duration is usually the same as 
that of the inspiratory act. The expiratory sound is in a cer- 
tain proportion of persons wanting. When present, it is much 76 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
shorter than the sound of inspiration; in pitch it is lower, 
and, as regards intensity, it is weaker than the latter. It has 
no vesicular quality, but its quality may be expressed by the 
term blowing. 
The healthy variations in different parts of the same chest, 
and the points of disparity between the two sides at the sum- 
mit, are of much practical consequence. Over the primary 
bronchi, and their primary branches, in front and behind, the 
vesicular quality of the inspiration is often less marked than 
elsewhere, and the pitch is higher, the expiratory sound is 
often prolonged with greater intensity, and it has a quality 
which is tubular instead of blowing. These variations are 
more marked on the right than on the left side. An imper- 
fect appreciation of these points of disparity between the two 
sides of the chest not infrequently leads to error in diagnosis. 
The normal vocal resonance is a resounding of the voice 
through the chest, when words are spoken aloud, which varies 
very much in intensity in different persons, and in different re- 
gions of the chest of the same person. It is low in pitch as com- 
pared with modifications caused by disease. It conveys to the 
ear the idea of diffusion and distance. It is frequently accompa- 
nied with more or less of a thrill or vibration, called fremitus, 
which is a tactile, not an acoustic, sensation. The sign may 
be defined a distant, diffused resonance of the voice, accompa- 
nied with more or less fremitus. It is highly important, in 
auscultating the voice with reference to disease, to bear in 
mind the fact that the vocal resonance, as also the fremitus, 
is in nearly all persons distinctly and often notably greater on 
the right than on the left side, in every region o'f the chest. 
The sign heard with the whispered voice in health is a 
short, blowing sound, low in pitch ; variable in different per- 
sons, and not always heard anywhere ; frequently wanting, 
except within the upper third; louder over the primary bron- 
chi and their primary branches than elsewhere; a little louder 
on the right than on the left, and a little higher in pitch on 
the left than on the right side, especially over the primary 
bronchi and their primary branches. This sigh may be called 
the normal bronchial whisper. Its characters correspond to 
those of the expiratory sound in the normal vesicular murmur. PULMONARY PHYSICAL SIGNS. 
77 
Having determined by direct observation the characters 
which belong to the healthy signs, the next step, in the analyt- 
ical study of the signs furnished by percussion and ausculta- 
tion is to resolve the signs of disease into the characters de- 
rived from intensity, pitch, quality, duration, and proximity to 
the ear; then, by comparing the signs of disease with the 
healthy signs, and with each other, their differential charac- 
ters, derived from their true sources, are rendered distinct, 
simple and reliable. The remainder of this paper will be de- 
voted to the differential characters of the pulmonary signs of 
disease, as determined by comparison with the healthy signs, 
and with each other, in respect of the points of difference just 
named. The differential characters of the signs furnished by 
percussion will be first considered, and afterward the signs 
furnished by auscultation. 
The number of signs obtained by percussion need not ex- 
ceed'six, and it is practicable to reduce the number to four, 
namely: flatness or absence of resonance, dulness or di min- 
ished resonance, tympanitic resonance and vesiculo-tympa- 
nitic resonance. The two signs known as cracked metal and 
amphoric resonance may with propriety be reckoned as varie- 
ties df tympanitic resonance; if not so reckoned, they are of 
course to be added to the four just named. What are the 
differential characters of these signs as determined by com- 
parison with the normal resonance and with each other ? 
Flatness or absence of resonance-the sign representing 
either pleuritic effusion, pulmonary cedema, solidification of 
lung, or a tumor within the chest-is quickly disposed of. The 
absence of resonance expresses at once and with sufficient dis- 
tinctness its sole character. As there is no resonance, there is, 
of course, no room for comparison with respect to pitch, qual- 
ity, etc. This is the only example of a sign furnished by per- 
cussion which is not a sound. 
Dulness or diminished resonance involves, as these names 
denote, an intensity less than the normal resonance. The 
vesicular quality is less marked than in health, chiefly because 
the intensity of the sound is diminished. The pitch is always 
higher than that of the normal vesicular resonance ; there is 78 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
no exception to this rule. Duration and proximity to the ear 
do not supply any important differential characters. We may 
formularize the signification of this sign by saying that it rep- 
resents a relative disproportion of solids or liquids over air 
within the chest, the disproportion not being such as to cause 
flatness; hence it is met with in cases of tuberculosis, pneu- 
monia, pleurisy, oedema of lung, carcinoma, gangrene, and 
extravasation of blood. 
Tympanitic resonance is a sign concerning which there is 
much confusion. There can be no room for obscurity or dif- 
ference of opinion, if we adopt as its distinctive character an 
entire absence of vesicular quality. It is a sufficient defini- 
tion of this sign to say that it is a resonance utterly devoid of 
that vesicular quality which characterizes the normal reso- 
nance, and, in a greater or less degree, other of the signs fur- 
nished by percussion. The absence of the vesicular quality 
always occasions more or less elevation of pitch ; a tympanitic 
resonance is invariably higher than the normal vesicular 
resonance. Accurate, direct observation will sustain this asser- 
tion, although it is in opposition to the statements of some 
authors. The point is, of course, not to be settled by argu- 
ment, but by direct observation only. There is no exception 
to the rule that a tympanitic resonance is higher in pitch than 
the normal vesicular resonance ; but the variation in pitch in 
different examples of tympanitic resonance is considerable. 
Much of the confusion concerning this sign arises from con- 
sidering it as being of greater intensity than the normal 
resonance. The sign derives no differential character from 
intensity. It may have greater or less intensity than the 
normal resonance. Duration of sound - and proximity to the 
ear supply no distinctive characters to this sign. The sign 
represents the following physical conditions : Air in the pleu- 
ral cavity (pneumo-thorax); solidification of an upper lobe, 
the resonance then coming from the air contained in the 
primary bronchus and its primary branches ; air in a pulmo- 
nary cavity with rigid walls, and the conduction of resonance 
from the stomach and colon, especially when the lower lobe is 
rendered by solidification a better conductor of sound than 
the healthy lung. PULMONARY PHYSICAL SIGNS. 
79 
The fourth sign is an increased, or, as I have preferred to 
call it, a vesiculo-tympanitic, resonance. This sign is often con- 
founded with tympanitic resonance. Its differential characters 
are : first, an increase of intensity, that is, an intensity greater 
than that of the normal resonance ; secondly, a quality which 
combines, in variable proportions in different cases, the vesicu- 
lar and the tympanitic, as expressed in the name vesiculo- 
tympanitic ; thirdly, the pitch is always higher than that of 
the normal resonance, and high in proportion as the tym- 
panitic preponderates over the vesicular quality. These dif- 
ferential characters, as well as those of tympanitic resonance, 
are distinct, simple, and reliable. The vesiculo-tympanitic 
resonance represents especially dilatation of the air-cells, or 
vesicular emphysema. It is obtained also over a healthy lobe, 
either the upper or lower, when the other lobe of the same 
lung is solidified ; and it is obtained over lung partially com- 
pressed by pleuritic effusion. 
Amphoric and cracked-metal resonance, as already stated, 
may be reckoned varieties of tympanitic resonance. The first 
is distinguished by the simple fact of the existence of a mu- 
sical quality, and the second by a resemblance to the sound 
produced by striking a cracked vessel, as the name denotes. 
The latter character is derived from analogy; and the former 
is also thus derived to some extent, the musical sound being 
compared to that caused by blowing upon the open mouth of 
an empty bottle. These signs represent either pneumo-thorax 
or pulmonary cavities which are empty and have rigid walls, 
with some important exceptions. In all the exceptional in- 
stances, the sound must come, if over the upper lobe, from air 
contained in the primary bronchi and their primary branches, 
or, if over the lower lobe, from air in the stomach or colon. 
Reviewing now the differential characters of the signs fur- 
nished by percussion, it will be seen that any practical diffi- 
culties in the way of their recognition and discrimination 
relate only to three, namely, dulness, tympanitic and vesiculo- 
tympanitic resonance. Of these three signs, the most dis- 
tinctive of the characters of two, namely, dulness and vesiculo- 
tympanitic resonance, are derived from intensity of sound; 
the intensity in the former of these two signs is less, and in the 80 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
latter it is greater than that of health. In both these two 
signs, the pitch is higher than in health. The advantage of 
directing attention to the pitch of sound, in deciding as to the 
presence of either the one or the other of these two signs, is 
exemplified in certain cases of emphysema. A patient has had 
cough and expectoration for a greater or less period, and the 
history may suggest the supposition of phthisis. On examina- 
tion by percussion, there is found to be a disparity between 
the two sides of the chest, in the infra-clavicular region, as 
regards intensity of resonance. Now, this disparity may be 
due either to dulness in the region where the intensity is 
relatively less, or to exaggerated resonance in the region 
where the intensity is relatively greater. If the former be 
true, the disease is probably phthisis; if the latter be true, 
the disease is probably emphysema. This problem, which is 
one of .the nicest in the practice of percussion, may be settled 
without resorting to auscultation, by a comparison of the pitch, 
together with the quality of the resonance, on the two sides. 
If the disparity be due to dulness on one side, the pitch of the 
sound will be higher where the resonance is less; if the dis- 
parity be due to an increase of resonance on one side, the 
pitch will be higher where the resonance is greater, and the 
quality, in the latter case, as compared with the resonance on 
the other side, will be a mixture of the vesicular and tympa- 
nitic, that is, vesiculo-tympanitic. 
It is worthy of note, that the abnormal variations in pitch 
and quality follow a definite law as regards the concurrence 
of these two points of difference. If the vesicular quality be 
diminished or annulled, the pitch is raised; hence the rule, 
without an exception, that dulness, tympanitic and vesiculo- 
tympanitic resonance are higher in pitch than the normal 
vesicular resonance. It will be found that, among healthy 
persons, in proportion as the vesicular quality of the normal 
resonance is marked, the pitch is low, and, per contra, in pro- 
portion as the vesicular quality is feeble, the pitch is high. 
This law obtains, too, over different portions of the healthy 
chest in the same person. Over the primary bronchi and 
their primary branches, the resonance, as compared with that 
elsewhere, is vesiculo-tympanitic in quality and higher in PULMONARY PHYSICAL SIGNS. 
81 
pitch. Over a part of the chest where comparatively the 
resonance is dull, namely, over the scapulae, the pitch is 
higher than in the infra-scapular region. 
It is needless to state to those who have given attention to 
percussion and auscultation, that, in comparing the signs of 
disease with those of health, the latter are always to be con- 
sidered as presented in the person under examination. In 
other words, owing to the considerable diversities of the 
healthy signs among different persons, there can be no abstract 
standards in respect of the degree of manifestation of the 
characters of these signs. Thus, limiting our attention to 
the normal vesicular resonance, not only is its intensity va- 
riable in different persons, but the vesicular quality is more or 
less marked, with corresponding variations in pitch. 
Proceeding to consider the differential characters of the 
signs furnished by auscultation, the first reflection is, that the 
number of the signs exceeds much the number of those fur- 
nished by percussion. 
Of the auscultatory signs, however, there are only a few 
which call for great nicety in their discrimination ; and these 
signs are chiefly among those which are abnormal modifica- 
tions of healthy sounds. The signs which are adventitious or 
superadded sounds, that is, the rales, are, in general, easily 
discriminated. The latter may be dismissed with a few w'ords. 
Of the former, I will notice first, the signs which pertain to 
the respiration; next, the vocal signs; and lastly, the abnor- 
mal modifications of the normal bronchial whisper. 
The respiratory signs, other than the rales, are, first, the 
bronchial or tubular respiration, the broncho-vesicular or 
vesiculo-tubular respiration, the cavernous respiration, and 
the amphoric respiration. These are distinguished, severally, 
by characters derived from points of difference relating 
chiefly to quality, pitch, and duration of sound. Intensity of 
sound enters very little into their differentiation either from 
each other or from the normal vesicular murmur; and the 
same is true of proximity to the ear. But, second, there are 
three respiratory signs, of which the differential characters 
relate exclusively to intensity. These signs are exaggerated 82 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
vesicular murmur, diminished vesicular murmur, and suppres 
sion of respiratory sound. The names of these three signs 
are sufficiently descriptive. I will notice the foregoing signs 
of tlie first and the second group, in the order in which they 
have been enumerated, with reference to the question, " What 
are their differential characters, as derived from their true 
sources, and are they distinct, simple, and reliable ? " 
A comparison of the bronchial or tubular respiration with 
the normal vesicular murmur, as regards points of difference 
pertaining to intensity, pitch, and quality, leads to the follow- 
ing differential characters : The inspiratory sound is variable 
in intensity, high in pitch, and for the vesicular quality is sub- 
stituted another which may be called tubular. The expiratory 
sound is as long as, or longer than, the inspiratory, higher in 
pitch, more intense in forced breathing, and tubular in quality. 
In general, both an inspiratory and an expiratory sound are 
present, but either may be wanting. With these highly dis- 
tinctive characters, the sign represents complete or considerable 
solidification of lung. It is by no means certain that it repre- 
sents ever simple dilatation of the bronchial tubes; but if it 
do, the examples are so rare of dilatation without solidifica- 
tion that they may practically be disregarded. 
The broncho-vesicular or vesiculo-tubular respiration repre- 
sents the different degrees of solidification below an amount 
sufficient to give rise to the bronchial or tubular respiration. 
The names of this sign express the distinctive characters re- 
lating to quality in the inspiratory sound; the quality is a 
mixture of the vesicular and bronchial, or the vesicular and 
tubular, in variable proportions. The pitch of the inspira- 
tory sound is always higher than that of the inspiratory sound 
in the normal vesicular murmur; and it is high in proportion 
as the tubular predominates over the vesicular quality, or, in 
other words, in proportion to the degree of solidification. The 
intensity is variable, and does not supply any character to the 
inspiratory sound. The expiratory sound is more or less pro- 
longed, in pitch it is high, in quality it is tubular, and its in- 
tensity is greater than that of the inspiratory sound. In these 
characters it approximates to the expiratory sound in the bron- 
chial or tubular respiration. This approximation is near in PULMONARY PHYSICAL SIGNS. 
83 
proportion as the inspiratory sonnet approximates to the inspi- 
ratory sound in the bronchial or tubular respiration ; and the 
approximation is comparatively remote in proportion as the 
inspiratory sound approximates to that of the normal vesicular 
murmur. The characters of the inspiratory and the expiratory 
sound in this sign are always in harmony; that is, if in the 
inspiratory sound the tubular quality predominate and the 
pitch be high, the expiration is proportionably long, high, 
intense, and tubular; but if, in the inspiratory sound, the vesic- 
ular quality predominate and the pitch be less high, the dura- 
tion, intensity, and tubularity of the expiratory sound are pro- 
portionately less, and the pitch is less high. These variations, 
as regards degree in tlie characters of the sign, represent dif- 
ferent degrees of solidification. In general, both the inspira- 
tory and the expiratory sounds are present, as in the examples 
of bronchial respiration, but either may be wanting. 
To appreciate the characters of this sign, it is necessary to 
study them in comparison with those of the normal vesicular 
respiration on the one hand, and the bronchial or tubular res- 
piration on the other. When fully appreciated, the charac- 
ters of the sign are sufficiently distinct, simple, and reliable. 
Its importance is to be estimated by reference to the diseases 
in which partial solidification of lung enters as a morbid phys- 
ical condition. It is of special importance in the diagnosis of 
incipient phthisis. It is present in a large proportion of the 
cases of partial solidification of lung; but in some cases the 
respiratory sound is suppressed, or the sound is too feeble for the 
characters to be ascertained, so that the absence of solidifica- 
tion cannot be inferred from the absence of the sign in such 
cases. This statement is also true of the bronchial or tubular 
respiration. 
The cavernous respiration is a sign concerning which there 
is great confusion among writers and practical auscultators. 
The existence of any characters distinctive of this sign is de- 
nied by Skoda; and the descriptions generally given of its 
characters are indistinct and unreliable. In practice the bron- 
chial respiration is often mistaken for the cavernous; many 
consider a bronchial respiration cavernous when the intensity 
of sound is unusually great. Laennec attributed to the sign a 84 
BELLEVUE AND CIIAEITY HOSPITAL EEPOETS. 
fallacious character, namely, the sensation of air entering into 
the ear of the auscultator, a character which he designated by 
the term blowing. Intensity does not furnish a character for the 
cavernous respiration ; it may be more or less intense. Its dis- 
tinctive characters are derived from pitch and quality; and, with 
regard to differentiation, it is to be compared with, on the one 
hand, the bronchial respiration, and, on the other the nor- 
mal vesicular murmur. What are the differential characters 
derived from pitch and quality of sound? The inspiratory 
sound is low in pitch as compared with the inspiratory sound 
in the bronchial respiration. Its quality is neither vesicular 
nor tubular; it has instead a hollow, or, as I would term it, a 
simple blowing quality. The expiratory sound has the same 
quality and is lower in pitch than the inspiratory sound. When 
these characters are present without any regard to intensity of 
sound, or of duration, or of proximity to the ear, the sign 
represents a cavity with flaccid walls, into which air enters in 
the act of inspiration, and from which air is expelled in the 
act of expiration. No other auscultatory sign is more distinct, 
simple and reliable. Its absence at the time of examination 
is not evidence that there is not a cavity, several conditions 
in connection with a cavity being necessary for the production 
of the sign, namely, emptiness of the cavity, a free communi- 
cation with the bronchial tubes, and proximity of the cavity to 
the thoracic parietes. 
The amphoric respiration requires but a passing notice, as 
regards its differential characters. Excluding the dry bron- 
chial rales which are musical, and with these it need never be 
confounded, this sign is sufficiently characterized by a musi- 
cal quality resembling the sound produced by blowing upon 
the open mouth of an empty phial. There is no difficulty in 
its recognition, and when present it denotes either perforation 
of lung or a pulmonary cavity with rigid walls. 
Of the auscultatory signs none are more important than 
those just considered, and, with the exception of the one last 
named (amphoric respiration), they involve in their discrimina- 
tion nicer points of difference than the great majority of those 
which remain to be noticed. The three abnormal modifica- 
tions of the normal vesicular murmur which are now to be 
considered are quite simple. PULMONARY PHYSICAL SIGNS. 
85 
An exaggerated respiratory murmur, called also puerile, sup- 
plementary, and hyper-vesicular respiration, is a simple increase 
of intensity, without any other notable modification. The 
vesicular quality is marked in proportion to the increase of 
intensity. The pitch, although variable in different cases, 
never rises to that of either the bronchial or broncho-vesicular 
respiration. This sign represents augmented functional ac- 
tivity of the respiratory function of flip lung over which it is 
heard, this increased functional activity resulting from the 
function of the other lung being weakened or suppressed. 
Diminished respiratory murmur, or weak respiration, is 
simply a decrease of intensity, without any other notable modi- 
fication. It is incident to emphysema, bronchitis, lessened res- 
piratory movements on one side from pain or paralysis, etc. 
The only point connected with this sign which I will stop to 
notice is one of considerable practical importance. With a 
weakened inspiratory sound, in certain cases of emphysema, 
the expiratory sound is lengthened, and its intensity may be 
greater than in health. In these cases, without attention to 
characters derived from pitch and quality, the prolonged expira- 
tion is liable to be considered as belonging to a bronchial or a 
broncho-vesicular respiration, and as consequently denoting 
solidification of lung. A prolonged expiration, without regard 
to characters aside from its duration, is not infrequently relied 
upon in the diagnosis of phthisis. But the prolonged expira- 
tion due to emphysema, or to any cause aside from solidifica- 
tion of lung, may always be discriminated by means of its 
pitch and quality. Its pitch is low and its quality blowing, 
instead of the high pitch and tubular quality which are the 
characters of a prolonged expiratory sound when it denotes 
solidified lung. 
Suppression of respiratory sound need only be named. It 
occurs in connection with pleuritic effusion, in some cases of 
emphysema, as a consequence of obstruction of bronchial tubes, 
sometimes when there is solidification of lung, and over an 
intra-thoracic tumor. 
Passing from the respiratory modifications to the vocal 
signs, meaning by this term the signs produced by the loud 
voice, the latter may be grouped into, first, vocal signs, the 86 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
characters of which are derived from pitch, quality, and prox- 
imity to the ear, the intensity being unimportant; and, second, 
vocal signs, the characters of which relate chiefly to intensity. 
The signs in the first group are, bronchophony, pectoriloquy, 
aegophony, and amphoric voice or echo; the signs in the second 
group are, increased vocal resonance, diminished vocal reso- 
nance, and suppression of vocal resonance. The characters of 
the latter signs are as simple as possible; and the analytical 
study of the former signs leads to differential characters less 
nice or difficult than those which belong to the correlative 
respiratory signs. 
If the transmission of the voice be such that it seems con- 
centrated and near the ear, and the resonance be notably raised 
in pitch, bronchophony exists, and the sign represents uni- 
formly complete or considerable solidification of lung. The 
intensity is frequently increased, but it may be less than that 
of the normal vocal resonance of the person examined; the 
intensity does not enter at all into the characters distinctive of 
the sign. The fremitus may be increased, but it is not infre- 
quently diminished ; this docs not belong to the acoustic sign, 
but is a superadded tactile sensation. It is important to re- 
mark that an approach to bronchophony, and even the well- 
marked characters of the sign, are in some persons found in 
health over or near the site of the primary bronchi. The ab- 
sence of the signs will suffice to show that this is a normal 
peculiarity. The bronchophony of health may be present on 
the right, and not on the left, side of the chest. As a morbid 
sign, bronchophony is correlative to the bronchial or tubular 
respiration, but a degree of solidification insufficient for the 
respiratory sign just named may suffice to give rise to bron- 
chophony ; hence, the sign is often associated with a broncho- 
vesicular respiration approximating to the bronchial. 
Pectoriloquy and bronchophony are often confounded. If 
the voice be transmitted with unusual intensity, pectoriloquy 
is incorrectly said to exist. Pectoriloquy requires more than 
the transmission of the voice, and, as will presently be seen, 
it may exist without the characters of bronchophony; it re- 
quires, as the name signifies, the transmission of speech, that 
is, of articulate words. This sign, interesting as the sign PULMONARY PHYSICAL SIGNS. 
87 
which first opened up to the mind of Laennec the subject of 
auscultation, has lost the importance attributed to it by the 
illustrious founder of auscultation; that is, it is no longer con- 
sidered as in itself the sign of a pulmonary cavity. Articulate 
words, without a doubt, may be transmitted through solidified 
lung. Pectoriloquy, however, may be a cavernous sign, and it 
is easy to determine this in certain cases. There is a bron- 
chophonic and a cavernous pectoriloquy, the former denoting 
only solidified lung, and the latter representing a cavity. I am 
not aware that the differentiation of these two kinds of pecto- 
riloquy has been made by others, but the points of difference are 
very simple, and it is a matter of surprise to me that, during 
many years of attention to the analytical study of auscultatory 
signs, these points have only recently suggested themselves. If 
the transmission of speech be accompanied by the characters of 
bronchophony, namely, elevation of pitch and proximity to the 
ear, the pectoriloquy is bronchophonic; it may be due simply 
to solidification of Inns'. If, on the other hand, the transmis- 
sion of speech be not associated with these characters of bron- 
chophony, the pectoriloquy is cavernous. 
^Egophony affords an illustration of the looseness and un- 
certainty of a sign distinguished solely by a resemblance to 
an extra-thoracic sound. Thinking only of the analogy to the 
bleating of the goat, it is common enough for bronchophony 
to be called segophony ; in fact, the latter may be considered 
as a variety of the former. If a well-marked example of 
aegophony be analyzed, the pitch is high, like that of bron- 
chophony ; the proximity to the ear may or may not be as 
marked as in the last-named sign. The aegophonic feature 
which is added to the bronchophonic characters is a tremu- 
lousness in which consists the resemblance to the bleating of 
the goat. Whether it be regarded as a variety of bron- 
chophony, or a separate sign, its significance, as representing 
a certain amount of pleuritic effusion, certainly, in the great 
majority of cases, is undoubted. 
Amphoric voice or echo requires only the statement that 
the vocal resonance is either accompanied or followed by a 
musical sound, such as characterizes amphoric respiration, and 
that its significance is the same. 88 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
The vocal signs, the characters of which relate chiefly to 
intensity, namely, increased vocal resonance, diminished vocal 
resonance, and suppression of vocal resonance, are without 
any difficulty recognized and discriminated from each other; 
the distinctive character of each is expressed in the name. 
Practically, they are important signs. Increased vocal reso- 
nance is simply a greater or less morbid increase of the in- 
tensity of the resonance, without any other notable change; 
the sound of the voice is distant, diffused, and not notably 
raised in pitch. The vocal resonance may be intensified to 
the utmost limit of loudness to which bronchophony ever at- 
tains, without the bronchophonic modifications; and, on the 
other hand, the bronchophonic characters may be well marked 
with a feeble resonance. An increase of the vocal resonance 
without the characters of bronchophony represents solidifica- 
tion of lung, but in a degree insufficient to produce bron- 
chophony. It is the vocal sign correlative to the broncho- 
vesicular respiration, when the latter denotes slight or moderate 
solidification. It is often a valuable siin the diagnosis of 
o o 
phthisis. 
Diminished resonance and the suppression of vocal reso- 
nance-in the former the characters of the resonance being 
the same as in health in all respects save intensity-are impor- 
tant signs in determining the existence of liquid effusion, and 
of a tumor within the chest. They belong among the signs 
which need only to be named to be understood. 
The abnormal modifications of the normal bronchial whis- 
per form a group of signs, heretofore not acknowledged as 
such, which are of considerable utility in diagnosis. Their 
differential characters are readily understood, when it is con- 
sidered that a whisper is usually an expiratory act. This be- 
ing so, the characters must be those of the sound of expiration. 
If a person pronounce in a whisper words with effort, the 
sound corresponds to that produced in expiration by forced 
breathing; it is apt to be louder, and is, therefore, more avail- 
able than the latter. An intense, high-pitched, tubular sound, 
produced by whispered words, corresponds to the expiratory 
sound in the bronchial respiration, and, of course, has the PULMONARY PHYSICAL SIGNS. 
89 
same signification. This sign may, therefore, be called the 
bronchophonic whisper, or whispering bronchophony. A 
sound, less intense, less high, and less tubular, corresponds to 
the expiratory sound in the broncho-vesicular respiration, and 
may be called increased bronchial whisper. It is correlative 
to increased vocal resonance, and denotes partial solidification 
of lung. A sound, low in pitch, and hollow or blowing in 
quality, the intensity being variable, corresponds to the expi- 
ratory sound in cavernous breathing, and may be called the 
cavernous whisper. It is a beautiful illustration of this sign, 
when, as is not infrequent, its characters are shown in marked 
relief by its being found side by side with the bronchophonic 
whisper. The amphoric whisper is, of course, at once under- 
stood. 
The transmission of the whispered speech, that is, the ar- 
ticulate words pronounced in a whisper, has heretofore been 
known by the name whispering pectoriloquy. It is much 
oftener met with than pectoriloquy with the loud voice. 
Like the latter, it is of two kinds, namely, bronchophonic and 
cavernous. If with the transmission of speech the whispered 
sound be high in pitch, and tubular, the pectoriloquy is bron- 
chophonic; if, on the other hand, the whispered sound which 
is transmitted be low in pitch, and hollow or blowing in qual- 
ity, the pectoriloquy is cavernous. 
As already stated, the rales may be dismissed with a few 
words. The dry bronchial rales (sibilant and sonorous) can 
hardly be confounded with other signs. Auscultation could 
well afford to dispense with the varied sounds embraced under 
this head, for they are apt to obstruct the appreciation of other 
signs which are of greater practical importance. The moist 
bronchial rales are useful, denoting liquid of some kind- 
mucus, serum, blood, or pus-in the bronchial tubes. They 
cannot be mistaken for other signs; and the large or small 
bubbling, generally expressed by the words coarse and fine, 
denotes the size of the tubes in which the rales are produced. 
The pleural friction-sound, metallic tinkling, and gurgling, 
also, have each its distinctive characters, which the names of 
these signs imply. 90 
BELLEVUE AND CIIAEITY HOSPITAL EEPORTS. 
The only differentiation, as regards the rales, which in- 
volves ranch nicety, is the discrimination between the crepi- 
tant and the subcrepitant. Both are important signs. The 
differential characters may be sharply defined as follows : The 
subcrepitant rale is a moist rale made up of small bubbles, 
often, apparently, of unequal size; it may be heard during 
any portion of the inspiratory act, and is liable to be heard in 
the expiratory act. The crepitant rale is a very fine, dry, 
crackling rale, made up of crackling sounds apparently of 
equal size ; it is rapidly evolved at the end of the inspiratory 
act, and is never heard in the act of expiration. The subcrepi- 
tant rale is especially valuable in the diagnosis of bronchitis 
affecting the tubes of small size, and of pulmonary tubercu- 
losis. The crepitant rale is often of value in the diagnosis of 
pneumonia. 
The subcrepitant and the crepitant rales derive a signifi- 
cance from their pitch, which is of interest and value. If 
they emanate from lung considerably solidified, their pitch is 
notably high ; if, on the contrary, they emanate from lung 
not solidified, their pitch is relatively low. The elevation of 
pitch is proportionate to the degree of pulmonary solidifica- 
tion ; hence it is practicable to determine the absence or ex- 
istence of solidification, and its degree, by the pitch of these 
rales, without the aid of other respiratory or the vocal signs. 
This incidental significance of these rales is, so far as my ob- 
servation goes, but little known among auscultators. It was ob- 
scurely and incompletely enunciated, many years ago, by Skoda. 
In conclusion, the motive which has prompted the prepa- 
ration of this paper is, a desire to promote a more thorough 
and widely-diffused practical acquaintance with percussion 
and auscultation. The writer has aimed to contribute to these 
ends by endeavoring to give a succinct exposition of the mode 
of study which he would distinguish as analytical; and, by 
giving in a brief article an account of the differential char- 
acters of the thirty signs furnished by percussion and auscul- 
tation, he has hoped to show that, to acquire a satisfactory 
knowledge of the subject, is by no means a tedious or difficult 
undertaking. III.-ENTIRE EXCISION OF THE OS CALCIS. 
On Entire Excision of the Os Calcis. By F. A. Burrall, Jr., 
M. D., of New York; formerly Visiting Surgeon to the 
Charity Hospital; one of the Surgeons to the Northern 
Dispensary. 
A few years ago opinions were much more divided than 
at present concerning excision of tlie calcaneum. It is not 
strange that a removal of this bone should have been regarded 
with distrust, for each one forms the posterior part of an arch, 
as is shown by the arrangement of its cancelli, which, under 
ordinary circumstances, sustains half the entire weight of the 
body. Hence, it would seem, from an examination of the 
bone and its relations to those adjoining, that its excision 
would be followed by much shortening of the leg, a tilting 
upward of the anterior part of the foot, weakness and distor- 
tion of the tarsus. Moreau considered the division of the tendo 
Achillis an objection to the operation, and states that " if the 
case be such that the tendo Achillis must be destroyed, it 
would be better to amputate the limb." 1 Other opinions of 
similar tenor are met with in the writings of eminent men, but 
experience has gradually demonstrated that many of the ob- 
jections are hypothetical, with no more basis than that of the 
venerated Pare, who held fracture of the calcaneum to be a 
fatal injury, in consequence of the laceration of the numerous 
vessels connected with the bone.2 
1 London Lancet, Nov. 2, 1867. 
a Desault's Surgery, translated by Charles Caldwell, M. D. Philadel- 
phia, 1811. 92 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Monteggia,1 of Milan, is said to have first performed or re- 
ported this operation in 1823. In Mott's translation of Vel- 
peau,2 it is recorded that Dupuytren, in one of his lectures in 
1816, stated that he had seen the os calcis in an infant pro- 
duced entire, but whether after an operation, or as the result 
of disease, is not mentioned. Until 1848, when Mr. Henry 
Hancock removed the right calcaneum from an adult in Char- 
ing Cross Hospital, there are scarcely any cases of this opera- 
tion on record, but since that time they appear more fre- 
quently. In the British and Foreign Medico-Chirurgical 
Review, of July, 1853, is a list of 12 cases, published by II. 
Martineau Greenhow, Esq., Mr. Hancock gives the particu- 
lars of 7 more in the London Lancet of November 2 and 9, 
1867, and Dr. O. Heyfelder, in his " Lehrbuch der Resec- 
tionen,"3 makes a further addition of 9 to those [previously 
reported. These writers also notice the names of distinguished 
surgeons who have approved or adopted the operation, and 
Mr. Hancock further states that he has collected particulars of 
34 cases. 
The present paper is a study of 48 cases, in which the en- 
tire bone was removed.4 The list includes those cases which 
have been previously tabulated, with the addition of 19, which 
have been mostly collected from various journals. 
1 The Excision of Joints, by Richard M. Hodges, M. D. Boston, 1861, 
p. 189. 
2 Vol. i., p. 761. 
3 Wien, 1862, p. 177. 
4 In Heine's case (No. 2), the tuberosity of the bone was left. ENTIRE EXCISION OF THE OS CALCIS. 
93 
Date. 
1 1823 
2 1834 
9 1837 
4 1845 
6 1846 
6 June 2, 1848. 
1 Aug. 15, 1848 
8 Oct. 9, 1848.. 
o 
bn 
13 
4 
21 
20 
16 
K k e : |sex. 
Condition or 
occupation. 
Child 
Butcher 
Pitman 
Diathesis. 
• 
Strumous 
Strumous 
Unhealthy and 
ill-nourished. 
Origin and nature of disease. 
Necrosis 
Central caries of the calca- 
neum, and syphilitic osti- 
tis with caries. 
Caries 
Caries of right os calcis and 
abscess. Left leg had 
been amputated three 
years before for caries of 
knee-joint. 
Wounded in left heel by a 
nail eight weeks previous- 
ly. Abscesses formed and 
were opened. Os calcis 
found to be extensively ca- 
rious, the disease extend- 
ing to the astragalus. Part 
of astragalus also removed. 
Ulceration and suppuration, 
which commenced six 
months previously. Ca- 
ries. 
By whom removed. 
Monteggia, of Milan. 
Heine, of Wurzburg. 
F. Robert 
Dr. A. Meyer 
Dr. A. Meyer 
Mr. Henry Hancock, 
of Leeds. 
Mr. Greenhow, New- 
castle Infirmary. 
Mr. Page, at Cum- 
berland Infirmary. 
Result. 
Successful. The tuberosity of the 
bone was left to serve as an at- 
tachment for the tendo Achillis. 
The child walked in a month, and 
the leg is said to have been al- 
most entirely regenerated. 
A portion of the external malleo- 
lus also removed. Partial re- 
covery. Two years later return 
of syphilis in the part. Ampu- 
tation of the leg. Recovery. 
Successful. 
Recurrent attacks of erysipelas. 
Amputation of leg four months 
after excision. 
Recurrent attacks of erysipelas. 
Patient able to walk, with only 
slight halt, December 29th fol- 
lowing. 
Patient had attack of inflamma- 
tion of tarsal joints, but at the 
end of a year found the foot 
which had been operated upon 
as serviceable as the other. 94 
BELLEVUE AND CIIAEITY HOSPITAL EEPOETS. 
Date. 
s 
o 
X 
Condition or 
occupation. 
Diathesis. 
Origin and nature of disease. 
By whom removed. 
Result. 
9 
Aug. 
Dec. 
1848 
29 1848 
29 
M. 
Pitman 
Strumous 
Disease of 2J< years' dura- 
tion, commencing with in- 
flammation and abscess. 
Extensive caries of os 
calcis. 
Disease of seven months' 
Mr. Greenhow, New- 
Slight sloughing of integuments. 
10 
5,1848. 
16 
IL 
Lived in the 
country ; no 
occupation. 
Deaf mute 
Strumous . 
castle Infirmary. 
Mr. Greenhow 
Able to walk freely on crutches 
February 10, 1849. 
Successful. 
11 
10 
M. 
duration, commencing in 
erysipelatous inflamma- 
tion. Os calcis in state of 
advanced caries. 
Caries of right os calcis.... 
Friction of tight shoe, pro- 
M. Giraldes 
Confined one month in hospital; 
12 
July 
9 
3, 1849. 
15 
M. 
Tailor 
Ill-nourished ... 
Mr. Potter, of New- 
then walked freely without any 
special apparatus. 
In October, 1850, patient had 
13 
19 
M. 
ducing ulceration, which 
resulted in caries. 
Caries 
castle. 
Dr. Paul 
walked six miles without incon- 
venience. 
Patient died of phthisis as the 
14 
1849 
30 
M. 
Jew 
Caries of the left calcaneum. 
M. Giraldes 
wound was nearly closed. 
Died of pyaemia, three weeks after 
the operation, in a hospital 
where the sanitary conditions 
were bad. 
Some months after the operation 
13 
Mar. 
11, 1851 
15 
M. 
Strumous 
In the posterior wall of 
the bone was a cavity, 
probably the seat of an 
encysted tubercle. 
Foot sprained five years pre- 
viously ; two years later 
abscesses and sinuses 
formed round the ankle. 
Os calcis carious. 
Had suffered from pain in 
heel and foot for ten years. 
Os calcis carious. 
Mr. Potter, of New- 
castle. 
Mr. Gay, at Royal 
Free Hospital. 
16 
Mar. 
20, 1851 
22 
M. 
House-painter.. 
• 
Strumous 
a sinus remained, and the boy 
could not walk. 
Complete recovery in six months. ENTIRE EXCISION OF THE OS CALCIS. 
95 
''April 28, 1851 
18 Dec. 12, 1851 
19 1851 
10 
16 
34 
29 
17 
28 
35 
20 
M. 
M. 
M. 
F. 
F. 
M. 
F 
M. 
Mill girl 
Impaired health 
Strumous 
Disease of four months' du- 
ration. Necrosis of al- 
most the entire calcaneum. 
Caries. Had had disease of 
foot for three years, which 
commenced with inflam- 
mation and swelling. 
Caries and necrosis 
Mr. Simon, St. Thom- 
as's Hospital. 
Mr. Lowe, of Congle- 
ton. 
Dr. F. Robert 
Discharged cured May 30th. 
Wound healed in less than two 
months, and patient walked 
easily. 
The resulting limb was useful, but 
a relapse occurred in eighteen 
months, and the patient died of 
phthisis. 
Unfavorable. Amputation became 
necessary November 2d. The 
astragalus, cuboid, scaphoid, 
and cuneiform bones were found 
carious. 
Successful. On the fourth day the 
dressings were renewed, and al- 
most complete union was found 
to exist between the cut sur- 
faces. 
Three years afterward limb ampu- 
tated for caries. The right leg 
had been amputated at the time 
of the excision. 
Complete cure in three months. 
September 18th went home in ex- 
cellent health, though not yet 
able to bear weight on foot. 
The os calcis and astragalus were 
removed. Unsuccessful. Gan- 
grene of foot; amputation of 
the ankle-joint. September 10th, 
stump doing well. 
20 May 18, 1852 
21 July 26, 1852 
29 1853 
Glassmaker. ... 
Strumous 
Exciting cause was erysipe- 
latous inflammation. The 
disease was of seven 
months' duration. Calca- 
neum extensively carious. 
Caries. Ulcers behind the 
malleoli, through which a 
probe could be passed to 
the bone. 
Caries ? 
Mr. Grcenhow 
Mr. Field, Royal In- 
firmary, Margate. 
Dr. Textor 
23 1852 
Caries of right calcaneum.. 
Extensive caries. Inflam- 
mation and abscess of 
eight months' standing. 
Caries of calcaneum and as- 
tragalus. A cart passed 
over heel in childhood. 
M. Giraldes 
24 June 20, 1854 
25 July 16, 1854 
Laborer 
Strumous 
Mr. Greenhow 
Mr. Greenhow 96 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Date. 
| Sex. 
Condition or 
occupation. 
Diathesis. 
Origin and nature of disease. 
By whom removed. 
Result. 
26 Aug. 22, 1854 
27 Oct. 24,1854. 
28 Dec. 1, 1855.. 
29 1855 
34 
12 
28 
24 
M. 
M. 
M. 
F. 
Married 
Three years ago fell and in- 
jured ankle. An abscess 
formed on dorsum of foot, 
which healed and again 
opened. Sinuses formed. 
The bone was carious. 
Nine months previously foot 
had been squeezed be- 
tween two railroad cars. 
The foot became swollen, 
and in a week or two ab- 
scesses formed, followed 
by sinuses. The bone was 
carious. 
Inflammation and abscess 
Oct., 1852. Subsequent 
formation of sinuses. An- 
terior part of bone found 
in a state of sub-inflamma- 
tion. Posterior carious. 
Caries 
R. W. Coe, Surgeon 
Bristol G. Hospi- 
tal. 
Dr. Morragh, N ew 
Brunswick, New 
Jersey, U. States. 
Dr. J. M. Carnochan, 
New York. 
Mr. Tolly 
Discharged cured September 17, 
1854. Eighteen months after 
the operation patient could walk 
ten miles daily without incon- 
venience. 
The wound healed mostly by ad- 
hesion. Two months after the 
operation the boy could run 
very swiftly. 
Patient was soon strong and 
healthy. Dec., 1856, walked 
well with a padded heel. 
Successful. 
Successful. Healing rapid- and 
complete. 
Successful. Perfect recovery and 
useful foot. 
Cure slow but uncomplicated. A 
year afterward patient walked 
freely without apparatus. 
Was confined seven months in bed 
after the original injury. He 
then recovered complete use of 
Laborer 
Healthy; stru- 
mous parents. 
30 1856 
F 
Dr. Jaeger 
3i 1856 
15 
27 
54 
M. 
M. 
M. 
Strumous 
Caries 
Dr. Lunn 
32 1857 
Caries and necrosis of left 
calcaneum. 
Wounded in 1856 in the 
heel by a fragment of a 
bomb-shell. 
M. Giraldes 
33 Feb. 1, 1857.. 
Jewish Rabbi... 
Mr. Atkinson, at Je- 
rusalem. ENTIRE EXCISION OF THE OS CALCIS, 
97 
34 1858 
17 
M 
Caries 
Dr. F. Heyfelder... . 
Mr. Mead, of Brad- 
ford, Eng. 
Mr. Pemberton, of 
foot. In 1850 a morbid growth 
sprang from the os calcis. This, 
with a slice of the bone, was re- 
moved by Mr. Sim. The disease 
returned and continued four 
years. After removal of the os 
calcis, progress was good, but 
on March 15, 1867, the wound 
still remained open. 
Astragalus also removed. Relapse 
occurred, and amputation be- 
came necessary. 
The disease seemed to be confined 
entirely to the os calcis. It re- 
turned in the tarsal bones, and 
amputation was performed at 
the lower third of the leg. 
Left hospital on crutches six weeks 
35 Mar. 12, 1859 
38 Sept. 28, 1861 
30 
29 
M. 
F. 
Married 
Strong and 
Caries confined to os calcis. 
Necrosis of right os calcis. 
37 Nov. 2, 1861. 
* 
5 
M 
Boy 
. healthy. 
So-called stru 
Disease of seven months' 
standing. 
Extensive caries 
Birmingham. 
Mr. T. Holmes, Lon- 
don. 
Mr. T. Holmes, Lon- 
after the operation. Two years 
later could walk any ordinary 
distance, and the wound was 
sound. 
Discharged Feb. 3, 1862. When 
seen, Jan. 30th, could run and 
dance like other boys. 
Discharged Sept. 7th. Wound 
38 July 5, 1862.. 
M. 
Boy 
mous. 
So-called stru- 
Extensive caries. The lower 
39 April 1, 1863. 
M. 
Soldier 
mous. 
surface of the astragalus 
was also removed with a 
chisel. 
Caries following gunshot 
wound. 
don. 
Dr. Janies C. White- 
hill, Med. Director 
Department of Ar- 
kansas. 
healed, and boy beginning to 
walk easily. 
By June 1st the wound had almost 
closed. The foot was natural 
in appearance, with movement 
of the joint. The astragalus 
also removed. 98 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Date. 
02 
Condition or 
occupation. 
Diathesis. 
Origin and nature of disease. 
By whom removed. 
Result. 
40 May 14, 1863 
41 May 16, 1863 
42 Feb. 18, 1865 
« 1865 
7 
7 
11 
42 
15 
10 
F. 
M. 
IL 
M. 
M. 
M. 
M. 
Girl 
So-called stru- 
mous. 
Extensive caries 
Mr. T. Holmes 
Asst.-Surgeon C. R. 
Greenleaf, U. S. A. 
Mr. T Holmes 
Discharged June 30th, wound not 
healed. Seen Feb., 1866. "The 
limb operated upon is smaller, 
and two inches shorter than the 
other, one inch of which is said 
to be due to atrophy of the tibia 
from disuse preceding the op- 
eration. Can walk with appa- 
ratus, but not stop or stand for 
any length of time. The leg is 
also colder than the other." 
Patient recovered. 
Wound healing slowly, when pa- 
tient was attacked with diph- 
theria and died March 23d. 
Left hospital five weeks after op- 
eration, and walked freely with- 
out apparatus. 
Patient able to resume work two 
months after operation. 
Left the hospital in two months. 
Walked freely. 
Prompt recovery and free walk. 
• 
Sergeant 
Five months previously the 
os calcis had been perfo- 
rated by a conoidal ball at 
short range. General ca- 
ries. 
Extensive caries 
Boy 
So-called stru- 
mous. 
Boy 
Hyperostosis and caries with 
vegetation of the left os 
calcis. 
Nine years previously fell 
from two-story roof and 
injured heel, since when he 
had suffered from pain and 
suppuration in that region. 
Caries 
M. Giraldes .• 
44 Mar. 1, 1866. 
« 1866 
House-carpenter 
Italian 
Reduced by dis- 
ease. 
Dr. J. Scott, Parkers- 
burg, Va., U. S. 
M. Giraldes 
4» 1866 
M. l'Agrege Boeckel. ENTIRE EXCISION OF THE OS CALCIS. 
99 
41 Nov. 
1, 1867 
8 
M. 
School-boy .... 
Healthy 
Inflammation and abscess Dr F A Burra 11. । Went down-stairs in iron wnnVa 
resulting in advanced ca- 
ries. 
New York. 
with foot in sling. Dec. 18th 
could wTalk. March 7th attends 
school, walks and runs in ordi- 
49 Jan. 
5, 1868 
13 
M. 
Boy 
Strumous 
Patient strained foot by fall- 
ing on it eight weeks pre- 
viously. The periosteum 
became separated from the 
bone, which died en masse. 
Dr. James L. 
Little, 
nary shoes with very slight limp. 
Tendo Achillis united with the 
remaining portion of heel. 
Entirely recovered, with good use 
of the foot. 
As much periosteum preserved as 
possible. Patient could walk. 
49 Mar. 
18, 1868 
New York. 
Mr. Annandale 100 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
A review of this list shows that the ages given in 40 of 
these cases varied from 4^ to 54. Six were under 10,16 from 
10 to 20, and 16 from 20 to 40. There were five from 40 to 
54; 38 were males, and 8 females. Thus the different periods 
of life are represented, and the majority of subjects for the op- 
eration is found among the young, the largest number being 
between the ages of 10 and 20. As might be inferred, males, 
in consequence of the greater exposure to which they are sub- 
ject, are more liable than females to disease of this bone. 
The disease, in 38 cases, is stated to have been caries, ca- 
ries and necrosis in 1, and necrosis in 4; and in 18 cases, in 
which the exciting cause of the caries is given, it is, in 5, in- 
flammation and abscess, 2 erysipelatous inflammation, 1 
syphilis, and 3 gunshot injuries. In the other cases, the pri- 
mary causes are stated to be-the friction of a tight shoe, a 
strain, the compression of a foot between two cars, the pas- 
sage of a cart over the foot, a severe fall, and the puncture of 
the heel by a nail. Evidently caries is the principal cause of 
the disorganization of this bone. 
Of 21 cases, the diathesis in 14 is stated as strumous, 3 
were healthy, and the remaining 4 were in impaired health. 
One patient died of diphtheria, to which fact no special signifi- 
cance can be given as bearing upon the operation, and even in 
this case the wound was healing slowly when the disease made 
its appearance. One amputation was performed after recur- 
rent attacks of erysipelas, and in the other the astragalus, cu- 
boid, scaphoid, and cuneiform bones were found carious. A 
sinus remained for some months after the operation in one of 
the two remaining cases, and in the other the patient was able 
to walk freely on crutches. As far as the evidence of these 
instances is of weight, it gives the strongest reason to hope for 
a good result from this operation even in debilitated constitu- 
tions. Of the entire number of cases under consideration (48), 
the operation was successful in 33 ; 1 was convalescent at date 
of report; 2 could walk with crutches; and in 1 a sinus re- 
mained several months after the operation. 
Only one death occurred which could be said to be con- 
nected with the operation, and even here it is doubtful whether 
any such connection existed. As was observed of the death ENTIRE EXCISION OF THE OS CALCIS. 
101 
from diphtheria, so it may be said of that from pyaemia, that 
it did not bear with any special significance upon this opera- 
tion. The other two deaths from phthisis occurred, one in 
four years and one in eighteen months after the removal of the 
bone. In both of these cases cicatrization had taken place, 
and the limb been of use for a year. Dr. Heyfelder thinks it 
worthy of note that the three deaths which he reports were of 
phthisis, but is uncertain how much significance should be 
given to the fact, since tubercles are likely to be developed dur- 
ing the weary convalescence which sometimes follows resections. 
Seven secondary amputations were necessary. In one of 
these cases the astragalus had been removed at the same time 
with the calcaneum; in another, the astragalus, cuboid, sca- 
phoid, and cuneiform bones were all carious, and in another 
the patient's left leg had been amputated three years before 
for caries of the knee-joint. One of the remaining amputa- 
tions was not performed until three years after the excision, 
the cause being caries of the ankle-joint; one was for gangrene, 
one for obstinate development of the syphilitic diathesis.in the 
vicinity of the resection, and in the last the disease returned 
in the tarsus, and the leg was amputated. In those cases 
where amputation was performed, the result seems to have 
been favorable, and it is 'worthy of notice that none of these 
amputations were necessary in children. The fact that, of 48 
cases of this resection, secondary amputation was necessary 
only in 7, is, as Mr. Hancock observes of those cases which he 
has recorded, a powerful argument against the primary adop- 
tion of that step. 
Of 17 cases in which the time elapsing from the opera 
tion to recovery is given, it will be noticed that, in 11, this 
period was from one to tw'O months, the ages of these patients 
being from 4| to 16. The others recovered in from 3 to 18 
months, their ages being from 20 to 35, with the exception of 
an ill-nourished patient of 16, who, nevertheless, at the close 
of a year, found the limb which had been operated upon as 
serviceable as the other. As will be observed, from noticing 
the list of ages, the prognosis would seem to be peculiarly 
favorable in children. 
The main practical point to be deduced from the study of 102 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
the preceding table is, that primary amputation is rarely if 
ever advisable for disease of the os calcis. As is shown by the 
table, the operation of excision was successful in 17 of 21 
cases, of which 14 were strumous and 3 healthy. The total 
number of these cases should rather be placed at 20, since 
one died of diphtheria. This leaves one case of amputation 
and one patient able to walk freely on crutches. 
Here the question of partial excision1 and gouging of the 
calcaneum must be noticed. As Mr. Holmes states, in his work 
on the surgical diseases of childhood, it would seem, at the first 
glance, as if it were desirable to save as much of the bone as pos- 
sible for the purpose of preserving the strength and shape of the 
heel, as well as its muscular attachments. But, on the other 
hand, the liability of the disease to return after gouging and 
the very useful heel left after excision lead him to advocate 
a removal of the entire bone, where the extent of the disease 
renders the question of gouging or excision a doubtful one. 
Dr. Heyfelder says: " Partial resection is to be preferred to 
extirpation, when possible, both for the sake of leaving intact 
the joint and adjacent bones, as well as to preserve the mus- 
cular and ligamentous attachments. The easiest and most 
promising operations are the removal of a superficial slice or 
the posterior tuberosity (Spornfortsatz). But partial resections 
of the calcaneum are not always successful (5 failures among 
54 cases), and amputation of the foot (twice) or extirpation 
of the bone (once) has been necessary. Of 60 cases of partial 
excision, in which superficial or deeper wedge-shaped portions, 
or even the larger part of the bone was removed, none ended 
fatally. Relapses occurred in 5 of 54 cases, rendering am- 
putation necessary in three. In one case the processus cal- 
canei had been twice removed before the amputation."4 
The teachings of the experience thus far recorded seem to 
be, that when the disease is trifling or limited, partial excision 
should be practised. In those cases where the disease seems 
to involve the deeper portion of the bone or involve it exten- 
sively, and does not yield to rest or local applications, com- 
plete resection should be performed. It is very satisfactory 
1 First performed by Formius for a gunshot wound, 1669. 
2 " Lehrbuch der Resectionen," p. 185. ENTIRE EXCISION OF THE OS CALCIS. 
103 
to know that in the majority of successful cases of entire ex- 
cision the deformity of the foot operated upon is compara- 
tively slight, and it is nearly as useful as when in a normal 
state. In performing this operation care should be taken not 
to make the incisions upon the sole, since the resulting cica- 
trix is likely to inflame and ulcerate. The operation of Mr. 
Holmes commends itself by its simplicity, and by the circum- 
stance that the incisions are chiefly upon the external surface 
of the foot. In this, a horizontal incision is made from the 
inner edge of the os calcis, severing the tendo Achillis and go- 
ing down to the bone, to midway between the heel and the pro- 
jection of the fifth metatarsal bone, where the calcaneo-cuboid 
articulation is situated. A vertical excision leads from the ex- 
tremity of the first to just within the sole, stopping short of 
the grooved internal surface of the os calcis where the vessels 
lie. The flap thus formed is dissected back, the calcaneo- 
cuboid joint opened, and the attachments of the bone to those 
adjacent severed. The wound is then united by sutures, and 
a sufficient number of straps applied to give support to the part. 
The indications for after-treatment are: perfect rest of 
the part, a free exit for discharges, and the support of the 
patient's strength. To insure the first, nothing is better than 
the plaster-of-Paris bandage, going round the foot and upon 
the leg, leaving the heel bare. This gives a firm support for 
the leg and foot, on which the limb may rest with the heel 
downward, so that the discharges may drain through the lower 
portion of the wound. Union by first intention sometimes 
occurs through nearly the whole line of incision. Ice or cold- 
water compresses should be applied at first, and afterward the 
part dressed according to the requirements of the case, and 
some detergent lotion, as a solution of carbolic acid or sul- 
phate of copper, be injected daily through such part of the 
wound as may remain ununited. Those who adopt the theory 
of the septic properties of the atmosphere would be careful to 
keep the vicinity of the wound constantly disinfected either 
by carbolic acid or a chlorinated wash. The after-treatment 
has been rather fully dwelt upon, because there is great reason 
to believe that a good share of success in this operation de- 
pends upon its observance. 104 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Mr. Holmes refers to the opinions of Sedillot upon the 
evidemment des os, and Ollier upon subperiosteal resection, but 
does not regard those operations as giving better results than 
entire excision, while being more complicated. 
There are other notices of resection of the entire cal- 
caneum on record, but the above are nearly, if not all, those 
which have been fully reported. Roux, of Paris, excised this 
bone ; Dupuytren, in 1833, related four cases in which he had 
operated ;1 Mr. Hamilton operated in 1856; Mr. Thomas II. 
Wakley in December, 1847;2 and it has been adopted by 
Fergusson, Teale, Humphry, Cann, Pemberton, the two Lans- 
downs, Folk er, Gibb, Erichsen, and others. 
In Heyfelder's work upon resections (p. 182) is given 
Linhart's description of a foot from which the os calcis had 
been removed three years before (case 23 of the table). It is 
as follows: 
" The foot was slightly curved, the sole flat, the projec- 
tion of the heel absent; at this point was a j^-shaped scar. 
Directly under the skin, in the region of the heel, was a tough, 
fibrous callosity, with which the tendo Achillis, as well as the 
tendons of the flexor brevis digitorum, abductor hallucis and 
digiti minimi, gradually blended. This fibrous tissue was also 
lost in the fascia, resp. ligamentum lanciniatum internum. 
The sheaths of this latter ligament were dry, and the contained 
sinews mostly united with them. . . . On the posterior 
border of the surface of the astragalus which unites with the 
tibia was a row of warty and spinous osteophytes. The 
under surface of the body of the astragalus which articulates 
with the calcaneum was united, by a soft, loose connective 
tissue, with the callous substance in the heel to which ref- 
erence has previously been made. The callosity could be 
easily detached in several places, and the surface was com- 
pletely denuded of cartilage. In its stead were broad, fibrous 
bundles, and, where these were wanting, the carious bone lay 
bare. The internal articulating surface on the neck of the 
astragalus (for the sustentaculum tali) was gone, and in place 
of the cartilage was a fibroid mass. The compact substance of 
'Mott's Velpeau, vol. ii., p. 760,'et seq. 
2 Successful removal of os calcis and astragalus. London Lancet, Nov. 
2, 1867. ENTIRE EXCISION OF THE OS CALCIS. 
105 
the bone seemed to be thinned and yielding. The posterior 
surface of the cuboid had approached the body of the astra- 
galus, and, while this surface was neither denuded nor softened, 
tlie opposite portion of the neck of the astragalus was soft- 
ened and rough. The inner half of the external lateral liga- 
ment (Schleuderband) was united with the common fibrous 
cicatrix. A process of the callosity, which has been men- 
tioned, extended toward the cuboid, to which, as well as the 
body of the astragalus, it was united. This served to 
strengthen the cuboid, although an imperfect substitute for 
the ligamentum calcan-cuboid-plantare. The smaller joints 
of the foot were rendered almost immovable by means of 
Kurzzellige (?) bands of attachment. 
" The most striking feature presented in examining the 
bones of the foot, was the absence of the plantar arch, which, 
in the normal condition of the bones, is formed by the union 
of the astragalus and os calcis with the scaphoid and cuboid. 
Like the pes valgus, the foot was turned outward and up- 
ward. The inner margin of the foot had, like the sole, lost 
its curvature. The eversion just mentioned existed only in 
tlie articulation between the astragalus and scaphoid (which 
joint was deprived of its strong plantar ligament), while the 
lesser curvature of the five metatarsal bones was not altered 
(differing in this respect from the similar deformity of the pes 
valgus). The head of the astragalus was, to a great extent, 
separated from the scaphoid and looked toward the sole, the 
articulating surface of the astragalus was not smooth but 
rough, and covered with short, firmly-attached fibrous fila- 
ments : where these fibres were wanting, the cartilage cover- 
ing the facet seemed ossified. The astragalus was firmly 
fixed in the position which has been described." 1 
Any operation which saves a valuable limb, and restores 
it to normal usefulness after, in some cases, an inactivity of 
many years, cannot but cause feelings of deep interest. An 
amputation for disease, however necessary, is yet a confession 
of inability to arrest that disease. It is'hardly indulging the 
imagination to say that every stump; however firm or well 
rounded, still seems to utter a mute appeal for the advent of 
'Lehrbuch der Resectionen von Dr. Oscar Heyfelder, etc. Wien, 1863. 106 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
that period in medical knowledge when therapeutics and 
manual aid can accomplish their utmost in reducing the neces- 
sity of amputation to the lowest degree. 
References.-Rankin's Abstract, July, 1857; Philadel- 
phia Medical and Surgical Reporter, March 1, 1866; Bulletin 
de la Societe Imperiale de Chirurgie de Paris pendant 1'annee 
1867, Seance, 27 February, 1866; American Medical Times, 
June 15, 1861, p. 383 ; Edinburgh Medical Journal, March, 
1868; Edin. Med.-Ch. Society, March 18 ; Braithwaite's Re- 
trospect, 1860, part xl., p. 86; Braithwaite's Retrospect, part 
xxxiv.; Med.-Chirurgical Review, July, 1853, p. 178 ; London 
Lancet, November 2, 1867, p. 545; Ibid., November 9, p. 
573; Ibid., January 21, 1865; Catalogue Army Medical 
Museum, U. S. A., p. 421, art. 1286; Lehrbuch der Resec- 
tionen, von Dr. Oscar Heyfelder, Wien, 1863, p. 176; New 
York Med. Record, June 15, 1867, p. 171; Vaquez. Quelque 
mots sur 1'Extirpation du Calcaneum, Paris ; American Med- 
ical Gazette, June 1, 1857; Mott's Velpeau, vol. ii., p. 760; 
Med. Times and Gazette, September 13 and 20, 1856; Ar- 
chiv. Gen. de Medecine, cinquieme serie, tome iii., p. 617; 
Prager Vierteljahrschrift, 1858, vol. i., p. 44; On Excision of 
Joints, by Richard M. Hodges, M. D., Boston, 1861; Med. 
Times and Gazette, April, 1857, p. 356; Deutsche Klinik, 
1856, p. 14; Lancette Frang., vol. ii., p. 215; Cases of the 
Excision of Carious Joints, by II. Park, etc., and P. F. 
Moreau, etc., Glasgow, 1806; Rankin's Abstract, January 2, 
1859; Publications of Sydenham Society; Year Book of 
Medicine and Surgery, 1859 ; The Surgical Treatment of the 
Diseases of Infancy and Childhood, London, 1868, by T. 
Holmes, etc., etc. IV.-SPRAINED ANKLE. 
On the Serious Consequences which result from the Neglect 
of slight Injuries of the Ankle-Joint. Illustrated hy 
Cases. By Lewis A. Sayre, M. D., Professor of Ortho- 
poedic Surgery, and of Clinical Surgery in the Bellevue 
Hospital Medical College. 
[Being a Clinical Lecture delivered at Bellevue Hospital, Nov. 1G, 1868.] 
Gentlemen: I desire to speak to you to-day upon the 
serious'consequences of neglecting slight injuries of the joints, 
and my remarks will have especial reference to the ankle, 
as it is this articulation that is above all others exposed to 
accidents of this sort; and the case before you is typical in its 
causation and progress. I shall, moreover, demonstrate to you 
the plan of treatment I pursue, which is somewhat at variance 
with that generally adopted, and exhibit and relate to you 
cases exemplifying the degree of success you may anticipate 
by this method of procedure. 
I have often expressed the opinion that injuries of joints 
were dangerous in proportion to their original insignificance, 
by which apparent paradox, I mean this: that serious in- 
juries compel attention and slight ones are neglected, and, 
generally speaking, the more slight the accident the Tnore apt 
to be neglected. If an injury is severe-a dislocation, a 
fracture involving a joint, a severe sprain even, for example- 
it cannot be overlooked or neglected; surgical aid is indis- 
pensable and immediately sought for, and generally a cure 
results after a reasonable time. When, however, a person re- 108 
BELLEVEE AND CHARITY HOSPITAL REPORTS. 
ceives what is termed " a slight sprain of the ankle," the 
amount of mischief resulting from its neglect is often extreme, 
the limb frequently being sacrificed as the only cure for a 
chronic inflammation of the joint involved. 
Let us consider for a moment how this comes about. I 
need not detain you with any extended remarks upon the 
anatomy of the joint, but simply call to your mind the ad- 
mirable provision which is made against injuries from concus- 
sion. Notice how both surfaces of the astragalo-tibial articu- 
lation are protected by cartilage, which is elastic, non-vascu- 
lar, receiving its nutrition by imbibition from the synovial 
membrane and from the vessels of the articular lamella, and 
'which consequently takes on inflammatory action with great 
reluctance. The malleoli, however, which stand as guards on 
the sides of the joint, are not so well protected, because in the 
normal movements of the foot they are not subject to pressure. 
You have probably all at some time twisted your ankles in 
walking, and you cannot have failed to notice how instantly 
the malposition of the joint is followed by a spasm of the 
muscles of the leg; in accordance with a peculiar kind oi 
sensibility which Mr. Harwell styles " the joint-sense." 
When one thus sprains his ankle, I believe that beneath 
the synovial membrane, or between the cartilage and the bone, 
is produced a slight extravasation of blood, quite analogous to 
the "blood-blister" which is formed upon the external surface 
whenever the skin is severely pinched but not broken. 
Such a " blood-blister " is considered as insignificant under 
ordinary circumstances, if it is allowed immediately to heal. 
If, however, the "blood blister" is constantly irritated by fric- 
tion, an ulcer is formed which rapidly increases in size and in- 
volves the deeper tissues. This, I believe, is exactly the morbid 
process going on in one of these neglected sprained ankles. The 
small quantity of blood effused behind the synovial mem- 
brane, or between the cartilage and the bone, would speedily 
be reabsorbed if sufficient rest were allowed to the part; but 
there is no swelling and little pain to give warning of the 
mischief done, and the patient does not stop his usual walks 
and exercise. The " blood-blister " becomes irritated and in- 
creases in size, finally obliging him to lie by for a short time. SPRAINED ANKLE. 
109 
The trouble apparently disappears, and he resumes his avoca- 
tions; a slight over-exertion, however, brings back the same 
train of symptoms, namely, exhaustion, stiffness, pain, tendei 
ness, and perhaps swelling. This is repeated again and again 
as often as rest allays and exertion awakes the morbid pro 
cess; the attacks becoming more severe and prolonged, till at 
last the condition of chronic inflammation is reached. The 
liquid now contained in the joint is abnormally abundant and 
is changed in consistency; instead of the clear synovia, there is 
a viscid substance. To this, in part at least, are due that peculiar 
distention and " boggy " feel which the joint now presents. 
Ordinarily suppuration very rapidly supervenes upon the 
above-described condition of the articulation. The cartilages 
ulcerate, and caries of the adjacent surfaces of the bones is set 
up. The pain is often excruciating, as is generally the case 
when cartilage is undergoing- disintegration. 
O o o o 
As a result, the constitutional disturbance is quite severe ; 
the pain produces directly sleeplessness and anorexia. The 
muscles affecting the articulation are constantly " on guard " 
to fix the joint and prevent any attrition of its surfaces. This 
constant tension causes an atrophy of the limb both above and 
below the joint; though, in the latter situation, it may be 
obscured by the swelling. At night, when the sleep has be- 
come so sound that the muscles relax their spasmodic con- 
traction, motion will take place in the joint, and the patient 
awakes with a sudden, piercing shriek. So quickly do the 
muscles resume their conservative contraction, that, by the 
time the nurse has reached the bedside, the patient is again 
asleep or is unconscious of the cause of his awakening. 
This pressure of the joint surfaces, although painful, is less 
so than the motion which would occur if the muscles were not 
thus contracted, and it very much increases the destruction of 
cartilage and bone; and you will find, in post-mortem exam- 
ination of the parts, erosion of these tissues farthest advanced 
in those points where the pressure of muscular contraction is 
greatest. 
When the joint is thus filled with a liquid, which is causing 
disturbance as a foreign body, one of two terminations is ne- 
cessary-the absorption or evacuation of this liquid. The 110 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
character of the liquid is such as to render its absorption very 
unlikely, and the chances are diminished by the debilitated 
condition of the patient's system, which only increases the 
severity of the difficulty. 
Still we have a chance of success by fixing the joint in 
such a manner as shall relieve the pain and defend it from the 
attrition, and allow our attempts to renovate and invigorate the 
system really to take*effect, so that absorption shall be possible. 
If, in addition, we apply some apparatus, which shall permit 
the patient to take' out-of-door exercise without disturbing the 
rest of the articulation, we shall have done the best that can 
be done, and, fortunately, our efforts will often be crowned 
with success. If, however, we do not employ such precau- 
tions, and often, in spite of them, the disease proceeds to ul- 
ceration of the bone, and, if we do not make an exit for the 
pus, it will eventually make one for itself. In the mean time, 
however, long and tortuous sinuses will have formed, the pus 
burrowing this way and that among muscles and between 
fascia, so that these tissues are involved, while by the long- 
continued action of the pus the disease of the bones becomes 
greatly extended. Much of this trouble is avoided by open- 
ing the joint when we are convinced that any considerable 
amount of pus is contained within its cavity. The old estab- 
lished doctrine of the great danger of opening a joint is, for 
the most part, fully accepted to-day. I must, however, ex- 
press my dissent from this general belief. Of course, no one 
would dream of opening a joint so long as there was a proba- 
bility of the integrity of the articulation. But, when the 
articular surfaces are wholly or in part destroyed, then, I say, 
the characteristics of a joint are also destroyed; there remains 
nothing but an abscess of a joint, which is to be treated in 
the same manner as an abscess elsewhere, or, more exactly, as 
any abscess connecting with bone. 
Now, the manner in which I accomplish the various indi- 
cations I have pointed out above is as follows: When I still 
have hope of preserving the joint intact, I employ an instru- 
ment which I have constructed for this purpose. This instru- 
ment consists of a firm steel or hard rubber plate, made to fit 
the sole of the foot; at the heel is a hinge-joint, and attached SPRAINED ANKLE. 
111 
to it a rod, slightly curved at the bottom, and extending up 
the back of the leg to near the knee. Over the instep is an 
arch, like the top of a stirrup, with a hinge-joint at its summit, 
from which springs another rod, which runs in front of the 
leg, of equal length with the one behind. These rods are 
made with a male and female screw, or ratchet and cog, for 
extension, and connected at the top by a firm band of sheet 
iron, on one side of which is a hinge, and a lock on the other, 
like a dog-collar. (See Fig. 18.) 
The instrument is applied with firm adhesive plaster, cut 
in strips about one inch in wudth, and long enough to reach 
from the ankle to two or three inches above the tubercle of the 
tibia, and placed all round the limb, as in Fig. 19. 
The plaster is secured in its position, to within two or three 
inches of its upper extremity, by a well-adjusted roller, as 
seen in Fig. 20. 
Fig. 18. 
Fig. 19. 
Fig. 20. 
The instrument is fixed, and the foot firmly secured by a 
number of strips of adhesive plaster, as seen in Fig. 21.1 A 
roller should be carefully applied over this plaster, to prevent 
its slipping, and the ends of the plaster at the top of the 
instrument turned over the collar, which has been previously 
locked, just tight enough to be comfortable, and secured by a 
turn or two of the bandage, as seen in Fig. 22. With the in- 
strument accurately adjusted, the extension can be regulated 
by the key and cog, so as to make the patient comfortable. 
1 The figures represent the instrument as applied to a joint which has 
been setoned. 112 
BELLEVUE AND CHARITY HOSPITAL REPORTS, 
If, however, the symptoms show the system to be suffer- 
ing from the poison of the pus retained in the joint, or if, the 
joint being open, the patient is sinking under the drain of 
prolonged suppuration, the diseased bone should be at once 
removed, and a perfect drainage established, so that no pockets 
or sinuses can be formed. If this latter accident be allowed 
to occur, the disease of the bone will not be arrested, and the 
operation will, therefore, be useless. 
Fig. 21. 
Fig. 22. 
Now, you cannot in the ankle exsect the bone, as you can 
at the shoulder or hip, by a straight incision. In these orbicu- 
lar joints the operation is simple ; you have but to cut down 
to the bone, open the capsule, throw out the head of the bone 
through the " button-hole " slit, remove it with the chain-saw, 
and finish with the rongeur forceps, if necessary. But in the 
hinge-joints, as a rule, and especially such complicated ones 
as the ankle, you cannot safely operate in this way. To make 
the necessary incisions, the muscles and vessels must be di- 
vided transversely, and so much damage is thus done as to 
seriously interfere with the success of the operation. The 
elbow-joint is the exception to this rule, the ordinary operation 
for orbicular joints, viz., a single incision parallel with the 
muscular fibres and vessels, being applicable to it. In view 
of this, I have for many years refused to operate by exsection 
upon any of the hinge-joints, except the elbow. The method 
which I substitute I shall now proceed to demonstrate to you, 
as, by so doing, I can much more clearly explain and more 
firmly impress the essentials of the operation than by any 
amount of lengthy description. SPRAINED ANKLE. 
113 
The history of the case before you is, in brief, as follows : 
Lewis R , aged nine, last winter, in December, '67, or Jan- 
uary, '68, sprained his ankle while skating. For some time he 
experienced no trouble in the joint, but eventually it began to 
swell, and the disease ran the usual course, till he was admitted 
to Bellevue, July 11, 1868, with an open joint. On the 22d 
of that month I removed what dead bone could be found, and 
passed a seton of oakum through the joint from side to side, 
below the malleoli. The joint was fixed by a plaster-of-Paris 
splint, which was changed in a few days for one of leather. 
The case remained under my care but a short time ; the sur- 
geon to whose care he next passed, holding different views re- 
garding the treatment of these cases, removed the seton a 
month after it had been inserted, and since then the treatment 
has been simply poultices and stimulating dressings. The sur- 
geon at present having the case in charge has kindly consented 
to surrender the case to me " for one year, at the end of which 
it is to be returned for an amputation." You see, he has no 
faith in my plan of treatment. 
You will notice the foot and ankle present the usual ap- 
pearance found in chronic inflammation and suppuration of 
this articulation, complicated with caries of the tarsal bones. 
The usual contours of the joint are obliterated, and it presents 
an irregularly rounded tumefaction, nearly twice the size of 
the opposite ankle, of a purplish color from venous conges- 
tion, which has been aggravated by long-continued poulticing 
of the part, and a " boggy, doughy feel," with several open 
sinuses, through which the probe readily passes to dead bone. 
I would remark, in this connection, that the long-continued 
use of hot poultices to a joint in the condition of this one is 
always injurious. The heat solicits more blood to the part, 
and the relaxing effect of the fomentation favors the passive 
congestion of the capillary vessels, and thus adds to the oede- 
matous and " boggy " condition of the part. 
While the patient is under the chloroform, I shall remove 
the carious bone sub-periosteally. If I destroyed the periosteum, 
I should defeat the chief object of my operation, namely, the 
regeneration of bone and the formation of a movable joint. Into 
the sinuses already existing I pass this instrument, Fig. 23, which 114 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
I have formerly called an " oyster-knife," as its form most re- 
sembles that of the implement used to open oysters, but it is 
more properly called a periosteal knife, or elevator. The blades 
are strong and wedge-shaped, the edges not being sufficiently 
Fig. 23.-Sayre's Periosteal Knife. 
sharp to cut the soft parts. With it I can enucleate the 
diseased bone without fear of lacerating the vessels, perios- 
teum, or other important parts. Make your excavation thor- 
oughly, seeking to remove not only all the dead bone, but 
especially the gelatinous matter so abundant in these diseased 
joints. In this case you see I have removed, besides a mass 
of detritus, a piece of carious bone about the size of a hickory- 
nut, which is from the lower end of the tibia, including a part 
of the articular surface. If I can, I generally, before finishing 
the operation, place my finger within the joint, to more per- 
fectly assure myself that I have reached all the diseased 
structures. 
Now I draw completely through the joint and also through 
the other sinuses a large seton of oakum, saturated with 
Peruvian balsam, letting the ends extend beyond the ulcers 
for some inches. The advantage of the oakum I will mention 
in a moment. 
The operation proper is now complete. Place the foot in 
a comfortable position, and at a proper angle with the axis of 
the limb, and fix it there by an anterior splint of plaster of 
Paris, from which arms extend around the foot and leg below 
and above the wTound, so as to leave the latter entirely free 
for daily dressing. 
When the plaster has "set," envelop the joint with a 
thick pad of oakum, and bandage the foot and ankle as firmly 
as possible. The reason why I insist upon the oakum is this: 
it is elastic and makes an equable pressure, but at the same 
time is always pervious for the escape of pus. You know SPRAINED ANKLE. 
115 
how dense compressed cotton is, how that it cannot be wetted 
thoroughly for a long time; lint has much the same qualities. 
I sincerely believe that the life of many a soldier was lost dur- 
ing the late war, simply from the lint with which his wounds 
were dressed, or rather plugged. Beyond this advantage, 
oakum is particularly serviceable as a seton by reason of its 
strength, and the tar with which it is so thoroughly impreg- 
nated prevents its becoming readily foul. Therefore, gentle- 
men, I use lint only to arrest or prevent hsemorrhage, and 
never after suppuration is fully established. 
In this case, then, I have accomplished what ? By my ex- 
cavation I have removed the essential morbid cause; by the 
splint I prevent motion, which would be a cause of a relapse; 
and by the firm pressure I have given the enfeebled and stag- 
nant circulation of the parts the best possible support. The 
seton will be moved daily, and the soiled part cut off; you can 
easily twist on more oakum, and thus continue it as long as 
necessary, and what debris of carious bone has been left behind 
will be drawn out entangled in the fibres of the oakum. By- 
and-by, when the reparative process shall have been fully es- 
tablished, the extension instrument which I have already de- 
scribed to you will be applied and the boy allowed to go about. 
Even before that, if your patient is of sufficient age to take 
proper precaution against injury, he may be allowed to go 
about on crutches a little. In this event, however, you will be 
especially careful that the bandaging be applied with sufficient 
accuracy and firmness to counteract the congestion from grav- 
itation of blood to the part. 
I hope, gentlemen, before this winter session closes, to be 
able to present you the result of the case I have just operated 
upon, but a longer time may be necessary for a perfect cure. 
I have, however, here, several persons upon whom I have 
already operated, and who, living in the city, have consented 
to come before you in order that you may see what degree 
ef success you may anticipate. And first let me present one 
which should follow the one just operated upon, because they 
both exemplify the danger of too speedy removal of the setons. 
This one, moreover, will satisfy any doubt which may have 116 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
arisen in your minds, regarding the propriety of repeating the 
gouging and setoning process.1 
Case II.-John Rush, Davenport, Iowa, aged 27. La- 
borer. In November, 1866, while ploughing, he sprained his 
left ankle. lie did not, however, experience sufficient incon- 
venience from the injury to prevent him from working until 
four months had elapsed, although during this interval he was 
aware that the joint was not quite sound. From the time he 
was obliged to give up work until he came to New York, in 
April, 1868, he had been under surgical treatment. His at- 
tendant advised him, last spring, to come to New York to 
consult me. The foot presented the general appearances 
already described in relating the other cases. Below both 
malleoli were openings, and in each dead bone could be recog- 
nized by the probe. Still another fistula opened on the outer 
side of the tibia, about five inches above the articulation. 
The general health of the patient was considerably impaired, 
and he was quite thin. 
At that time, April, 1868, I dug out a large quantity of 
carious bone, consisting of the scaphoid bone, a part of the as- 
tragalus, and pieces which appeared to be parts of the smaller 
tarsal bones. The calcaneum was then quite sound. The 
dressing, with the seton and plaster-splint, was applied as you 
have already seen done. Three weeks after the operation I 
sent him to this hospital, as his lodgings were not suitable 
for his wants. The surgeon, to whose care he fell, removed 
the plaster-splint at once, and four weeks later removed the 
setons. This change of treatment was due to the fact that 
the surgeon holds the opinion that motion is necessary to the 
cure of the joint, in order to excite a healthy action. Now, I 
have already insisted upon the absolute necessity of rest, 
in certain stages of the diseased joint, but there is a period 
where motion becomes necessary, and I should do well, I 
think, to explain to you where motion is injurious and where 
it is demanded. 
So long as there is active inflammation in a joint, motion is 
injurious, and rest absolutely necessary. In the first stages of 
1 January 6, 1869, the boy was examined before the class; he was able 
to bear his weight upon the ankle, and there was motion at the new joint. SPRAINED ANKLE. 
117 
inflammation of any joint, rest is also absolutely necessary, 
and, in fact, is the essential element of the treatment-and, 
as long as acute pain is produced by pressing the synovial 
surfaces and articular cartilages together, rest must be 
enjoined, or, if motion of the joint is requisite, in order to 
prevent anchylosis, then this motion must be always accom- 
panied with extension in order to relieve this pressure. But, 
when pressure can be borne without pain, and the difficulty 
in motion depends upon the contraction of tissues around 
the joint from want of use or from deposits, as the result of 
an antecedent inflammation-then motion-passive motion- 
applied with discretion, is just as much a part of the treat- 
ment, as rest was in the anterior stage of the disease. 
So, also, when a joint has been opened for suppuration and 
caries, so long as there is dead bone remaining, and excessive 
suppuration, rest is imperative, and motion injurious; but, 
when the dead bone has all exfoliated and been removed, 
the pus diminished and of a healthy character, then the 
setons can be removed, the sinuses allowed to close up, and 
passive motions commenced, which can be increased with 
judgment and discretion, in order to make a new or artificial 
joint in the new bone formed from the original periosteum, 
which, as I stated to you before, must always be left for this 
purpose, when making your resections. 
When I came on duty, July 1st, I found the patient's foot 
presenting nearly the same appearance as at first. The prema- 
ture removal of the setons had allowed the accumulation of pus 
within the joint, and the caries had been reestablished. Ex- 
amination with the probe showed the calcaneum to be now 
involved. The operation of excavation was repeated, and 
a large portion of the os calcis removed, a seton passed 
through the joint, another from each of the openings on the 
side to an artificial opening at the point of the heel, so that, in 
any position the patient might assume, the drainage would 
be perfect. 
You see the present condition of the patient. The setons 
have been all removed, and the wounds are closed. There is 
no pain in the joint. You see the patient walks without limp- 
ing, showing there is no tenderness. The fistula on the leg 118 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
and that on the point of the heel are so perfectly healed that 
the cicatrices can be with difficulty found. The contour of 
the foot is so perfect that any one would naturally doubt that 
so much bone had been removed. This is, I think, evidence 
that the bones of the tarsus have in some sort been repro- 
duced by the periosteum. I have never had the opportunity of 
examining, post mortem, any of these reproduced ankle-joints. 
This man now appears to be perfectly cured, and you 
might think treatment should be suspended. On the con- 
trary, the limb must be carefully bandaged for months to 
come, until all the discoloration from congestion shall have 
disappeared. If you neglect this precaution, there is great 
danger of relapse. You will notice in this case, when I let 
his foot hang down, that the skin becomes discolored from 
capillary congestion ; and I therefore reapply the roller with 
considerable firmness, in order to support the circulation in 
these new tissues, and this accurately-adjusted compression 
must be continued for months after the cure has been appar- 
ently complete. 
Case III.-Suppuration and Caries of both Ankle-Joints 
from Injury; double Talipes-equinus; Operation: Re- 
covery, with Hotion.1 
Elizabeth Bruen, set. 16. Admitted to Bellevue Hospital, 
January 29, 1864. Her father died of phthisis. In 1862 she 
sprained her right ankle. The injury produced a chronic 
form of inflammation, and in two months it had increased so 
much that she could bear no weight at all upon it. She now 
moved about by hopping on the well (left) foot, and in about 
six weeks she had excited the same form of inflammation in 
that one as in the other. Two years after the first injury, 
when admitted to the hospital, her appearance was cachectic 
and miserable. The disease in her ankles had gone on to the 
formation of abscess, and several sinuses led into the joint, 
through which disintegrated bone had escaped. 
The gastrocnemii of both sides were so contracted as to ex- 
1 Cases III, V, and VI, were included in a report to the American 
Medical Association in 1865, but are again presented to show the perma- 
nence of the cure. SPRAINED ANKLE. 
119 
tend the foot nearly to a straight line with the tibia. She 
could not bear the slightest pressure on either foot, and could 
not use crutches, as she could not poise herself on the ends of 
her toes, which were the only points that could touch the floor 
when in the erect posture. She was, therefore, compelled to 
move about upon her knees, as seen in Fig. 24, which also 
shows the sinuses connecting with either joint. 
Fig. 24. 
All active disease about the joints had subsided ; but the 
discharge from the various sinuses was considerable, and, by 
probing them, several small pieces of bone escaped. 
On the 17th of February, 1864, in the presence of the 
class at this Hospital, I divided subcutaneously the tendo 
Achillis on both sides, and restored the feet to their natural 
angle with the legs. Leather splints were then applied, to re- 
tain them in this new position until the 24th of February, just 
seven days after the section of the tendones Achillis, when 
the above-described instruments were applied in the presence 
of the class. 
The sinuses were enlarged, and a seton of oakum drawn 
through the ankle-joint, as indicated in Figs. 19, 20, and 21. 
A wad of oakum thoroughly wet in cold water was placed over 
each ankle, and secured by a firm roller. The screws were 
extended, and the difference in the appearance of the ankle 
before and after is well represented by comparing Figs. 21 
and 22. 120 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
These drawings were taken from life by Dr. Henry C. 
Eno, House-Surgeon of Bellevue Hospital, and are as accurate 
as any photograph could be. 
As soon as the instruments were properly adjusted, she 
stood upon her feet, without the aid of crutch or cane, for the 
first time in two years, and without any pain whatever ; bnt 
the instant the screws were shortened, the pain was most in- 
tense. 
She was directed to have the oakum around the joints kept 
constantly wet with cold water, and firmly supported by a 
bandage, and changed as often as necessary. The seton was 
to be pulled through, and the soiled part cut off daily, and to 
be continued as long as any bone was exfoliating, until the 
matter should change from its sanious condition to a consistent 
pus, when it was to be removed, the wounds allowed to heal, 
and, if possible, passive motion made. If motion could not 
be attained, then the feet were to be anchylosed in their natu- 
ral position, deeming that a stiff ankle was better than an 
amputation. 
The following notes of the case, copied from the hospital- 
records, which were taken by Dr. Irving W. Lyon, House- 
Surgeon, now of Hartford, Connecticut, will show the prog- 
ress and the result of the treatment: 
" February 28.-She is very comfortable, and there is no 
pain about the ankles. 
" diarch 15.-Has been out of bed most of the time since 
the operation; but remained sitting at the bedside until to- 
day, when, with the aid of crutches to balance the body, she 
walked about, bearing her entire 'weight upon the feet; the ex- 
tension made by the instrument being so perfect as to prevent 
pressure upon the joint surfaces. 
" April 6.-Apparatus removed from both feet, and mo- 
tion made at the ankle-joints, which are perfectly free and 
movable, but pressure is yet very painf ul. The apparatus is 
reapplied. It should be stated that the patient was put upon 
the best diet the hospital could afford, together with cod-liver 
oil. 
" Jtfay >1.-The adhesive plaster having become disar- 
ranged, necessitated its readjustment. It was now discovered SPRAINED ANKLE. 
121 
that the sinuses had all closed completely; but pressure while 
extension was off still gave her some pain. Her general health 
very materially improved. 
"July 20.-All extension being removed, she is able to 
stand erect without pain in either ankle; but attempts at 
walking occasion a considerable amount of pain and uneasi- 
ness. The motions of the ankles are all unimpaired. Her 
health is thoroughly restored, and she has not only grown 
taller since her admission, but has also grown much more 
fleshy, and will weigh at least thirty pounds more now than 
in February. The splints are reapplied, and will require to 
be worn a little while longer to complete the cure." 
In a foot-note I find the following record : "It should be 
mentioned that since the 15th of March (the date of her com- 
mencement to walk upon the shoes) she has continued to walk 
upon her feet, bearing the entire weight of her body upon 
them, and only needed crutches to supply the place of the 
muscles of the leg, which, on account of being confined by 
the apparatus, were unable to balance the body." 
Dr. Lyon left the hospital about this time, and I can find 
no further notes of the case on the records of the institution. 
She wore the instruments, however, until about the middle of 
January, 1865, when they were permanently removed, and a 
plaster cast taken of both her legs and feet, from which Figs. 
Fig. 25. 
Fig. 26. 
25 and 26 are copies. The motions are almost perfect, and 
she can walk without pain. 122 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
From this time she continued to improve steadily, the 
wounds cicatrized perfectly, and for three years she has been 
able to take long walks. She lodges in the sixth story of a 
building, and has to go up and down the stairs several times a 
day in attending to her work. You can see for yourselves 
how perfectly free from halt her gait is. 
Last spring, in crossing the ferry from Brooklyn, she hurt her 
right ankle, and an abscess resulted, which opened in June last. 
This connects with the new joint, and is still open, and I can 
touch dead bone with the probe. She states she experiences 
no inconvenience from the ankle, save when the opening closes; 
at these times she feels uncomfortable, and opens the wound, 
and the symptoms disappear. You see, then, before you, what 
would formerly have been deemed impossible, a person walk- 
ing without pain with an open ankle-joint. She prefers let- 
ting the bone work out in its own time to discontinuing- her 
work for an operation. 
Case IV.-This little boy, John Francis Kennedy, came 
under my care, November 13, 1865, for chronic synovitis of 
the left ankle-joint, which had been caused by an injury re- 
ceived when jumping, five months before. At the time I saw 
him, the ankle was swelled and distended by synovia, and ab- 
normally hot. The limb above was somewhat smaller than 
its fellow, and the foot somewhat shorter. Pressure exerted 
on the tibio-tarsal articulation caused pain, which was relieved 
by extension. I applied an angular tin splint, placed on the 
anterior surface of the leg and foot, and fastened it with ad- 
hesive plaster, thus fixing and extending the joint. In addi- 
tion, the joint was painted with tinct. iodine, and compressed 
with sponges. The disease progressed, however, till, after 
three months' treatment, three openings formed, which dis- 
charged strumous pus. I then passed three setons through 
the joint, dressing the ulcers with balsam of Peru, and ap- 
plied the extension-splint. The setons remained in a long 
time ; one for eighteen months. Numerous small pieces of 
bone were discharged, and. on the 5th of July, 1867, a piece 
of the astragalus, about the size of an almond, was exfoliated. 
The discharge then became healthy, and after about six 
months ceased entirely. The joint has now considerable mo- SPRAINED ANKLE. 
123 
tion. The deep cicatrices mark the position of the setons. 
The foot is somewhat flattened in the instep, as compared with 
the sound one, but the motions are nearly perfect. (See Figs. 
27 and 28.) 
Fig. 27. 
Fig. 28. 
Case V.-Suppuration and Caries of the Ankle-Joint ; 
Operation • Seton ; Extension: Recovery, with ^Lotion. 
In January, 1855, I was sent for by Dr. L. C. Ferris to 
amputate the leg of Ella Stanley-aged 5 years-for disease 
of the right ankle-joint. In March, 1854, ten months pre- 
vious, she had fallen from a chair, striking her right ankle 
against the sharp corner of a bedstead. The injury was im- 
mediately followed by considerable swelling and very great 
pain. The pain soon subsided, but the swelling continued. 
For two or three weeks she seemed tolerably well, but at 
the end of that time she began to limp badly. She was then 
put upon crutches, and various lotions applied to the foot and 
ankle. 
The disease, however, continued to progress, her general 
health became much affected, with loss of appetite and sleep, 
and she was greatly emaciated. The limb was much smaller 
than the other, but the foot and ankle were swollen into a 
shapeless mass. In November she began to have repeated 
chills and hectic fever, and in the early part of December the 
ankle opened in several places, giving exit to a large amount 
of ill-conditioned or strumous pus. Iler general health be- 124 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
came much impaired, and in January, 1855, I was sent for to 
amputate the limb. Iler suffering was most intense; she 
would not permit the limb to be handled until she was under 
the influence of chloroform, when crepitus was readily de- 
tected ; several sinuses around the joint discharged quite 
freely a curdy pus mixed with a material very much resem- 
bling quince-jelly. 
A probe passed into one of these sinuses, just posterior to 
the internal malleolus, went into and through the joint, mak- 
ing its exit at a point in front of the external malleolus. A 
strip of linen (in default of any thing better) was torn from 
the child's dress, passed through the eye of the probe, and 
drawn through the joint. 
A piece of firm sole-leather, cut to fit the front of the leg, 
and dorsum of the foot, having been thoroughly soaked in 
cold water, was then applied over the top of the foot, and 
secured by a nicely-adjusted roller; the foot was firmly ex- 
tended so as to separate the tibia and astragalus, and the roller 
then carried up the lee:, over the leather, which, when dry, 
served to extend the joint and at the same time prevent all 
motion. This gave her great relief, and her limb could be 
moved with comparative comfort. The child was put upon 
the most nutritious diet, with quinine, cod-liver oil, and iron. 
The dressings were removed and changed as often as they 
became soiled with pus, and, in the progress of the case, com- 
pression with sponges and cold water was resorted to. Iler 
improvement was most marked and rapid. At the end of a 
few weeks the instrument was applied, as in the other cases, 
and with the same happy results, enabling the patient to walk 
with crutches and obtain the benefit of out-door exercise, 
which added materially to the improvement of her general 
health. 
The setons were retained nearly ten months, being grad- 
ually reduced in size as the bone ceased to exfoliate and the 
pus became more healthy, until for a number of weeks they 
were hardly larger than a single thread. When they were 
finally removed, the sinuses healed in a few days, and passive 
motion was commenced as in the other cases. The patient 
continued to wear the instrument for nearly a year after she SPRAINED ANKLE. 
125 
was perfectly well, as a means of prevention against accident, 
and then left it off entirely. 
It is now eleven years since this case was operated on, and 
she is as well in the one leg as the other, and the motions are 
almost as perfect. The foot is one size smaller than the other, 
and the leg a little shorter; but the limb is perfectly de- 
veloped, as represented in Figs. 29 and 30, which were taken 
from a plaster cast of her limb, and which also represent the 
cicatrices where the seton passed through the joint. 
Fig. 29. 
Fig. 30. 
This cast was taken more than five years ago, since which 
time her limb has continued to increase, until it is now as well 
developed as the other, and the motions are equally perfect; 
in fact, she is the prize female skater of the city. 
Case VI.-Caries of the Ankle- Joint ; Seton: Recovery. 
B. W., aged 7, of healthy parents, and whose brothers and 
sisters were all healthy, had himself always enjoyed good 
health, until in the summer of 1854, when he injured his left 
ankle by a fall. 
The joint swelled immediately, and was quite painful; but 
still did not confine him to his bed until after four or five 
days. It then became so painful as to prevent motion, and 126 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
for a number of days he was treated by perfect rest, and 
alternate applications of hot and cold water. As he made no 
improvement, after a few weeks his ankle was blistered, and 
this was repeated every eight or ten days for a great number 
of times, but without any improvement. 
His general health became much affected, with loss of ap- 
petite, and of sleep; he became greatly emaciated, and suf- 
fered intense pain constantly, which was greatly aggravated 
at night by frequent spasms, or "jerkings of his foot" as he 
described it. 
The development of the leg and thigh on the affected side 
became arrested, the ankle and foot very much swollen and 
shapeless, a number of sinuses formed, leading into the joint, 
and the bones crepitated when the joint was moved. 
Dr. Valentine Mott saw him in July, 1855, and advised 
amputation as the only means of saving his life. The mother, 
however, would not consent to the operation, and I was 
called to see him in consultation with Dr. David Green in 
October, 1855. Several sinuses then existed, leading into the 
joint, through which the probe was passed without difficulty, 
but coming in contact with carious bone in almost every 
direction. 
On the 21st of October, 1855, I opened the joint freely on 
either side by connecting some of the sinuses, and found the 
joint carious throughout. 
Two setons of oakum were passed through the joint, the 
one laterally, and the other antero-posteriorly; and the foot 
extended in the instrument as in the case of Elizabeth Bruen, 
above described. As the seton was pulled through, a num- 
ber of small pieces of bone were drawn entangled in its 
meshes. 
When he recovered from the effects of the chloroform, he 
could bear pressure on the foot without pain, and would 
permit it to be handled in any direction without complaint, 
although, before its application, he would not permit it to be 
touched, and it was impossible to move it in any direction, 
even in the most careful manner, without giving him in- 
tense agony. 
He slept quietly the night after the operation, without any SPRAINED ANKLE. 
127 
anodyne, although he had been compelled to use anodynes 
freely for many months, and never resorted to them again 
during the time he was under treatment. 
His general health began to improve almost immediately 
from the time of the operation and the application of the in- 
strument, his appetite returned, and he was able to ride out 
in the open air with comparative comfort. The setons were 
pulled through daily, and the soiled parts cut off; and the 
whole ankle constantly surrounded with oakum saturated in 
cold water, and sustained by a tight bandage. 
For two or three months small pieces of bone were fre- 
quently found entangled in the fibres of the seton, when pull- 
ing it through; but the discharge gradually diminished in 
quantity, became more consistent in character, and, as it did 
so, the setons were gradually reduced in size, until, finally, 
they were a mere thread or fibre. At the end of eleven months 
from their first insertion they were removed entirely, and the 
sinuses closed up in a short time after, never to be reopened. 
The extension was continued for nearly two years before it 
was removed permanently, although he had walked about for 
many weeks before the instrument was dispensed with. As 
soon as the sinuses had become closed, and he could bear mod- 
erate pressure upon the foot, when the extension was off, with- 
out suffering pain, I commenced passive motions daily, by 
acting on the anterior and posterior screws alternately, thereby 
imitating the natural motions of the joint. In about two years 
from the first operation, the instrument was removed perma- 
nently, when he could walk without difficulty, having consid- 
erable motion in the affected joint. This motion has very 
materially increased, and is now (nearly ten years after the 
operation) almost as perfect as the other. The foot is smaller 
than the other, and about half an inch shorter, but he sup- 
plies the deficiency by a thick sole inside his boot, and can 
run and skate with any of his playmates without the deformity 
being detected. 
Drs. Mott, Stephen Smith, and other surgeons of this city, 
saw this case when under treatment, and therefore know that 
the setons passed through the ankle-joint; but as there has 
been some question about it by others who have not seen the 128 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
case, I have had his foot daguerreotyped on both sides by Mr. 
Gurney, and the cicatrices on either side, giving the entrance 
and exit of the setons, show conclusively that they did pass 
through the ankle-joint. (See Figs. 31 and 32.) 
Fig. 31. 
Fig. 32. 
You will observe, gentlemen, that all the cases I have pre- 
sented to you, as well as the one just operated upon, have 
been the result of injuries which were at iirst so insignificant 
as not to attract especial attention, or for some time to prevent 
the patient from taking his usual exercise ; and you therefore 
see the necessity of compelling your patients to give immedi- 
ate and positive rest to the part, until all pain shall have sub- 
sided, in all cases of even the slightest sprain of the ankle-joint, 
for, if neglected, the result is more serious than if they had 
fractured the leg. V.-FRACTURED CLAVICLE. 
A Method of dressing Fractured Clavicle. By Lewis A. 
Sayre, M. D., Professor of Orthopoedic Surgery, Bellevue 
Hospital Medical College, and Professor of Clinical Sur- 
gery, Bellevue Hospital. 
[Being part of a Clinical Lecture delivered at Bellevue Hospital.] 
I wish to call attention to a method of dressing fractured 
clavicle, which, so far as I know, is not described in any 'work 
upon the subject. The plan is not original with me, or new, 
as I have used it many years, having first done so at the sug- 
gestion of a surgeon residing, I think, in Western New York, 
but whose name I regret that I am quite unable to recall. 
All surgeons are agreed as to the indications for the re- 
duction of a fractured clavicle; namely, that the shoulder be 
carried upward, outward, and backward. But the fulfilment 
of these indications and the retaining the parts in position 
after the reduction have proved problems of great difficulty. 
A very large variety of apparatus has been devised by dif- 
ferent surgeons, but the success attending their use has so 
little compensated for their inconvenience, that in this country, 
at least, they have very generally been surperseded by the 
treatment by position • that is, the confining the patient to 
bed, keeping him constantly upon his back, with the head, 
neck, and shoulders supported by pillows in such a manner 
that the weight of the injured shoulder shall draw the outer 
fragment into proper position, and union be thus brought 
about. 
Now, I find this plan of treatment quite irksome to patients. 130 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
In the first place, the position is very fatiguing. Again, a 
man of business is generally unwilling to abandon his occu- 
pations for the two or three weeks necessary for the union of 
the bone; and, with poor men, it is often of vital importance 
that the support derived from their labor should not be taken 
from their families for even so short a time as this. Beyond 
these objections on the part of patients, it has been my experi- 
ence that, if the point of fracture be near the outer end of the 
clavicle, the action of the deltoid will frequently prevent 
union when the postural treatment is employed. This is the 
case with the patient whom I am about to dress, who has 
been for three weeks confined to bed without accomplishing 
the desired end. The fragments are apparently as movable 
to-day as on the day the fracture was received. You will ob- 
serve that I rub the fractured ends against each other for the 
purpose of exciting a fresh inflammation; otherwise, there is 
danger that in this case we would not get bony union of the 
fracture, so long a time having elapsed since the accident. 
The dressing is prepared by cutting from strong adhesive 
plaster-that spread on Canton flannel, or jeans, is the best- 
two strips four to six inches in width, and longer by half than 
the circumference of the chest. 
These are to be applied as follows: Begin by fixing the 
end of one strap upon the inside of the arm of the injured 
side, opposite the insertion of the deltoid. Carry the strap 
across the belly of the biceps and around the back of the arm, 
bringing the arm well back (Fig. 33). Continue the strap 
horizontally across the back and around under the nipples 
(Fig. 33). In fixing the end to the arm, care must be taken 
not to bemn too far back, lest the arm be girdled and the cir- 
O 7 O 
culation be arrested. 
This first bandage is the peculiar characteristic of the 
dressing, as it serves as a fulcrum by which the leverage of 
the other bandage is brought to bear. 
Into the axilla a pad of proper size should then be placed, 
and the elbow pressed to the side, which carries the shoulder 
well outward. The hand should then be carried upon the 
sound shoulder as high as, or even higher than, is shown in FRACTURED CLAVICLE. 
131 
Fia. 33. 
Fig. 34. 
Fig. 34, and the elbow supported at the desired point, while 
the second strap is applied as follows: 
Begin in front of the sound shoulder and carry the strap 
over the shoulder, diagonally down and across the back, so 
that its upper edge shall cross the injured arm about at the 
junction of the middle and lower thirds. The plaster is then 
moulded to the back of the arm and elbow, and dorsal and 132 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
ulnar surfaces of the forearm, and finally drawn firmly over 
the back of the hand and overlaps the other end of the 
plaster on the top of the shoulder. It is well to fasten the 
ends together by a pin, which prevents the possibility of slip- 
ping. At the elbow the plaster should be made to fit accu- 
rately by cutting nicks in the edge and overlapping them. 
The three indications-upward, outward, and backward- 
are then thus answered : 
1. Upward, by the direct lifting of the shoulder upon its 
fellow as a point of support. 
2, and 3. Outward and backward, by carrying the elbow 
inward and forward, while the middle of the humerus is fixed 
as a fulcrum by the first bandage; the axillary pad assisting 
somewhat the leverage. 
If the fragments show a tendency to tip forward, I place 
over them a pad which is held in position by an adhesive 
strap passing from the back of the shoulder over the point of 
fracture and around the forearm, like a slmo*. The weight of 
the arm makes sufficient pressure upon the displaced frag- 
ments to keep them in position. 
An additional strap over the arm and body, to prevent 
motion, may occasionally be necessary. 
The peculiarities of this mode of dressing will at once be 
recognized, namely, that the bandages, being adhesive, remain 
as originally adjusted ; and the furnishing of a firm fulcrum 
gives a means of reducing the displacement which cannot be 
attained by other modes of dressing. 
The firmness of the apparatus is shown by the fact that, 
after it is applied, the patient, as you see, can endure a pretty 
rough shaking of the injured shoulder without complaint and 
without displacement. 
I have had patients return to their labor immediately after 
being dressed, and I particularly recall the case of one-a 
blacksmith-who, I think, lost not more than one hour's work 
on account of his accident, simply the time occupied in 
coming to my office and returning to his shop ; as you see in 
this case, it takes but a few minutes to apply the dressing. 
If the plaster is well made and spread upon good material, FRACTURED CLAVICLE. 
133 
one dressing will prove sufficient. If not, you must supply 
new ones as occasion requires. 
In young children, you will find this dressing of the 
greatest advantage, and the only one that I have seen used 
with equally satisfactory results. 
A fractured clavicle, dressed in this manner as soon as re- 
ceived, allows the man of business to immediately pursue his 
labor, and the child to at once engage in his frolic and sport. 
Care must of course be taken not to apply your dressings so 
tightly as to interrupt the circulation, but a little tact and close 
observation will soon give you the necessary experience for an 
accurate adjustment. VI.-THE MITRAL DIRECT AND THE TRICUSPID 
DIRECT CARDIAC MURMUR. 
On the Diagnostic Characters, Mechanism, and Pathological 
Significance of the Mitral Direct or Obstructive Cardiac 
Murmur, and on the Occurrence of a Tricuspid Direct 
Murmur. By Austin Flint, .M. D., one of the Attending 
Physicians to Bellevue Hospital, etc., etc. 
The existence of a mitral direct or obstructive cardiac 
murmur, that is, a murmur produced by the current of blood 
in its direct course from the left auricle into the left ventricle, 
is denied by some and doubted by others. The validity of a 
murmur thus produced rests, of course, on clinical cases in 
which a murmur, having the diagnostic characters of the 
mitral direct murmur, was observed during life, and mitral 
lesions are found after death. The proof is complete in such 
cases if the murmur was observed to occur prior to the ven- 
tricular systole; for, assuming the murmur to come from the 
mitral orifice, how is it possible for it to be produced other- 
wise than by a current from the auricle to the ventricle, pro- 
vided it be not caused by contraction of the left ventricle ? 
Now, the relation of this murmur, as regards the time of its 
occurrence, to the first sound of the heart, is such that it can- 
not be caused by the contraction of the left ventricle. It will 
not be denied that the first sound of the heart represents the 
occurrence of the ventricular systole; this sound is caused by 
the ventricular systole, and there cannot be any appreciable 
lapse of time after the contraction of the ventricles and the 
first sound. The mitral direct murmur precedes the first 
sound of the heart. It ends with this sound. It is produced, 136 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
therefore, prior to the ventricular systole; and, occurring in 
this pre-systolic relation, there is no current of blood to pro- 
duce it except the direct mitral current; that is, the current 
from the auricle to the ventricle. Observation of the living 
heart, exposed in inferior animals, shows that the auricles con- 
tract at the time this murmur occurs; they contract just be- 
fore the ventricular systole, and their contraction continues up 
to the time when the latter occurs. 
It will aid in appreciating the most distinctive diagnostic 
feature of the murmur under consideration, to place distinctly 
before the mind's eye the succession of movements which takes 
place during the revolutions or successive beats of the heart. 
Taking the auricles as the point of departure, these contract; 
next comes the contraction of the ventricles, causing the first 
sound, the apex impulse, and the arterial pulse; lastly, the 
recoil of the arterial coats causes the second sound. The con- 
traction of the auricles, which produces the mitral direct cur- 
rent of blood, thus occurs after the second and before the first 
sound; that is, during the pause between the second sound and 
the succeeding first sound. The auricular contraction, how- 
ever, is in closer relation to the first than to the second sound ; 
it is pre-systolic rather than post-diastolic. The mitral direct 
current is going on when the contraction of the ventricles takes 
place, and this current must be instantly and completely ar- 
rested when the ventricular systole takes place. 
With a clear apprehension of the order of succession of the 
three successive movements which are concerned in the pro- 
duction of the heart-sounds and the heart-murmurs-namely, 
1. The auricular contraction ; 2. The ventricular contraction ; 
and, 3. The arterial recoil-the most distinctive of the diag- 
nostic characters of the mitral direct murmur cannot fail to be 
appreciated. The murmur begins after the second, and ends 
with the first sound of the heart; this is expressed by the term 
pre-systolic murmur. The murmur continues until the first 
sound occurs. It increases in intensity until it ends in the first 
sound, and it seems to be, as it were, suddenly cut short when 
the first sound is heard.1 It does not, as of course it cannot, 
1 I do not think an instance has ever fallen under my observation in 
which this murmur ended before the first sound. Niemeyer, however, THE MITRAL DIRECT, ETC. 
137 
continue an instant after the first sound. In discriminating 
this murmur from -other endocardial murmurs, it is only neces- 
sary to determine its pre-systolic character, for no other mur- 
mur from the left side of the heart occurs in the same relation 
to the first sound. If its pre-systolic character be understood 
and ascertained, the murmur cannot be confounded with a 
mitral regurgitant murmur, for the latter begins precisely 
when the mitral direct murmur ends. It cannot be confounded 
with an aortic regurgitant murmur, for the latter begins with 
the second sound, its intensity gradually diminishes, and it 
generally ends before the succeeding first sound. The young 
auscultator, who may not always readily distinguish the first 
sound of the heart, will sometimes find it convenient to place 
tire finger over the carotid artery, and determine in this way 
that the murmur is arrested when the first sound occurs, the 
carotid pulse being synchronous with this sound. The apex- 
beat of the heart, if this can be felt, will answer the same end. 
The quality of the mitral murmur is another diagnostic 
character. The quality of sound is peculiar and quite uni- 
form. I have incorrectly said, in my work on the " Diseases 
of the Heart," that this murmur is soft; the quality is more 
properly called rough. The sound may be imitated by throw- 
ing the lips into vibration with the expired breath, and hence 
I have been accustomed to use the word blubbering to express 
the quality. This peculiar quality is quite characteristic; the 
reason for this quality will appear presently in connection with 
the mechanism of the production of the murmur. 
The murmur is often quite intense. Its intensity in cer- 
tain cases has been cited as evidence that it is not produced by 
the auricular contraction, the force of this contraction being 
supposed to be insufficient to produce so loud a murmur. 
When its mechanism is explained, however, the intensity will 
be found to be sufficiently intelligible. Finally, this murmur, 
however intense, is not diffused over a large space. It is gen- 
erally heard within a circumscribed area around the situation 
of the apex-beat of the heart. 
quotes a statement by Traube, that, if the action of the heart be much re- 
tarded by digitalis, the murmur ends before the first sound ; that is, there 
is an appreciable interval between the murmur and this sound. 138 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
In my clinical experience at the Bellevue and the Charity 
Hospital during the past seven years, together with private 
practice, I have met with a large number of examples of this 
murmur. I have notes of a considerable number of cases in 
which the connection of the sign with mitral lesions was es- 
tablished by autopsical examinations. The lesion which espe- 
cially gives rise to this murmur is the union of the mitral cur- 
tains so as to cause the button-hole contraction, the curtains 
remaining flexible. In this form of obstruction, the mitral 
curtains, on their auricular aspect, present a funnel-shaped 
space, the communication with the ventricle being through a 
slit which is more or less narrow. Under these circumstances, 
the current of blood, forced through the aperture by the con- 
traction of the auricle, throws the flexible curtains into vibra- 
tion, as the lips or the tongue may be made to vibrate by the 
current of expired air. Hence, the blubbering quality of the 
murmur. This being the mechanism, it is easy to understand 
that the murmur may be quite intense, although the force of 
the mitral direct current of blood be not great. Let any one 
throw the lips into vibration with a feeble expired breath, and 
it will be at once seen how little force is requisite to produce 
a loud blubbering sound. The intensity of the murmur, there- 
fore, is no obstacle in the way of its being attributable to con- 
traction of the auricle. 
This murmur is not so infrequently met with as I formerly 
supposed. Among from fifteen to twenty hundred patients in 
the Bellevue and the Charity Hospital, several examples may 
always be found. It is, however, quite rare in comparison 
with the mitral regurgitant murmur, and is by no means as 
frequently met with as the aortic direct and the aortic regur- 
gitant murmur. In my work on the " Diseases of the Heart," 
I have stated that this murmur is " usually accompanied by a 
systolic mitral regurgitant murmur, the same lesions giving 
rise to both." When this statement was made, my practical 
acquaintance with this sign was much less than now. The 
statement is by far too strong; the occurrence of the mitral 
direct without a mitral regurgitant murmur is the rule rather 
than the exception. This is intelligible when the lesion most 
favorable for the production of the mitral direct murmur is con- THE MITRAL DIRECT, ETC. 
139 
sidered. The button-hole obstructive lesion, in many cases, ex- 
ists without insufficiency of tlie mitral valve; and this is espe- 
cially apt to be the case when the mitral curtains are flexible, 
and thereby capable of vibrating so as to produce a loud mitral 
direct murmur. The association of a mitral direct with a mi- 
tral regurgitant murmur renders the differential characters of 
the former extremely clear and simple. The mitral direct mur- 
mur, with its peculiar vibratory quality, begins after the second 
sound, and, progressively increasing in intensity, ends abruptly 
and completely with the first sound of the heart, or with the 
carotid pulse, or with the apex-beat; then, with the first sound, 
or the carotid pulse, or the apex-beat, begins the mitral regurgi- 
tant murmur, which is oftener soft than rough, differing thus 
notably in quality from the mitral direct murmur. The first 
sound of the heart, or the carotid pulse, or the apex-beat, is 
thus between the two murmurs, forming the ending of one and 
the beginning of the other. 
The mitral direct murmur may be produced when no mi- 
tral lesion exists. So far as the mitral valve is concerned, the 
murmur may thus be purely functional or inorganic. Not 
only does the murmur occur without mitral lesion, but it may 
be intense, and have the peculiar vibratory or blubbering char- 
acter in a marked degree. I have notes of two cases in which 
this murmur was observed, its characters unmistakably present, 
its intensity considerable, and, on post-mortem examination, 
the mitral orifice was free from any lesion; but in both these 
cases there was aortic regurgitation, as shown by an aortic re- 
gurgitant murmur, and by lesions found after death. In one 
of the cases sudden death was caused by paralysis of the 
heart, resulting from accumulation of blood in the left ventri- 
cle, in consequence of the aortic regurgitation. 
An adequate explanation may be given of the occurrence, 
in some cases of aortic insufficiency, of a mitral direct murmur 
without mitral lesion. Assuming that free aortic regurgitation 
takes place, the quantity of blood returned into the left ventri- 
cle immediately after the systole may be sufficient to float and 
bring together the mitral curtains, an effect of filling this ven- 
tricle with liquid, as shown by the physiological experiment 
of injecting liquid into it from the left auricle. At the time 140 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
of the auricular contraction, then, the ventricular cavity already 
containing considerable blood, and the mitral curtains being 
in apposition, the mitral direct current throws the latter into 
vibration as the lips are made to vibrate with the expired 
breath, and the murmur is produced. Whether this be the 
correct explanation or not, it being a clinical fact that a mitral 
direct murmur may be produced without mitral lesion, if there 
be aortic insufficiency, the practical maxim is, that this mur- 
mur, when associated with an aortic regurgitant murmur, does 
not warrant a positive diagnosis of a mitral obstructive lesion. 
It is probable that the murmur, when produced without mitral 
lesion, is liable to occur intermittingly, and to fluctuate at dif- 
ferent times as regards intensity. I have observed intermit- 
tency and fluctuations in some cases in which I was thereby 
led to suspect that mitral lesion did not exist, but in which the 
opportunity was not offered of verifying the correctness of this 
suspicion by autopsical examinations. 
Is a tricuspid direct or obstructive murmur ever produced ? 
I am not aware that the affirmative answer to this question 
has been established. An obstructive lesion of the kind which 
is of frequent occurrence at the mitral orifice, and which is 
favorable to the production of a direct murmur, namely, ad- 
herence of the curtains, so as to leave a button-hole-like aper- 
ture, the curtains remaining flexible and readily vibrating, is 
exceedingly rare at the tricuspid orifice. More especially, in- 
stances in which such a lesion, existing at the tricuspid orifice, 
is unaccompanied by a mitral lesion, must be rare; I do not 
recall a single example in my own experience. An example, 
however, of the button-hole contraction existing both at the 
mitral and tricuspid orifice has come under my observation, 
and there is reason to believe that in this case there was both a 
mitral and a tricuspid direct murmur. The patient was ex- 
amined by me at a clinic in the summer of 1866. There was 
an unusually intense pre-systolic murmur, but I did not sus- 
pect any other source of the murmur than the mitral orifice. 
The murmur was so loud that the case served to illustrate it 
to numerous students. Subsequently the patient was under 
the care of Dr. George K. Smith, demonstrator of anatomy in THE MITRAL DIRECT, ETC. 
141 
the Long Island College Hospital. Dr. Smith observed, not 
only that the murmur was notably intense, but that it was 
heard at the apex of the heart, at the ensiform cartilage, and 
that it extended to the right of the latter. The patient died 
in May, 1867, and, on examination after death, the following 
lesions were found: The mitral curtains adhered too-ether at 
their sides, leaving an opening which admitted only the end 
of the little finger, the curtains being flexible; the tricuspid 
curtains were in like manner adherent, leaving an opening 
which admitted only one finger, these curtains also being flex- 
ible ; the aortic valves were thickened, and their edges studded 
with small vegetations; both auricles were much dilated, the 
right auricle more than the left; the ventricles were moder- 
ately dilated and hypertrophied, the dilatation predominating. 
The probable existence of a tricuspid, as well as a mitral 
direct, murmur in this case, is predicated on the unusual in- 
tensity of the pre-systolic murmur, and on the fact of its being 
heard considerably to the right of the area within which it is 
usually confined.1 
1 The short duration of the auricular systole has been considered as 
rendering impossible either a tricuspid oi- a mitral direct murmur. It is 
claimed that the murmur, so-called, is sometimes longer than the period 
occupied by the active contraction of the auricles. Admitting this to be 
true, the current of blood from the auricle to the ventricle requires so little 
force for the production of the murmur in the manner described in this 
article, that the current, taking place before the auricle contracts, may be 
supposed to throw the curtains into vibration sufficiently for a murmur to 
be produced. It is consistent with this supposition that the mitral direct 
murmur is apt to be feeble at its beginning, its loudness increasing pro- 
gressively up to its sudden ending. The elasticity of the walls of the 
auricles, and their situation above the ventricles occasion a current with a 
certain amount of force directly after the ventricular systole, and before 
the auricular systole. VII.-ON THE VENOUS HUM. 
On the Mode of obtaining the Venous Hum, and the Value 
of this Physical Sign. By Austin Flint, M. D., one of 
the Attending Physicians to Bellevue Hospital, etc., etc. 
The continuous murmur, frequently musical, obtained by 
placing tbe stethoscope over the veins of the neck, is now 
commonly known by the name venous hum. The French 
term bruit de diable, introduced by Bouillaud, expresses very 
well the character of the sound, with the understanding that 
the portentous word diable means here a very innocent toy, 
namely, the humming or spinning-top. Practical ausculta- 
tors have for several years past recognized the significance of 
this sign as denoting impoverishment of the blood, and, when 
found in connection with an aortic direct murmur, as favor- 
ins; the conclusion that the latter is inorganic or anaemic. 
Heretofore, in my experience, the value of this sign has been 
much restricted by its frequent absence in cases of anaemia, 
and by the irregularity of its presence in the same case, that 
is, it being now present and now absent even when successive 
examinations were made after short intervals. In seeking for 
examples among hospital patients, in order to illustrate the 
sign to private classes, I have often found it necessary to ex- 
amine a large number, some of whom presented the unmis- 
takable facies of anaemia; and, wdien I had found the sign 
well marked, not infrequently it had apparently disappeared 
when the cases were brought before the class, or sometimes 
it was readily discovered by a portion of the class and not by 
the remainder. In short, its unreliability was such that I 
was not accustomed to attach any value to its absence, as ex- 
cluding anaemia. But for the past three years my experience 
has been quite different. I now find the sign almost invari- 
ably in cases of well-marked anaemia; it is often present 144 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
when the face does not show impoverishment of the blood, 
and I do not fail in finding it on each successive examination. 
Hence, I have come to depend upon the sign as a constant 
and reliable criterion of the existence of anaemia. 
This difference, as regards my experience, between the 
past and the present time, has arisen from a simple change in 
the position of the head of the patient while the stethoscope 
is applied to the neck. The patient being either sitting or 
standing, the head is turned as far as possible to the left, and 
the stethoscope is then placed within the triangular space 
posterior to the sterno-cleido-mastoid muscle, on the right 
side. The stethoscope is shifted from point to point within 
this triangular space, and with varying degrees of pressure, until 
either the murmur is heard, or its absence is ascertained. I 
should add that Cammann's binaural stethoscope is the only 
one which I employ in auscultation, and that I have had no 
experience for the past ten years with any other; I am not 
able, therefore, to say whether the same success is to be ob- 
tained with the wooden cylinder. 
I was led accidentally to discover the effect of the position 
of the head just stated; and for a time, finding the murmur 
so frequently, I suspected that its presence might be due ex- 
clusively to this position, the sign, therefore, under these cir- 
cumstances, not representing faithfully impoverishment of the 
blood. But having now for about three years been in the 
habit of examining daily patients in hospital and private 
practice with a view to determine the value of the sign, I am 
satisfied that the frequency of the sign is owing to the large 
number of the cases into which the anaemic condition enters 
as a more or less important element. This conclusion is based 
on, first, the constancy of the sign in cases of well-marked 
anaemia produced by haemorrhages, lactation, etc., the anaemic 
condition being shown by pallor of the prolabia and face; 
second, the association of the sign with ailments pathologi- 
cally consistent with anaemia, in cases in which the anaemic 
complexion is not marked nor even apparent; third, the dis- 
appearance of the sign, conjoined with improvement or re- 
covery, as otherwise manifested, under measures of treatment 
addressed to anaemia; and, lastly, on the absence of the sign ON THE VENOUS HUM. 
145 
when the symptoms are not consistent with the supposition 
that the patient is anaemic. 
Before I had learned the value of the venous hum, I had 
been led not to rely upon the absence of pallor of the prolabia 
and face as conclusive evidence against the existence of anae- 
mia. This is a point which I have for many years endeav- 
ored to impress in clinical teaching. Anaemic patients some- 
times have even a rosy complexion. I was accustomed to say 
that the physician must trust much to the history and symp- 
toms, without regard to the facies, in determining that anae- 
mia exists; but, with my present knowledge of the manner in 
which the venous hum is to be obtained, I am satisfied to 
depend on its presence as proof of the existence of anaemia, 
not only when the countenance fails to show this condition, 
but when the history and symptoms would not warrant a 
positive opinion. 
It is well known that anaemia, when incident to certain 
chronic diseases, namely, tuberculous and carcinomatous 
affections, degenerative diseases of the kidneys, chronic 
dysentery, etc., does not, as a rule, involve the physical con- 
ditions requisite for the venous hum. So far as my present 
experience goes, I have found this rule to hold true when aus- 
cultation is practised in the manner above described. It is in 
cases in which the anaemia may be distinguished as func- 
tional, that is, anaemia not dependent on some serious chronic 
disease, that this sign, when sought for in the manner de- 
scribed, is to be depended upon; and obviously the practical 
w value of the sign is limited to these cases. In the treatment 
of cases of functional anaemia the practitioner will find aus- 
cidtation of the neck extremely useful by enabling him to de- 
termine, by the persistence of the sign, that the anaemic con- 
dition continues, and, by the disappearance of the sign, that 
the blood is no longer impoverished. I would add, in con- 
clusion, that the intensity of the murmur is not proportionate 
to the degree of the anaemia as evidenced by its patho- 
logical effects; a loud hum is frequently found in cases in 
which the appearance and the ailments do not denote a high- 
ly anaemic condition, and, on the other hand, the hum is often 
feeble when it is evident that the blood is much impoverished. VIII.-ABDOMINAL HERNIA. 
Cases illustrating Strangulated Abdominal Hernia, with 
other Abdominal Hernia, not Strangulated, of Unusual 
Character, etc., etc., in all, seventy-three Examples; ac- 
companied with Practical Remarks. By Frank Hastings 
Hamilton, M. D., one of the Visiting Surgeons to Bellevue 
and to Charity Hospital, Professor of the Practice of Sur- 
gery, with Operations and Clinical Surgery, in the Belle- 
vue Hospital Medical College. 
CHAPTER I.-INDIRECT INGUINAL HERNIA. 
Sec. I.-Congenital (into the vaginal process of the peri- 
tonceum). 
A.-Strangulated ; reduced by Surgical Operation. 
Case I.-Indirect inguinal hernia; congenital; funicular ; 
concealed ; testicle not descended ; abnormal formation of 
inguinal canal and rings; strangulated four days; re- 
peated attempts to reduce by taxis ; operation under ether ; 
stricture at internal ring ; recovery. 
A German lad, aged eighteen, was admitted to ward 13, 
December 16,1867. The history of his case up to this time was 
as follows : Neither of his testes has ever descended. Has al- 
ways, since he was three years old, had an oblong swelling 
over the course of the right inguinal canal. Never diminished 
or increased in size. (This circumstance seems to have been 
explained, in part at least, during the operation, by the pres- 
ence of the right testis in the inguinal canal.) 
December 13.-Without any apparent cause the swelling 
became a little larger. He felt pain and began to vomit. 
December 16.-Dr. H. G. Piffard was called. Patient had 
already taken three drops of croton-oil and other physic. No 148 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
movement of bowels for three days; vomiting. Dr. Piffard 
discovered the oblong swelling, but could not lessen it by taxis. 
Sent him to Bellevue. 
Dr. Sayre saw him in the evening of the same day. He 
also applied taxis until the swelling seemed to be lessened. 
On the following day, December 17, the patient being in 
my service, he was examined by Dr. Wood and by myself. No 
hernia could be detected ; but the symptoms of strangulation 
still continued. He was vomiting bile. His bowTels had not 
moved, except as they had been moved by an enema. He was 
exceedingly prostrated, and the chance of his recovery, even 
with an operation, seemed small. 
Examining the seat of the oblong swelling more particu- 
larly, it was found to correspond to what is the usual course 
and length of the inguinal canal. It was soft, and apparently 
contained neither intestine nor omentum. It was further ascer- 
tained that the external abdominal ring was two and a half 
inches in its longest diameter, and that the oblong swelling 
corresponded in fact only to the diameter of the ring. 
There was no pain in the region of the supposed hernia, 
nor tenderness. Both of these symptoms were referred only 
to the upper half of the belly. 
On the same day ether was administered, and I operated 
in the presence of the class. 
An incision was made over the oblong swelling in a direc- 
tion corresponding to the usual position of the inguinal canal, 
and of about the same length. The arteria ad cutem abdomi- 
nis was divided and tied, and a peritoneal sac or pouch was 
opened. This was found to extend down into the scrotum ; it 
was very thin, and contained about one ounce of nearly trans- 
parent fluid, without odor. The testis w'as found lying behind 
this pouch, in about the middle of the track of the wound. 
Carrying the Anger up, I found the pouch expanding in 
that direction, on all sides. At first no stricture could be de- 
tected ; and, as the upper end of the incision appeared to cor- 
respond to the usual point of the internal ring, it seemed as if 
the finger must have passed through the internal ring into the 
cavity of the belly. 
Pushing the finger up still farther, however, it was finally ABDOMINAL HERNIA. 
149 
arrested by a septum, through which the point of the finger 
entered a small circular opening, having sharp and firm edges. 
This opening seemed to be of the size of a five-cent piece, and 
in it lay what felt like a knuckle of intestine. 
In order to determine the exact position of this opening, I 
passed the end of my finger outward toward the wall of the 
belly, and found that it was nearly in the middle of a line 
drawn from the antero-superior spinous process of the ilium 
to the umbilicus ; or, to be more accurate, about one inch 
nearer the umbilicus than the middle, and three-quarters of an 
inch below this line. 
The finger remaining in this ring, I carried up a long, nar- 
row, blunt-pointed bistoury, and with much difficulty entered 
it sufficiently to cut it upward and outward. Now passing 
the last joint of the finger entirely through, the margins of the 
ring were still felt to be very sharp and firm, and having 
hooked my finger over the margin I drew it down with con- 
siderable effort, to the upper angle of the external wound, 
where it was seen and cut more freely. The intestine was 
never seen. / 
It is probable that the intestine was adherent to the inner 
wall of the ring and sac, from which it was impossible to dis- 
place or to return it within the cavity of the belly. 
After a digital examination had been made by Drs. Sands 
and Piffard, the wound was closed and the patient returned to 
the ward. 
About four hours after the operation, the patient, unob- 
served by the orderly, arose from his bed and had a copious 
evacuation of his bowels. The following day all symptoms of 
strangulation were found to have disappeared. Indeed, they 
never returned after the operation. On the third day the 
orderly gave him, by mistake, the dose being intended for the 
patient in the next bed, a large portion of sulphate of mag- 
nesia, which operated several times, and, fortunately, did him 
no harm. 
He was discharged, cured, January 10, 1868; since which 
time he has, at my request, called upon me repeatedly at my 
office. The hernia still passes down at the seat of the opera- 150 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
tion, and he is obliged to wear a truss; but the strangulation 
has not recurred. 
Remarks.-The non-descent of the testicle is a common 
event; and it is known to predispose to the occurrence of her- 
nia ; but the peculiar abnormal condition of the inguinal canal 
or of the tunica vaginalis propria funiculi, which existed in 
this case, has never before been noticed by me. The external 
ring covered the entire length of the space usually occupied 
by the inguinal canal; while the internal ring occupied a 
position two or three inches farther outward and upward than 
usual, and the space between the outer margin of the external 
ring and the internal ring was remarkably broad, forming a 
capacious pouch, in which the hernia had probably been lodged 
for a long time before the strangulation occurred. 
The term " congenital " is applied to this case because, the 
testicle remaining in the canal, and lying close behind the 
hernial sac, furnishes all the evidence that is required to estab- 
lish this fact. It belonged to that variety of congenital hernia 
called by Mr. Birkett " funicular," in which the lower portion 
of the peritoneal process has closed, but not the upper. It is 
probable also that an abortive attempt on the part of Nature 
to close the peritoneal process at the seat of the internal ring 
gave rise to the stricture and strangulation. It will be ob- 
served, moreover, that the protrusion occurred suddenly, as is 
generally the case in congenital hernia-not slowly and grad- 
ually, as happens most often in other forms of hernia. 
Case II.-Indirect inguinal hernia ; congenital; scrotal; en- 
ter ocelestrangulated seven hours ; repeated attempts to 
reduce by taxis • operation under chloroform ; stricture at 
external ring ; division of stricture outside of the sac af- 
ter opening the sac. Intestine thrust out, a few hours after 
the operation, by vomiting ; sloughing of scrotum; com- 
plete recovery. 
Patrick Johnson, aged thirty-four, admitted to Bellevue 
Hospital March 15, 1865. He stated that when fifteen years 
old he began to experience some pain in the right inguinal 
region. At twenty the hernia descended suddenly, since 
which time it has often been down, but was easily reduced. ABDOMINAL HERNIA. 
151 
When admitted the hernia had been down five hours, and 
violent efforts had been made to reduce it. It was enormously 
large, very tense and tender. After several attempts to re- 
place the intestine by taxis, I placed him under the influence 
of chloroform and operated-two hours after admission and 
seven hours after the strangulation occurred. I found only 
intestine with a large amount of serum ; and both were con- 
tained in the cavity of the tunica vaginalis testis. There were 
no adhesions. Intestine congested, but its color was not very 
dark. The stricture was at the external ring ; which I relieved 
by cutting the fibrous bands outside of the sac; after which 
the intestine was easily reduced. I closed the lower three- 
fourths of the wound with five or six small silk sutures, and 
laid him on his back in bed, with instructions to remain in 
this position. A few hours after, he was seized with a par- 
oxysm of vomiting, occasioned by the chloroform, and the in- 
testine was protruded violently through that portion of the 
wound which had not been closed by sutures; and the House 
Surgeon, not finding it possible to return it, was compelled to 
cut away the remaining sutures; after which it was easily 
returned, and was then maintained in place by a compress and 
bandage. 
On the second day slight peritonitis appeared, but this was 
easily controlled by the moderate use of opium. About this 
time the scrotum began to slough, destroying ultimately quite 
three-fourths of the whole. While, however, the sloughing 
was going on, the pulse remained almost undisturbed, and the 
general condition of the system was good. 
April 19, 1865, a little more than one month after the 
operation, the wound was nearly closed, and not long after he 
was discharged cured. 
Remarks.-In this example the peritoneal process had re- 
mained open through its entire length, so that the hernia, in- 
stead of being arrested at the external ring, by a normal con- 
traction and obliteration of the process from this point down- 
ward, had been permitted to descend to the bottom of the pro- 
cess, i. e., fairly into the tunica vaginalis propria testis. From 
which circumstance it derives its name as the " vaginal " or 
" scrotal " form of the congenital oblique hernia. There had 152 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
existed for many years, however, a narrowing of the perito- 
neal process opposite the external ring, sufficient to prevent 
the descent of the hernia; at the same point at which in Case 
I. there was a complete occlusion. This obstruction was sud- 
denly overcome when twenty years old. 
When admitted to the hospital the strangulation had ex- 
isted only five hours, but the surgeons had employed great 
force in their attempts to reduce it; the consequence of which 
was that the coverings of the sac were greatly inflamed and 
swollen, and to this circumstance no doubt must be attributed 
the sloughing of the integuments which took place subsequent 
to the operation. The sac itself was, in consequence of this 
violence, inflamed also, and filled with serum, and the intes- 
tine w'as more congested than it is usually found to be after a 
strangulation of seven hours. 
The subsequent protrusion of the hernia, from vomiting, 
suggests the propriety of closing the entire length of the wound, 
but especially the upper portion, with sutures, adhesive straps, 
a compress and bandage. Why these precautions were omit- 
ted in this case, I do not remember. It is my general practice 
to close these wounds in this manner, leaving only a small 
opening for the escape of blood at the lower angle. As addi- 
tional precautions I frequently elevate the hips a little with a 
folded blanket, and forbid the patient to rise or even turn over 
in bed. When anaesthetics have been used, the danger of vom- 
iting is so much greater, that these precautions cannot safely 
be omitted. 
Strangulated congenital hernia, especially when it occurs 
late in life, is in general more difficult to reduce by taxis than 
other hernia, because of the more unyielding nature of the 
stricture; and, when its character is clearly made out by the 
surgeon, he will do well not to prolong his attempts at reduc- 
tion by taxis very much. 
The stricture was relieved, after opening the sac, by cut- 
ting on the outer side. It may be, therefore, that this was 
one of those more rare examples of old hernia, in which the 
stricture was due, not to the contraction of the peritoneal 
process or canal at this point, but to the formation of fibrous ABDOMINAL HERNIA. 
153 
bands outside which encroached upon and thus strictured the 
peritoneal canal. 
Case III.-Indirect inguinal hernia ; congenital • enterocele ; 
strangulated thirty-one hours ; taxis prolonged ; operation 
under chloroform and ether; principal stricture at inter- 
nal ring, divided ly tearing ; smaller stricture at external 
ring, divided with the knife ; recovery. 
October 31,1865.-I was called in consultation by Dr. S. D. 
Wadsworth, to see George Post, aged twenty-eight, at 388 
Fourth Avenue, N. Y. Fie had a congenital, strangulated, indi- 
rect inguinal hernia of the right side. The hernia had existed 
since birth. Had been strangulated several times beforQ. 
Patient had never worn a truss. The strangulation had now 
existed about twenty-eight hours. Taxis had been employed 
faithfully, but gently, under the influence of full doses of mor- 
phine and of chloroform. He had nausea and vomiting, and 
the bowels were very tender. 
An attempt was made to reduce the hernia by taxis con- 
joined with posture-placing the feet of the bedstead upon a 
table. This was continued three hours, but with no effect. 
I operated, the patient being under the influence of chlo- 
roform and ether. The sac was now ascertained to be the 
tunica vaginalis. Nothing but intestine in the sac ; no adhe- 
sions. Sac filled with straw-colored, inodorous serum. Intes- 
tine of a dark-brown color. Stricture at internal ring; and 
the sac had a second narrowing or slight stricture at a point 
near the external ring. I tore the stricture at the internal 
ring with my finger, after cutting the lower stricture. The 
hernia was easily reduced. The wound was closed with 
sutures and a compress, and the hips were then elevated by 
pillows to diminish the chance of descent of the intestine. 
No vomiting followed the operation. No physic was admin- 
istered. He took opium moderately, and in three weeks the 
wound was healed. 
Remarks.-Dr. Wadsworth, under whose excellent man- 
agement he remained after the operation, and to whom the 
patient is especially indebted for his complete recovery, 
informs me that the hernia is permanently cured. He does 154 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
not wear a truss, but labors daily in a store where he is 
required to do much heavy lifting, without inconvenience. 
The occurrence of the stricture in the peritoneal process, 
at or near the external ring, the same as in Case II., and at the 
same point at which the hernia was arrested in Case I., is wor- 
thy of notice; since it illustrates what has been often observed 
in the autopsy of persons whose peritoneal process has never 
closed-namely, a narrowing of this canal not only just above 
the testicle, and at the fascia transversalis, or internal ring, 
but also at some point near its middle. The stricture might 
therefore occur at either of these three points, and in either 
case it would probably be due to a contraction of the perito- 
jieal canal alone. In two of the three cases now recorded, 
the stricture was at or near the external abdominal ring. 
Case IV.-Indirect inguinal hernia ; congenital; temporary 
strangulation ' inflammation and suppuration of the her- 
nial sac ; operation under chloroform ; recovery from the 
operation, and death after six months. 
January 13, 1852.-I was consulted by G. P., of Attica, N. 
Y., aged eighteen, in reference to a swelling in his left inguinal 
reg-ion and scrotum, lie stated that his left testis did not 
descend until he was nine years old, since which time he had 
noticed something, which he knew now to have been the 
testis, occasionally descending into the scrotum, and again 
disappearing. Eight days before consulting me he was seized 
with a severe pain in this part, accompanied with much 
swelling and tenderness, and this was soon followed by nausea 
and vomiting. Four days later his surgeon, Dr. Royce, dis- 
covered what he supposed to be a hernia, which he reduced 
by taxis, as he believed; but the hernia was said to have 
immediately returned into the scrotum. 
When seen by myself, it was impossible to recognize the 
existence of a hernia. His bowels had moved several times 
freely during the last few days; the vomiting had ceased ; the 
cavity of the tunica vaginalis seemed filled with fluid, and it 
was tender on pressure. 
January 15th, ten days after the accession of the acute 
symptoms, the swelling and tenderness had increased, but ABDOMINAL HERNIA. 
155 
there were yet no symptoms of strangulation. Believing that 
it was inflammation, with suppuration of the tunica vaginalis 
testis, it was decided to operate. Having placed him under 
the influence of chloroform, assisted by Drs. Royce and Cotes, 
I laid open the sac freely, and gave exit to a large amount of 
fetid pus. The sac contained no hernia ; but its internal sur- 
face was roughened and covered with granulations. A probe 
could be made to pass upward as far as the internal ring, but 
it did not seem to enter the cavity of the abdomen. 
The wound was dressed with a poultice, and the patient 
was left in charge of Dr. Royce. 
I have since learned that this patient survived the operation 
about six months, but that the wound never entirely closed. 
Whether he died directly and solely from this cause, or from 
some other malady, I have never been able to learn. 
Remarks.-I can have no doubt that a hernia existed- 
that some days prior to my visit it became strangulated, and 
was reduced. The subsidence of the vomiting at this period 
confirms this view; but the sac of the tunica vaginalis testis 
was already filled with serum and perhaps pus, and led the 
surgeon to suppose that the hernia was not retained in the 
belly. The subsequent symptoms were only those of an in- 
flamed hydrocele, or inflamed hernial sac. The offensive odor 
connected with the pus did not indicate any lesion of an 
intestine. It is present in many cases of strangulated intes- 
tinal hernia where there is no lesion, and is not at all uncom- 
mon in abscesses which have no connection with intestine or 
the external air. 
The closure of the canal communicating with the cavity 
of the belly was not rendered absolutely certain; but, if it was 
actually closed, no doubt this was a result of the inflammatory 
process continuing after the reduction of the hernia. 
B.-Strangulated; reduced without an Operation. 
Case V.-Indirect inguvnal hernia; congenital; infa/nt; 
strangulated several hours ; ineffectual taxis ; reduced by 
the application of ice. 
Infant son of Jonathan Fuller, Auburn, N.Y., August, 1835, 
had a congenital hernia, which had become strangulated the 156 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
day before. Patient much prostrated and vomiting. After a 
prolonged and unsuccessful taxis, I applied a beef's bladder 
containing pounded ice with water, interposing a folded nap- 
kin between the skin and the bladder. During the applica- 
tion of the ice, the hips of the child were kept constantly 
elevated, but no taxis was employed. After about four hours 
the hernia suddenly retired, and the recovery was complete. 
Remarks.-In this case the seat of stricture seemed to be 
at or near the external abdominal ring. It certainly was not 
in the lower part of the funicular canal, since the hernia 
expanded freely from this point downward to near the bottom 
of the scrotum. Taxis failed, as it does more often in con- 
genital than in other hernia; and the hernia was finally 
reduced by rest, cold, and position. 
Precisely how these causes operated in the reduction, it 
might be difficult to say. It is probable, however, that rest, 
with the cessation of crying and straining, favored the reduc- 
tion simply by removing the most active causes of the extru- 
sion, and not at all by removing the sources of strangulation. 
Anaesthetics operate in the same manner, but more efficiently, 
since they put at rest completely the action of the abdominal 
muscles. They are, however, of less value in congenital and 
in all cases of old hernia, for the reason that the stricture in 
these examples depends more upon a narrowing of the perito- 
neal canal than upon the condition of the muscular and fibrous 
tissues outside of the peritonaeum. The cold applications prob- 
ably diminished the congestion of the vessels in the narrow or 
constricting portion of the funicular canal. It is probable, 
also, that the cold diminished the congestion and swelling of 
the hernial protrusion itself; that is to say, of the coats of the 
intestine, and thus facilitated its return. Finally, the air, with 
the other contents of the hernia, was probably in some degree 
condensed by the cold. In one or all of these conditions we 
must seek for an explanation of the influence of cold in facili- 
tating the reduction of this and of other herniae. ABDOMINAL HERNIA. 
157 
Case VI.-Indirect inguinal hernia; congenital; strangu- 
lated; spontaneous reduction after failure of taxis; re- 
covery. 
Charles Cobb, aged three years. The mother discovered the 
hernia about six months before consulting a surgeon. The 
surgeon who examined it pronounced it a hydrocele. Sep- 
tember 10,1857, she consulted me on account of the occurrence 
of pain and other unusual symptoms. I found a strangulated, 
indirect inguinal hernia on the right side, which occupied the 
peritoneal process and the tunica vaginalis testis. The mother 
said it had never been so large as it was at this time, and that 
frequently it disappeared entirely. She was now unable to 
reduce it. I made taxis for some time ineffectually, and, as 
the symptoms of strangulation were not urgent, I left the 
child for the night, with the intention of employing anaes- 
thetics in the morning ; but, when I returned on the following 
day, I learned that the hernia had disappeared spontaneously 
during the night. 
Rema/rks.-With infants, the difficulty of reducing a her- 
nia is always greatly increased by the crying and straining of 
the child. Rest during sleep, in the recumbent posture, which 
posture encourages the return, by emptying the intestine of its 
contents, and by dragging the viscera upward, may alone 
accomplish more than taxis applied while the little patient is 
awake. We shall refer to the subject of posture again. 
Case VIL-Indirect inguinal hernia; congenital; stran- 
gulated twelve hours; reduction easily accomplished by 
taxis, aided by posture. 
March 10, 1854.-Samuel Tolhurst, aged two years. Her- 
nia strangulated twelve hours; nausea and vomiting. I re- 
duced this hernia in a few seconds, by simple taxis, while the 
mother held the legs and body on a pillow, considerably 
higher than the head. No surgeon had been called previously, 
but the mother had tried for some time to reduce it by press- 
ure alone. 
Remarks.-This case is introduced only as another illus- 
tration of the value of posture in conjunction with taxis ; and 
in this connection I shall take the liberty of reporting another 158 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
case, not my own, in which, a congenital hernia was reduced 
by the same method. The facts have been given to me in a 
brief note from my colleague, Dr. George T. Elliot, Jr. 
Case VIII.-Indirect inguinal hernia ; congenital; stran- 
gulated when thirteen days old ; reduction under chloro- 
form, hy posture, after taxis had failed, l)y Dr. George 
T. Elliot, Jr. 
" In 1852 or 1853, when I was resident physician of the 
Lying-in-Asylum of this city, there was in the house a male 
infant with oblique inguinal hernia. When the child was 
thirteen days old, I could not reduce this hernia as I had done 
on previous occasions. The late Dr. John C. Cheesman then 
saw the case in consultation, and failed with the taxis. With 
the doctor's consent I administered chloroform, and as soon as 
anaesthesia was produced, and the child held up by its legs, 
the hernia was reduced with the greatest facility. I subse- 
quently cured the hernia with a truss." 
Case IX.-Congenital hernia mistaken for a hydrocele • oint- 
ments applied for the purpose of dispersing it. 
C. Y., of Rose, Wayne County, consulted me in 1847, in 
relation to a congenital hernia in the case of his infant son, 
fourteen months old. It was discovered the next day after his 
birth. It presented the usual appearance of a congenital 
hernia, which had descended into the scrotum, and was with- 
out difficulty reduced; yet his physician had called it a 
hydrocele, and had been attempting to disperse it with oint- 
ments, which had at times occasioned considerable excoriation. 
Remarks.-Several cases, in which the same errors have 
been committed by physicians and surgeons, have come under 
my notice. On the other hand, it has happened to me still 
more frequently to meet with examples of congenital hydro- 
cele mistaken for hernia, and in some of 'which prolonged 
efforts at taxis have been made. The diagnosis is, in general, 
so easily made, that I do not think it necessary to detail these 
cases, or to enumerate the differential signs. A mistake of 
this kind implies great carelessness, or very little knowledge 
and experience in this department of surgery. ABDOMINAL HERNIA. 
159 
C.-Congenital, Indirect Inguinal Hernia in a Female. 
Case X.-Congenital, indirect inguinal hernia in a female ; 
descending through the canal of Nuck and into the upper 
portion of the pouch of Broca ; probably intestinal ; re- 
ducible. 
April 25, 1855.-Dr. Boardman, of Buffalo, desired me to 
see, in consultation with himself, the infant daughter of Jacob 
Anderson, then four months old. Six weeks after birth, the 
parents first noticed a small swelling, situated over the external 
abdominal ring, and which had presented itself at intervals 
ever since. Crying occasionally forced it down, but it was 
more apt to descend when she wras constipated, and strained to 
have a stool. 
I found the tumor situated about one inch below the riner, 
in the labia; oval in form, and elastic; it seemed to contain 
intestine. Pressing upon it a few moments, while she was in 
the recumbent posture, it was made to retire through the ring 
into the cavity of the abdomen. 
A truss was applied by Dr. Boardman, and its reduction 
was maintained. 
D.-Congenital and Non-congenital Inguinal and Femoral 
Hernia, containing the Ovary, Fallopian Tube, etc. 
Case XI.-Congenital, inguinal hernia; ovarian; suppura- 
tion of the ovary. 
Minerva Ellis, living near Geneva, X. Y. When two weeks 
old, her sister, aged ten years, jumped upon her belly, ac- 
cidentally, bruising her severely, and bending the ribs in upon 
one side and forcing the sternum forward, the injury being 
such that for several days she could not be moved without 
causing severe pain. Soon after, a small tumor was discovered 
over the right external abdominal ring, of the size and form 
of a large bean, which was movable. This tumor never dis- 
appeared, nor could it even be pushed into the belly. Some- 
times, while playing violently, another and wholly distinct 
swelling, or tumor, would present itself on one side of the 
original and permanent tumor, and which often became as 
large as a hen's egg, was sometimes a little discolored-pur- 160 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
plish-but was never red. It was always tender, and very 
painful until it was returned. Its return -was easily accom- 
plished, however, either spontaneously, while lying on her 
back, or by moderate pressure, or by the addition of warm 
fomentations. Sometimes it would not disappear until she 
had lain one, two, or three hours. In a few instances it re- 
turned spontaneously while she was standing erect. Until 
menstruation commenced, this second tumor had presented it- 
self as often as two or three times a week, except that during 
the third and fourth year of her life it did not appear at all. 
She began to menstruate when thirteen years old; and 
from that time until I last saw her, in October, 1847, a period 
of eight years, her troubles and suffering had been increased. 
Her menstruation was always painful, scanty, and irregular, 
she having once passed five moiiths without menstruation. 
But, whether the menstrual discharge occurred or not, the 
" period " was generally announced by some pain and tume- 
faction in the permanent or original small tumor. Often the 
pain was severe, and occasionally it was suddenly transferred 
to the loins, the hips, or even to the head. The pain and tu- 
mefaction would then regularly decline, and disappear in two 
or three days, even though menstruation had not occurred. 
When fifteen years old she was suddenly seized with un- 
usually severe pain in the tumor, which continued two or 
three days, and was relieved, after an abrupt and copious dis- 
charge of offensive matter through the vagina. I saw her not 
long after this last event, in consultation with Dr. Sumner 
Rhoades, a distinguished physician and surgeon, now residing 
at Ithaca, N. Y. She was exceedingly feeble, and was con- 
fined to her bed. She had a constant vaginal, leucorrhoeal 
discharge, and had occasional chills. The deformity of her 
ribs and sternum, caused by the original injury, was still man- 
ifest. The permanent tumor, which had for so many years 
varied but little in size, as I have already described, now, for 
the first time, became as large as a goose-egg, and was tender, 
red, and painful. The diagnosis was still doubtful; but, as it 
seemed to have suppurated, Dr. Rhoades opened it freely, and 
gave exit to a moderate quantity of pale-yellow serum, with 
perhaps a little pus. Introducing the probe, we now ascer- ABDOMINAL HERNIA. 
161 
tained that the tumor was composed of a cyst, the walls of 
which were thick and firm, and the interior of which was 
divided into large compartments or cells, constituting thus a 
multilocular cyst; we could find no point at which the cyst 
communicated with the cavity of the abdomen. This wound 
soon closed. Subsequently she was seen by Dr. Sprague, of 
Buffalo, and still later by Dr. Briggs, of Auburn. Dr. Briggs 
found a swelling, much like that which I had seen. He opened 
it freely, and discharged the same character of fluid matter 
as before, resembling serum. 
October 9,1847.-Five years after my first observation, the 
family having removed to Buffalo, I was consulted again. The 
tumor had now become much swollen for the third time. It 
was very tender and painful, and she was confined to her bed. 
In the main, however, her health had much improved since 
I first saw her. I opened the tumor, and gave exit to about 
two ounces of pale-yellow serum, but no pus. A tent was 
laid in the wound and a warm poultice applied. 
From this period my knowledge of this interesting case 
ceases. I have omitted to mention, however, that I never saw 
the second or occasional tumor, it having ceased t$ protrude 
soon after menstruation began, at the time that the original 
tumor had increased a little in size, and had probably thus 
prevented its descent. 
Remarks.-No doubt can exist, I apprehend, that this was 
an ovarian hernia, to which was added, during a period of her 
life, an intestinal hernia. 
Examples of hernia of one or both of the ovaries through 
the inguinal canal of the female have occasionally been re- 
ported. 
Case XII.-In the first volume of Mr. Pott's surgical 
work, at p. 436, a case is related of a woman, twenty-three 
years of age, in whom both ovaries had thus escaped; and, as 
they could not be returned, and as they occasioned much in- 
convenience, they were both exposed by incision, ligatures 
were applied " close to the tendons, and they wTere cut off." 
The result was, that she became more muscular, she ceased to 
menstruate, and her breasts disappeared. 162 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Case XIII.-M. Guersant found a small tumor in the left 
labium of a girl, eleven years old, and which had existed since 
she was one year old. It was extremely movable, and could 
be pushed up as high as the external ring, and as far down as 
the fourchette. lie thought it was a cyst, and cut it out, tying 
its pedicle in the same manner that Pott had done. Peritoni- 
tis ensued, and she died on the third day.1 
M. Lenoir, in listening to M. Guersant's report of this 
case, stated that Pott made the same mistake. Pott does not 
intimate that he removed the ovaries under a misapprehension 
of their nature, but one finds it difficult, upon any other sup- 
position, to excuse his operation. 
The following eight cases have been collected from the 
German literature by my friend Dr. C. C. Terry, and are pub- 
lished with the five cases reported or collated by myself, in 
order that the reference to these very rare accidents may be 
complete: 
Case XIV.-M. Deneux reports the case of a woman who 
had a swelling in the left groin, which was the seat of severe 
pain during the period of pregnancy. Three days after con- 
finement, the swelling was of the size of a " large nut," rounded 
in the centre, uneven at the edges, irreducible and excessively 
painful. There was neither constipation nor vomiting. M. 
Deneux operated, supposing it was an ordinary hernia, but he 
found a portion of the ovary constricted in the ring, to which 
it had become adherent. On the ovary was a cyst as large as 
a hazel-nut, which, with the attached and constricted portion 
of the ovary, was contained in a hernial sac. Three-fourths 
of the cyst and nearly all of the ovary were cut away, and the 
remaining portion retracted within the abdomen in a few days. 
Iler recovery w'as complete in twenty-nine days? 
Case XV.-Neboux operated, on the third day after 
strangulation, upon an inguinal hernia in a female, and found 
it to contain an ovary of tlie size of a pigeon's egg. He cut 
1 Guersant. Provincial Aled, and Surg. Journ., 1851, p. 440; also 
New York Med. Gaz. (Reese), vol. ii., p. 252. 
8 Deneux. Giintber Blutige Operationen, 4th Abth., Seitc 133-'4. ABDOMINAL HERNIA. 
163 
the stricture and broke up the adhesions of the ovary to the 
sac, returning the ovary into the cavity of the pelvis. She 
was well in forty days? 
Case XVI.-Muler treports that a woman, forty-six years 
old, had noticed, four times during the previous year, a swell- 
ing in her left groin, which was very painful, compelling her 
to lie down on her back, with her thighs drawn up. The 
swelling and pain had each time gradually subsided. On the 
last occasion, however, it became more severe and caused 
vomiting. Mulert found an egg-shaped swelling over the ex- 
ternal ring, which was hard, movable, and slightly sensitive. 
The pain extended from the ring to the umbilicus and stomach. 
Taxis proved ineffectual, and he proceeded to operate. There 
was no distinct hernial sac, but an ovary presented itself, at- 
tached to the adjacent tissues. It was of the size of a pigeon's 
egg, tense, and livid. Having separated the adhesions by his 
finger and a sound, he released the stricture by cutting Gim- 
bemat's ligament in two places, and replaced the ovary deep 
in the pelvic cavity. The wound was healed in forty-eight 
days. 
Case XVII.-Mulert also states that he reduced by 
taxis another inguinal ovarian hernia, which was strangu- 
lated. (The diagnosis in each of the last two cases has been 
regarded as doubtful?) 
Case XVIII.-A servant-girl was found by Krieger, having 
an elliptical, elastic, fluctuating, translucent swelling, resem- 
bling a hydrocele, of the size of a pig's bladder, occupying 
the right labium, and extending by a pedicle to the inguinal 
ring, which had existed as long as she could remember, and 
always of the same size. When seen by Krieger, she had been 
lifting a heavy weight, and the tumor was painful, and she was 
vomiting. He diagnosticated it as an irreducible hernia, with a 
collection of water. On the following day he operated. The 
sac contained half a pint of serum, a mass of fat, intestine, 
an ovary, and tube. After rupturing the stricture with his 
1 Neboux. Ibid. 2 Ibid. 164 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
fingers, and after cutting away the fat and a portion of the 
sac, he was able to reduce the intestine, ovary, and tube, and 
to retain them in place. She recovered slowly.1 
Case XIX.-Berard reports a case in which the Fallopian 
tube alone was in the hernial sac. 
A woman, forty-five years of age, who had borne two chil- 
dren, had for twro years a swelling in the right groin, which 
disappeared under pressure. Finally, it became as large as a 
pullet's egg. It was then irreducible, fluctuating, and seemed 
to extend into the abdominal canal. Believing it to be a 
serous cyst, it was opened by a trocar, and six or eight ounces 
of serum were discharged, and there was discovered a round 
body, about the size of a hazel-nut, occupying the ring. On 
the third day, the sac having closed and refilled, and the 
patient having pain in the abdomen, accompanied with vomit- 
ing, it was opened again more freely, and a milky serum wras 
discharged; suppuration of the sac, and erysipelas ensued, and 
she died on the seventh day. The autopsy revealed the fact 
that the sac contained a portion of the Fallopian tube, which 
was hypertrophied and adherent to the sac. The interior of 
the sac communicated freely with the cavity of the abdomen. 
The right ovary was normal, but there existed a fibroid tumor 
in the substance of the uterus. There were also present the 
usual signs of fatal peritonitis.3 
Case XX.-Loeper relates that a woman, ten days after 
confinement, had a glandular swelling in the site of a former 
inguinal hernia. The tumor reached the size of a pigeon's egg. 
Loeper diagnosticated hernia of the right ovary, and operated, 
replacing the ovary, and a cure followed.3 
Case XXI.-Billard reports an example found in an in- 
fant, who died when seventeen days old. The tumor in the 
left inguinal region was about the size of a filbert, somewhat 
hard, and could not be reduced by taxis. On dissection, he 
found the ovary lodged at the bottom of the sac, and the cord 
1 Ibid. 2 Ibid. 
3 Monatschrift fiir Geburtskunde, xxviii., 453. ABDOMINAL HERNIA. 
165 
occupying the canal of Nuck, which was much larger than nat- 
ural. The uterus was tilted to the left side, and the kidney 
upon that side lay below the level of the opposite kidney.1 
The following case has been communicated to me by Dr. 
J. C. Nott, late of Mobile, and now of this city: 
Case XXII.-" About ten years ago, while residing in 
Mobile, I was requested by Dr. Henry S. Levert to see Mrs. 
W., with strangulated inguinal hernia. She was sixty years 
old, and had a large family of children. General health deli- 
cate. She had been troubled with the tumor about two years, 
and described it as a ball, which passed in and out of the ab- 
dominal ring. At the time I saw it the tumor had been out 
about twenty-four hours, and, through her flaccid skin, felt hard, 
round, and about the size of an English walnut. It was so 
hard and round that my first idea was of scirrhus, or other tumor 
connected with the omentum. She had a good deal of nausea, 
and pressure upon the tumor produced a very disagreeable 
sensation, accompanied by an inclination to vomit. Our 
efforts at reduction were unavailing, and we applied ice, gave 
opium, and determined to wait. In the afternoon no change 
had taken place, and it occurred to me, for the first time, that 
it might be the ovarium. With the view of aiding the diag- 
nosis, I introduced two fingers of the right hand into the 
vagina, while the left was placed on the tumor. The fundus 
of the uterus was evidently dragged toward the hernial side; 
and when the fingers were placed upon the side of the neck of 
the uterus nearest the tumor, and pressed firmly, I could dis- 
tinctly feel the lateral ligaments pull upon the tumor. 
" It was forty-eight hours after I first saw her before the 
tumor was reduced, making about three days altogether of 
the protrusion, and she had each day thorough evacuations from 
her bowels. 
" Opium, ice, and gentle taxis were the only means em- 
ployed. I saw this lady occasionally for some years after this. 
1 Atlas d'Anatomie Pathologique pour Servir a 1'Histoire des Maladies 
des Enfants; also, Traitfi des Maladies des Enfans. Troisi&nie ed., p. 492, 
et seq. Same case, copied byBouchut, Maladies des Nouveau u6s, 4th ed., 
1862, p. 597. 166 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
The tumor occasionally protruded, but w'as kept up, by proper 
care, with a truss, and gave no more inconvenience than a 
small intestinal or omental hernia." 
Case XXIII.-Dr. Parker reports a case of femoral hernia 
occurring in an old woman, in which the sac was found to 
contain intestine, the ovary, and the fimbriated extremity of 
the Fallopian tube. The latter was attached to the walls of 
the sac, and he did not ascertain its true nature until he had 
dissected it away and cut it off. The ovary and intestine were 
then returned into the cavity of the abdomen, and the patient 
made a good recovery.1 
Mr. Birkett, in his excellent article on Hernia, in " Holmes's 
Surgery," vol. iv., p. 321, says that in one case the Fallopian 
tube and ovary have been found in an obturator hernia. 
Frequent examples of vaginal ovarian hernia have also 
been reported; but, so far as I have been able to learn, they 
were all examples of simple falling or prolapse of diseased 
ovary, which pressed upon the vaginal walls, or perhaps had 
become adherent, without causing a real vaginal hernial pro- 
trusion. Braun reports five cases of ovarian hernia into the 
vagina, all impeding parturition; and which probably were of 
the character just described.2 
Sec. II-Indirect, Inguinal Hernia ; not Congenital. 
A.-Strangulated, and reduced by Operation. 
FIRST.- ENTEROCELE. 
Case XXIV.-Indirect inguinal hernia; not congenital; 
enter ocele; strangulated twenty four hours; operation 
under ether ; stricture at the internal ring ; division of 
stricture within the sac ; recovery. 
Michael Klutz, of Black Rock, N. Y., aged forty. During 
several years had an indirect inguinal hernia, which had grad- 
ually descended into the scrotum, and was at the time of the 
operation very large. He was exceedingly fat, weighing 
probably two hundred and fifty pounds. The strangulation 
1 New York Med. Times, for 1855, vol. iv., p. 109. 
9 Wien, Med. Woch. 1859, S. 848-49-51. Schmidt's Jahrb., 107, 215. ABDOMINAL HERNIA. 
167 
took place September 7, 1852, the day previous to the ope- 
ration. Some attempts had been made to reduce it before my 
arrival. The patient was vomiting and was suffering greatly 
from abdominal pains. The bowels were obstinately consti- 
pated. 
After having placed him under the influence of ether, taxis 
was made, but to no purpose, and I proceeded at once to the 
operation. The integuments and subjacent tissues were much 
infiltrated with serum, and the hernial sac was only reached 
after the incisions were extended to a depth of two inches. 
The sac contained considerable serum, which was, however, 
inodorous. A large coil of intestine was exposed, of a 
dark brown color, and with slight, recent adhesions. The 
stricture was found to be at the internal ring. This was divi- 
ded within the sac, by cutting upward and outward. The 
hernia was then easily returned, after breaking up the adhe- 
sions with my finger, and the wound was closed by several 
sutures, adhesive plasters, and a compress. His recovery was 
speedy and uninterrupted. 
Remarks.-Obesity in itself does not favor the occurrence 
of hernia, unless it be one particular form of hernia, namely 
the omental; indeed, I think it constitutes, in most cases, an 
impediment to its descent; but persons who have been fat and 
have suddenly, from any cause, emaciated, are very liable to 
hernia. The fat being removed from the natural openings, 
or from the interstices between muscular or tendonous fibres, 
opportunities are left for the hernia to escape. Moreover, the 
subcutaneous areolar tissue remains thereafter loose and unre- 
sisting, as does also the skin itself. 
If, however, fat people are no more prone to hernia than 
others, their hernias are generally found more difficult to 
reduce, and to retain in place. The tumor cannot be grasped 
and manipulated as fairly, nor can the taxis be directed as 
skilfully; and, when reduced, the truss cannot be applied as 
accurately and steadily. 168 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Case XXV.-Indirect inguinal hernia; enterocele; stran- 
gulated four days; operation by Dr. liarhoe ; division 
of stricture within the sac ; cured. 
August Haufman, aged fifty-two, admitted to ward 10, 
Bellevue Hospital, February 9, 1868. Twenty years ago, 
the patient strained himself, and, immediately after, a small 
swelling appeared in his groin, which gradually increased in 
size. 
February 8th.-The gut, which had hitherto been reducible, 
protruded, and taxis was tried without avail. 
February 11th.-Ice applied, and taxis again employed 
without success. Vomiting, and tenderness over the tumor. 
Has had two stools since admission. 
February 12th.-Dr. Markoe, visiting surgeon, operated, 
and on opening the sac there were found serum, clotted blood, 
and a knuckle of small intestine, which was congested. The 
stricture was divided and the hernia reduced. The wound 
was closed with interrupted sutures, an opening being left at 
the lower part for drainage. The dressing consisted of simple 
cerate, lint, and spica bandage. The patien trallied well from 
the operation. Discharged cured, March 8, 1868. Reported 
by T. Cross, M. D., House Surgeon. 
Case XXVI.-Indirect inguinal hernia; not congenital; 
enterocele ; strangulated twenty hours ; operation without 
anesthesia; stricture at internal ring; division within 
the sac ; secondary hemorrhage ; recovery. 
September 20, 1857, I was called to operate upon John 
Maloney, of Dunkirk, N. Y., aged about thirty-five years. 
He had had a hernia in the right inguinal region for many 
years. About twenty hours before I saw him it had become 
strangulated. Dr. Irwin had attempted to reduce it, but had 
failed. The swelling was now very large and exceedingly 
tender. He was constantly vomiting. After a moderate 
attempt at taxis, we proceeded at once to operate. No anaes- 
thetic was employed. The tegumentary incisions were free, 
but no vessels required the ligature. The sac was found filled 
with blood and serum. The intestine was very dark, but not ABDOMINAL HERNIA. 
169 
gangrenous. The stricture was at the external ring; and, after 
incising its margin, the intestine was returned. 
The wound was closed in the usual manner, and several 
hours after I left for home, the patient remaining in care of 
Dr. Irwin ; who subsequently informed me that a haemorrhage 
occurred from some part of the wound, causing the scrotum to 
rise into a swelling of the size of a fist; and that this was fol- 
lowed by a slough. His recovery was, in consequence, much 
retarded, but it finally took place. 
Remarks.-The notes of this case are incomplete, but the 
large amount of blood found in the sac indicated, I believe, a 
rupture of some of the mesenteric vessels, as a consequence of 
the strangulation. The serum was not simply stained with 
blood, as it is pretty often found to be, but the blood was in 
masses, more or less separated from the serum. 
The subsequent haemorrhage was probably from some of 
the vessels of the scrotum; and illustrates the danger from 
this source, which all surgeons have observed, when great care 
has not been taken to secure such vessels as have retracted 
into the loose cellular tissue of these parts. It will be remem- 
bered that no vessels were tied during the operation, as none 
seemed to require the ligature. It is quite probable that, if 
the wound had been kept open longer, and the haemorrhage 
solicited by warm applications, vessels requiring the ligature 
would have been found, and this secondary bleeding would 
have been avoided. 
Case XXVII.-Indirect inguinal hernia ; not congenital ; en- 
terocele ; strangulated twenty four hours ; moderate taxis ; 
operation under ether; stricture at internal ring; di- 
vided icithin the sac ; recovery. 
Frederick Braumlich, of Buffalo, N. Y., aged thirty-eight, 
had an indirect inguinal hernia of the left side fifteen years; 
had worn a truss. Strangulated occasionally before, but he 
had always succeeded in reducing it himself. April 17, 1853, 
it became strangulated and he was unable to reduce it. On 
the following day he was found suffering great pain, with nau- 
sea and vomiting. After the trial of taxis, and having ad- 
ministered ether, I operated, dividing the stricture at the in- 170 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
ternal ring. The sac contained a knuckle of intestine 
moderately congested, no adhesions. The wound was closed 
by sutures, etc., and his recovery took place without a single 
untoward symptom. 
Remarks.-This operation was made after only a mod- 
erate trial of taxis, and before either the sac or the intestine 
had become greatly inflamed. The result justified the prac- 
tice, since the recovery took place in less than the usual 
period, and with no accidents. 
Case XXVIII.-Indirect inguinal hernia, with violent lace- 
ration of the fascia transversalis, etc. ; become straight ; 
enterocele ; strangulated about two hours j operation after 
moderate taxis, without anaesthetics; stricture at external 
ring ; death in a few hours from shock of the original 
injury. 
Michael Murphy, aged forty, a cartman, admitted to the 
Buffalo Hospital of the Sisters of Charity, August 3, 1848, 
having been caught between his cart and a locomotive engine, 
causing the sudden protrusion of an old hernia on the right 
side, through the external abdominal ring. One hour after 
the accident I found him pale, his face covered with a cold 
sweat, his pulse scarcely perceptible at the wrist, vomiting, 
and apparently in articulo mortis. According to the best in- 
formation we could obtain, it had been originally an oblique 
hernia, but it now presented the appearance of a direct hernia. 
We made some attempts to reduce the hernia by taxis, 
but, failing, I proceeded at once to operate. The fascia trans- 
versalis, and other structures in the neighborhood, were found 
extensively lacerated; the sac was firm and much thickened, 
as it is often in old herniae, but not torn. It contained intes- 
tine, with some bloody serum. There were a few slight and 
apparently recent adhesions. The stricture was wholly at the 
external ring. I divided the stricture ; tore up the slight ad- 
hesions, and returned the intestine. 
The patient never recovered from the shock of the injury, 
but died a few hours after the operation was made. The 
friends would not permit an autopsy. 
Remarks.-It is apparent that this man died of the in- ABDOMINAL HERNIA. 
171 
ternal injuries received, independent of the occurrence of the 
hernia, and of the operation made for its relief. It is not im- 
probahle, indeed, from the rapidity and manner of his death, 
that there was a rupture of some of the viscera of the belly, 
causing a fatal internal haemorrhage. It would be entirely 
proper, therefore, to exclude this case in an analysis of the 
cases of strangulated hernia resulting in death. 
Case XXIX.-Indirect inguinal hernia • become straight; not 
congenital; enter ocele ; strangulated twenty-four hours ; 
prolonged taxis j operation without anaesthetics; strict- 
ure whole length of canal; divided within the sac ; death 
in forty-seven hours. 
Aaron Sperry, of Chili, Monroe County, X. Y., aged fifty- 
one, rather corpulent. Had an indirect inguinal hernia of the 
right side many years, until the canal had become straight, so 
that it was made to resemble a direct hernia. June 7, 1841, 
it became strangulated, and was with difficulty reduced by his 
surgeon. June 15th it again became strangulated, and the 
same surgeon was unable to reduce it. The means employed 
were such as were generally authorized before the introduction 
of amesthetics. He was bled to syncope; he was directed to 
chew tobacco and swallow the juice until it caused nausea; 
injections of castor-oil were given until they produced consid- 
erable faecal evacuations; cold applications were made to 
the tumor, and taxis was diligently employed in the usual 
manner. 
Nausea and vomiting continued until the morning of the 
16th, when he was given forty drops of laudanum. At six 
o'clock on the morning of this day I found his bowels very 
tender, the hernial tumor large and tender from repeated efforts 
at reduction, and the patient inclined to sleep, from the effects 
of the laudanum. In presence of Dr. Wells and several other 
surgeons I immediately proceeded to operate. 
The external incision was five inches in length. Only two 
fasciae could be distinctly made out, namely, the fascia superfi- 
cialis and the fascia cremasterica; the latter was thickened 
and inseparable from the sac, so that, as Scarpa has observed, 
it might easily have been mistaken for the sac itself. The sac 172 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
being opened, gave exit to about three ounces of serum. The 
intestine, which proved to be a portion of the ileum, was of a 
dark-red or brown color. There were no adhesions. The in- 
testine contained only gas. The stricture or narrowing ex- 
tended the whole length of the canal. A probe-pointed bis- 
toury was introduced, and the canal was incised through its 
whole length, the edge of the knife being directed upward and 
forward. When the knife reached the internal portion of 
the canal, or the internal ring, and it was being cut, the pa- 
tient complained of a sharp and intense pain, which was fol- 
lowed by excessive prostration and a cold, clammy perspiration. 
The intestine was now easily reduced. The pain caused by 
the incision continuing after he was laid in bed, we gave him 
eleven drops of laudanum, and this was repeated at the end 
of an hour. 
I did not see my patient after this. At three o'clock, p. m., 
he was bled sixteen ounces by Dr. Wells, which diminished 
the tenderness of his bowels, and gave him considerable relief 
as to the pain. 
June 17th, his bowels had become more tender, and, not- 
withstanding his physician had given him castor-oil, and 
other cathartics, his bowels had not moved. From this time 
he sank rapidly, and died forty-seven hours after the opera- 
tion, and ten minutes after signing his will. No autopsy was 
permitted. 
Remarks.-To those who practised surgery twenty-five 
years ago, there will be no novelty in the treatment pursued 
before the operation, unless it be in the use of tobacco through 
the stomach. There were precedents at that time for even 
this, but the general practice was to use tobacco enemata, in 
accordance with the advice of Professor William Gibson, of 
Philadelphia, and other distinguished surgeons; and I have 
myself once or twice seen a strangulated hernia reduced by 
this method. I have, however, always regarded the practice 
as unsafe, from the excessive irritation which it was likely to 
produce in the lower portion of the alimentary canal, and 
from the great prostration which it sometimes induced. It is 
well, I think, that it has been abandoned. 
The narrowing of the entire length of the canal has been ABDOMINAL HERNIA. 
173 
noticed in other cases of old indirect hernia, even when they 
were not congenital. 
A point of special interest is the severe pain inflicted by 
the incision of the internal ring. Before the introduction of 
anaesthetics I had occasion to notice this fact several times; 
and I used to think I could pretty certainly prognosticate a 
fatal issue when the patient cried out at this moment. The 
peritonaeum has, in its normal condition, very little sensi- 
bility, but when acutely inflamed it becomes exceedingly 
sensitive, and the sharp pain only indicated the existence of 
acute inflammation, and thus became an indication of what 
was to be the probable result. 
Case XXX.-Indirect inguinal hernia ; not congenital • en- 
terocele ; strangulated nine hours; violent taxis', opera- 
tion under chloroform ; stricture at external and internal 
rings ; cut within the sac ; death in thirty-six hours ; ex- 
travasations of hlood from taxis. 
March 6,1869, Patrick Donovan, aged sixty-eight, admitted 
to ward nine, Charity Hospital, Blackwell's Island. Had 
an indirect inguinal hernia on the right side fifteen years. 
Never been strangulated before. About five o'clock, in the 
morning of the day on which he was admitted, while lying in 
bed, he found it strangulated, and he was soon after carried to 
the hospital. The experienced house-surgeon, Dr. Inches, 
endeavored for some hours to reduce it by taxis, and by placing 
him in a warm bath. 
When I saw him on my regular visit to the hospital, at 2 
p. m., it had been strangulated nine hours. It occupied the 
scrotum, and was very large. He had vomited some, but was 
not much prostrated. After repeating the effort to reduce 
the hernia by taxis, and by elevating the lower portion of the 
body in the manner particularly described in other cases, both 
before and after the exhibition of chloroform, I proceeded to 
operate. 
The sac was thin, and contained only small intestine, with 
about half a pint of bloody serum. No adhesions. Intestine 
injected and thickened. Strictures existed at both the exter- 
nal and internal rings. I could, however, easily pass my fin- 174 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
ger through the rings beside the gut, into the belly, but it was 
found impossible to reduce the gut until both strictures were 
divided. The internal ring was nearly opposite the external. 
In closing the wound, after reducing the intestine, a pro- 
cedure was adopted which is probably unusual. The edges of 
the sac were brought first carefully together and closed by five 
sutures, nearly to the bottom of the pouch. After which the 
integuments were closed by sutures also. A compress was 
placed over the internal ring secured by a bandage. Patient 
was ordered half a grain of opium every six hours. 
This man died in about thirty-six hours, with signs of 
peritonitis. A note received from Dr. Inches, after the au- 
topsy had been made, informs me that taxis was first made by 
the house surgeon, at the almshouse; that, on his arrival at 
the hospital, it was repeated by himself; then by his assistant; 
while in the warm-bath it was tried again for half an hour; 
subsequently the assistant tried for one-quarter of an hour; 
and finally, for the sixth time, it was attempted by myself. 
Some of these attempts, he states, were made with violence. 
The autopsy disclosed not only the ordinary signs of peri- 
tonitis, but extravasations of blood under the peritoneal cov- 
erings of the intestine and of the mesentery to the exent of 
fifteen inches ; and he properly concludes that the fatal peri- 
tonitis was more due to the taxis than to the strangulation or 
the operation. 
Case XXXI.-Indirect inguinal hernia', enter ocele, with 
large mass of mesentery ; not congenital; strangulated 
nineteen hours ; moderate taxis ; operation under ether ; 
mesentery incised through mistake; stricture at external 
ring ; cut within the sac ; death in forty-eight hours, from 
peritonitis. 
M. Cook, aged sixty-six, admitted to Bellevue Hospital, 
April 23, 1868. The hernia, which had existed for eighteen 
years, had been kept in position by a truss almost constantly. 
At 2 a. m., April 23d, while the patient was in bed, with his 
truss on, the hernia came down, and he was unable to reduce 
it. In the afternoon it became very painful, and he vomited 
a green-colored material. Admitted to the hospital Y p. m., ABDOMINAL HERNIA. 
175 
when, on examination, a very large tumor was discovered in 
the scrotum, on the right side, which was tympanitic, but gave 
no impulse upon coughing. Near the external ring could be 
felt a hard constricting band. Taxis was immediately resorted 
to, but failed. Patient put in a hot bath, and I was called. 
At 9 p. m. I found the hernia very large, tender, and 
painful; after a moderate attempt at taxis, he was placed 
under the influence of ether, and with the light furnished by 
candles, the operation was made. The incisions were made 
with my usual care, the blood not being allowed at any time 
to obscure the surface of the wound. After traversing several 
fasciae, an opaque layer was brought into view, but, as this was 
an old hernia, I presumed it to be the fascia transversalis thick- 
ened. It did not separate itself from the overlying fascia, and as 
the sac had not yet been recognized, and no fluid had escaped, 
no suspicion arose that the sac had already been opened. 
Nearly all the house staff were present, holding the candles and 
assisting, and looking intently, with myself, at the wound. 
After a moment's delay, therefore, I made in it a long super- 
ficial incision, and found that I had penetrated its thickness, 
and that as the edges spread asunder, a still more opaque or 
whitish substance was presented below. Now, for the first, I 
began to suspect that I had before me the mesentery. A little 
further investigation proved this suspicion correct. A large 
coil of small intestine occupied the lower portion of the sac ; 
and this opaque structure which I had incised was the mesen- 
tery dragged down, presenting a broad, smooth, convex surface 
in front, and occupying the middle and upper half of the hernial 
pouch. It was pushed forward with much force, and, being 
slightly adherent, it did not separate from the sac when the 
latter was incised. 
The error being detected, the sac was more freely laid open 
and the intestine examined, which was found to be much con- 
gested ; but the sac contained only a little serum at its fundus. 
The stricture, at the external ring, was divided. I then closed 
the wound in the peritonaeum covering the mesentery, with 
four fine silk sutures (there was no haemorrhage from the 
mesentery), and reduced the intestine, with the mesentery, 
easily. The external wound was closed with sutures, a com 176 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
press, and roller. On the following day, while vomiting, the 
hernia escaped between the sutures, the compress having be- 
come displaced. Ue died in about forty-eight hours, from 
peritonitis. An autopsy was made by my request, but the 
result was not recorded, because the medical officer whose duty 
it was to make the record thought I would prefer that such an 
error should not be made public. 
Case XXXII.-Indirect inguinal hernia • enterocele ; stran- 
gulated eight days', sac opened by Dr. Sands, and gut 
reduced without dividing the stricture • death on third day. 
Leonard Buier, aged thirty-seven, admitted to Bellevue 
Hospital, ward 5, January 19, 1866. Visiting surgeon, 
II. B. Sands, M. D. Had a double inguinal hernia for twenty- 
eight years, but has suffered very little inconvenience, as the 
gut on both sides was very easily reduced. Thursday, June 
15th, while at work, the gut on the left side suddenly pro- 
truded, and on attempting to return it, he found himself unable 
to do so. He then went to a dispensary, where ice was applied 
and taxis used, but without success. On admission, said that 
he had had no passage from his bowels since Thursday, the 
15th instant. Complained of pain over the lower part of 
abdomen, and vomited at intervals. His pulse was good. 
He was etherized, cold applied to the tumor, and attempts 
made to reduce it, which, however, failed. 
June 23d.-Vomiting continues. Patient seems to be 
suffering more pain, tenderness on pressure over the ab- 
domen ; pulse one hundred and twelve. Dr. Sands operat- 
ed at 6 p. m. The sac was opened, and the gut reduced 
without the division of the stricture. A quantity of dark- 
colored fluid escaped from the sac; the gut was slightly 
congested. After the operation, the patient's pulse was one 
hundred and fourteen. Had cold clammy sweats. Abdomen 
slightly tympanitic, with pain on pressure in the left iliac re- 
gion. 
He was put under the influence of morphine immediately, 
and its effects were maintained, with from forty-five to ninety- 
five in. of Magendie's solution daily, until death, which oc- 
curred on the third day. ABDOMINAL HERNIA. 
177 
Autopsy.-There were signs of general peritonitis; lymph 
uniting the opposed surfaces of the intestines. Very little serum. 
The inguinal canal was obliterated, the internal ring having 
been drawn down upon the external. A knuckle of ileum, 
about four inches from the ileo-csecal valve, was just within the 
ring, and attached to its borders by lymph; the peritoneal 
surfaces of the gut at this point were very much inflamed, but 
showed no signs of gangrene. The sac was three and a half 
inches long, and one inch in diameter at its widest part. Within 
it were 3 ii of serum. The walls of the sac were thickened, 
and the peritoneal lining was thrown into folds and covered 
with a small quantity of lymph. Reported by T. Cross, If. D., 
House Surgeon. 
Case XXXIII.-Indirect inguinal hernia • recent; entero- 
cele ; strangulated three days ; operation by Dr. Howe ; 
stricture at external ring ; death in twenty-nine hours 
after operation. 
Geo. McConnell, aged , admitted to ward 16, Bellevue 
Hospital (Dr. Hamilton, visiting surgeon; Dr. J. W. Howe, 
house surgeon), September 20,1867. Had scrotal hernia since 
August 20, 1867. Had experienced no difficulty at any time 
in reducing it, prior to Tuesday, September 17th, when, after 
violent exertion, he was unable to return it. He continued at 
his daily avocation for three days after this accident, although 
he had diarrhoea, when he was seized with an acute pain in 
the right groin, and became aware that the tumor had sud- 
denly increased in size. He was taken home, and soon began 
to vomit. Had pain in the abdomen, and two loose passages 
from the bowels. Morphine was given, and hot fomentations 
applied ; but, obtaining no relief, he was brought to the hos- 
pital. On admission, patient was suffering much pain, and 
was vomiting every few minutes. Pulse was weak and rapid. 
On examination a large scrotal tumor was found, which was 
shining and red ; also resonant on percussion at the lower two- 
thirds, but dull above. External ring, which was hard and 
thickened, could be felt embracing the neck of the tumor. 
Half a grain of morphine was given, and taxis employed, but 
without success, after relaxing the parts by means of a hot 178 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
bath. Patient put to bed and given stimulants, but he still 
continued to vomit. At 8 a. m., taxis was again employed 
by Dr. Howe, the patient being under the influence of 
chloroform; but, this failing, he immediately cut down and 
divided the stricture, which was at the external ring, and 
returned about six inches of intestine, which was gangre- 
nous, into the abdominal cavity. During operation, the 
patient vomited stercoraceous matter; afterward was very 
much depressed, and vomited continually. Died at 1 p. m. 
the following day. No autopsy. Reported by T. Cross, H. D.^ 
House Surgeon. 
Remarks.-This patient was admitted to one of the wards 
under my charge, but the case never came under my notice. 
The hernia had existed only one month, and its strangulation 
was for this reason accompanied with extra hazard. 
Case XXXIV.-Indirect inguinal hernia ; enterocele ; stran- 
gulated several hours; operation by Dr. Stoddard; in- 
cision of external ring within the sac ; death in about sixty 
hours. 
Henry Cooper, admitted to Bellevue Hospital, ward 13, 
March 31, 1868. Visiting surgeon, T. M. Markoe, M. D.; 
house surgeon, H. B. Stoddard, M. D. General health good. 
Had a hernia twelve years. Had always worn a truss. At 
10 a. m., March 31st, the gut came down, and could not be 
reduced. He now suffered considerably with pain and vom- 
iting. Twelve hours after, he was admitted to the hospital, 
suffering much from pain. A very large tumor was found in 
the scrotum, soft and elastic, resonant above and dull below. 
The patient was etherized, and taxis was tried, but without 
success. Operation was performed by Dr. Stoddard, in which 
the sac was opened. Considerable serum escaped from the 
sac, which contained about two feet of small intestine, some 
parts of which were dark red and mottled, others constricted 
and of a very dark color. After freely incising the external 
ring, the protrusion was reduced. The wound was closed by 
sutures, and a spica bandage applied. Magendie rixv given. 
Patient kept under influence of morphine until April 2d, pulse 
meanwhile ranging from ninety to one hundred. Respiration ABDOMINAL HERNIA. 
179 
eighteen to twenty-four. April 2d, pulse one hundred and fifty, 
respiration thirty-six. Stimulants given. At 10 p. m. patient 
commenced to vomit, and died suddenly. Autopsy revealed 
well-marked signs of diffused peritonitis. Reported by T. 
Cross, M. D., House Surgeon. 
Case XXXV.-Indirect inguinal hernia ; probably entero- 
cele; strangulated thirty-six hours; failure of taxis ; 
operation under ether; spontaneous reduction before the 
sac was opened, and without dividing the stricture; re- 
covery. 
Edward Housman, aged twenty-five, admitted to Buffalo 
Hospital of Sisters of Charity, December 14, 1851, with a 
strangulated indirect inguinal hernia of the left side. The 
hernia had existed several years, and he had worn a truss. 
About thirty-six hours before admission, the hernia had come 
down, and he had found it impossible to reduce it. When 
admitted, the hernial tumor was large, tense, elastic and very 
tender on pressure. He had severe abdominal pains, and had 
vomited several times. Taxis had been tried, and since his 
admission ice-water had been constantly applied. During 
nearly or quite thirty minutes I tried to reduce the hernia by 
taxis, but without success. 
Believing that there ought to be no longer delay, I at once 
resorted to the operation, the patient having been already 
placed under the influence of ether. 
While making my incisions, and when I had divided all 
but the fascia transversalis, at the moment when the sponge 
was applied to remove the blood from the bleeding surface, a 
slight gurgling sound was heard, and in a moment the whole 
hernia had disappeared. The wound was at once closed, and 
in a few days he left the hospital cured. 
Remarks.-The incision extended a little above the exter- 
nal ring, and the margins of the ring were visible, but no 
portion of it had been divided. The reduction occurred prob- 
ably independently of the operation, and would have occurred 
if the operation had not been made. It furnishes no argument, 
however, for delay in a similar case hereafter, since the proba- 180 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
bility of such a fortunate occurrence while the operation is in 
progress is certainly very small. 
Case XXXVI.-Inguinal hernia ; strangulated four days ; 
operation ; death in fifteen minutes. 
John McGuire, aged twenty-six, admitted to Bellevue Hos- 
pital, September 18, 1861, ward 7; house surgeon, S. Walter 
Coles, M. D. States that he had had a reducible hernia for 
eight years, which was caused by lifting a heavy weight. On 
the 16th of September, the hernia became strangulated, and 
taxis was employed. On admission, the patient was vomiting, 
and apparently suffering from peritonitis. The scrotum was 
enlarged, and occupied by a tumor, which was dull on per- 
cussion. Dr. operated, September 20th, and found the 
sac of an old hernia, which was filled with serum. Patient 
died in fifteen minutes after the operation. 
Autopsy.-September 21st.-Intestines were much congest- 
ed . About a foot of the ileum, eighteen inches above the caecum, 
was in a gangrenous condition. This had undoubtedly been 
strangulated, and reduced before patient was brought to the 
hospital. Reported by T. Cross, II. D., House Surgeon. 
Case XXXVII.-Indirect inguinal hermia ; entero-epip- 
locele; strangulated one hundred and twenty-fire hours ; 
operation under ether, by Dr. A. B. Hott; division of 
stricture at internal ring, within the sac ; omentum and 
intestine returned ; death on twenty-fifth day, of pneu- 
monia. 
Hugh Tully, aged forty-five. Admitted to Bellevue Hos- 
pital, ward 5, March 24, 1868 ; A. B. Mott, M. D., visiting sur- 
geon ; Albert Strang, house surgeon. Has been a very intem- 
perate man. In 1856, while lifting a heavy block of stone, he 
felt something give way in the left inguinal region, which proved 
to be an oblique inguinal hernia. It seldom came down, and 
then only to a limited extent, and, as the tumor was small, he 
found no difficulty in returning it. From the time of the rup- 
ture until the 20th of March, 1868, he had constantly worn a 
truss, at which time, by accident, the truss came off, and 
the hernia protruded. Being unable to reduce it, he waited ABDOMINAL HERNIA. 
181 
four clays, suffering, however, no unpleasant symptoms, before 
he applied for medical assistance. Taxis having been tried at 
the dispensary by Dr. Janeway, without success, he was sent 
to Bellevue Hospital. On examination, a tumor was found in 
the left inguinal region, extending from the internal ring 
downward along the cord into the scrotum. Throughout its 
whole course it was hard, with no signs of fluctuation. Below 
it was symmetrical, even and oval in outline. Dull on percus- 
sion, with slight tenderness on pressure. The testis could be 
detected below and behind, both by its shape and by the sen- 
sation produced by pressure. The patient's bowels were regu- 
lar, and he passed his water freely. His tongue was clean, 
pulse and respiration normal, and he was up and about the 
ward. There was, however, an impulse conveyed to the tumor 
by the act of coughing. Patient given 1 gr. morphise sulph. 
March 25th.-Patient to-day complains of a sharp pain 
along the course of the spermatic cord. His pulse is smaller and 
irritable, but he has not vomited, and feels no nausea. 
March 26th.-A consultation was held to-day, and an 
operation was decided upon. At 2.30 p. m., the patient being 
under the influence of ether, Dr. Mott made an incision five 
inches in length, extending from the external abdominal ring 
along the course of the spermatic cord. The sac was opened, 
and the constriction divided. The tumor was now found to be 
composed of omentum, which was tumefied, dark colored, and 
nearly gangrenous, and a small portion of intestine. The in- 
ternal ring was divided and the hernia returned. The oper- 
ation lasted forty minutes: 11 oz. of ether were used. The 
wound was brought together by sutures and adhesive straps, 
and a graduated compress placed over the abdominal ring, 
and secured by a spica bandage. Stimulants and opium 
were given pro re natd. 
March 27th.-Pulse 86, stronger than yesterday, increased 
temperature of the body, and tenderness of the abdomen. 
Sulph. morph, f gr. given every two hours. Diet, milk and 
eggs. 
March 28th.-Pulse 90, and quite weak, abdomen is still 
tender. Compress renewed. Lower part of wound united. 
Over the inguinal canal there was some suppuration, but ex- 182 
BELLEVUE AND CIIAEITY HOSPITAL EEPOETS. 
isting only immediately beneath the integument and superfi- 
cial fascia. Compress and bandages reapplied. Olii ricini 3 ss 
given to move the bowels. 
March 29th.-Patient very weak, with some fever. Scro- 
tum slightly erysipelatous. Bandages removed. Quinine and 
morphia in gr. doses givenyw re nata. Lotio plumbi et opii, 
locally applied. 
April 1st.-Pulse 120 and very weak. Respiration hurried. 
Large bronchial and tracheal rales can be distinctly heard. 
Wound looks badly. 
April 3d.-Has had two passages from his bowels, of a 
grayish color, and extremely fetid ; appetite improving. Pulse 
104. Respiration 22. Wound improving. Tinct. opii gtt. 
xx; olii ricini 3 ss; mucilag. acacise 3 iss, given as an injection 
and internally. Spts. vini gallici 3 i, quinise sulph. gr. ii, 
morphine sulph. gr. £ every two hours. 
April 4th.-Pulse 108. Respiration 24. Had four very 
offensive evacuations from the bowels. Tongue furred and 
brown. Quinise sulph. grs. xxxii, acidi sulph. dil. m xcvi, aquae 
3 ij. M. Teaspoonful every two hours. 
April 5th.-Profuse perspiration. On examination of the 
lung, pneumonia discovered on the right side, involving nearly 
one-half of the lung. Pulse 118, respiration 24. 3 j brandy 
given every two hours, and the same prescription before men- 
tioned continued, with a generous diet of milk and eggs. 
April 9th.-Condition of patient much improved. The 
pneumonia advancing, but the consolidation at lower part of 
the lung is disappearing. 
April 12th.-Patient worse. Pneumonia advancing. 
April 14th.-Died at 8 a. m. 
Permission was obtained to examine the parts only around 
the wound. On examination, marked local peritonitis was 
discovered. Reported Vy T. Cross, M. D., House Surgeon. ABDOMINAL HERNIA. 
183 
Case XXXVIII.-Indirect inguinal hernia; omental; 
strangulated six days; operation without anaesthetics; 
large number of fasciae ; stricture at internal ring ; cut 
within the sac ; excised all of the protruding omentum ; 
recovery. * 
Allen McPherson, of Caledonia, Monroe County, N. Y., 
aged thirty-nine, quite fat; had a hernia live years, during 
which time he wore a truss, but the hernia was not well re- 
tained. February 10, 1841, it became strangulated. His sur- 
geon tried taxis, and then administered large and strong to- 
bacco-enemata, which, the patient said, nearly killed him, 
but did not reduce the hernia. I saw him February 16th, at 
two o'clock in the morning, and immediately operated, in 
presence of Dr. Graham and several other physicians. (The 
physician who was first called had died suddenly.) 
At this time his bowels had not moved in five days; the 
hernia was very large and tender; abdomen not tender. On 
making the incision, the coverings were found thickened, and 
six distinct fasciae were exposed, and, if I had not been admon- 
ished by the patient not to give a lecture, but to proceed 
with the operation, I have no doubt several more would have 
been demonstrated. The sac contained a small amount of se- 
rum, but it was filled with a large mass of omentum, of a dark- 
red color, and firmly adherent to the sac on all sides. Most 
of the adhesions had evidently existed for a long time, as they 
were long and firm. They were particularly strong at the in- 
ternal ring, the seat of stricture. 
I tore the omentum from the sac, and in the same manner 
forced the adhesions at the neck. I then cut the stricture; with 
the edge of the bistoury directed forward. It was now appar- 
ent that the mass could not be returned without enlarging the 
ring to an inordinate size, and I determined at once to excise 
the whole of the omentum, which I did, leaving only a small 
portion of the neck, which still retained sufficient adhesion to 
the neck of the sac not to allow it to be withdrawn into the 
belly. There was no bleeding from the cut surface of the 
omentum, and of course no ligatures were applied. The ex- 
ternal wound was closed by sutures, etc. The patient made a 184 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
speedy recovery; but, contrary to my hopes, the hernia con- 
tinued to descend after his recovery, even worse than before 
the operation. 
Remarks.-We see in this example how long the strangu- 
lation may exist in the case of an omental hernia without caus- 
ing urgent symptoms, or inducing fatal congestions. 
Several of the older writers, among whom we may now 
enumerate Sir Astley and Samuel Cooper, and William Gibson, 
recommended the employment of tobacco-injections in stran- 
gulated hernia, but they did not fail to notice that they must 
be employed with caution. Liston used to declare them 
always dangerous, and never recognized them as proper agents, 
however carefully employed. Without taking any part in the 
discussion of this point, since it is not very probable that rem- 
edies of this class will ever be employed again, I wish to ob- 
serve that I have seen them used with apparently good effect; 
a very weak solution being thrown into the rectum, after 
a few moments a rumbling would commence in the belly, fol- 
lowed by a sudden disappearance of the hernia. This has oc- 
curred before the induction of nausea and prostration, at 
the moment when the tobacco, as it seemed to me, had caused 
only irritation and considerable vermicular action of the lower 
portion of the intestinal tube, by which means the hernia was 
actually pulled back into the belly. In the same manner, I 
believe, an emetic has occasionally reduced a hernia, as in one 
case which I shall relate. This was not, however, the theory 
of those who used to employ these agents, but they believed 
their agency consisted in relaxing and enlarging the openings 
through which the hernia had passed, and for this reason they 
deemed it necessary to cause excessive and dangerous prostra- 
tion. In my opinion, if employed to the production of muscu- 
lar contraction of the intestinal tube-vermicular action- 
nothing would be gained by pushing the influence of the agent 
further. 
The number of fasciae disclosed is no greater than I have 
seen in other old herniae, while, in still others, the fasciae have 
been consolidated, condensed, thinned, and almost lost. The 
small amount of serum is peculiar to omental hernia, that is to ABDOMINAL HERNIA. 
185 
say, there is usually less in omental than in intestinal hernia, 
with the same grade of inflammation or congestion. 
Sir Astley Cooper long since advised, when the omentum 
was enlarged and adherent to the neck of the sac, to remove a 
large portion or the whole of the protruding omentum, by 
the knife, and to return the remainder to the mouth of the sac 
to plug up the opening.1 This advice -was followed in the 
above case, but the result anticipated by Sir Astley did not 
ensue; the hernia continued to descend afterward as before ; 
and indeed it was subsequently larger than before the opera- 
tion. It is probable, however, that in a certain number of 
cases the plan would prove successful, especially where the 
adhesions to the neck of the sac are firm, and have not been 
much disturbed by the operator. 
Sir Astley and Mr. Key call attention to the necessity of 
tying the arteries of the omentum which may be found to 
bleed, before returning it to the cavity of the abdomen; and 
Mr. Key relates a case in which his own omission to do this 
came near proving fatal; and he recommends that, in order 
to bring the vessels better into view, the omentum should be 
unfolded before the excision is made. 
In two other cases (Cases LVIII. and LIX.), I have cut away 
large portions of the omentum, and in neither of these have I 
found any vessels requiring the ligature. All three have recov- 
ered without secondary haemorrhage. I do not mean to intimate, 
however, that the vessels ought not to be sought for, and tied 
if practicable; but I suspect that they are seldom large enough 
to bleed. Indeed, they have seemed to me obliterated in some 
way, so that the structure is not so vascular as in the natural 
condition of the parts. Moreover, in each of the three cases 
the omentum was adherent at the neck of the sac; and where 
this is found to be the case, if it be determined to excise, no 
doubt the safety of the patient might be increased by not dis- 
turbing these adhesions. 
The uniform recovery of these patients confirms the state- 
The Anatomical and Sui'gical Treatment of Abdominal Hernia, by 
Sir Astley Cooper; from the second London edition, by C. Aston Key. 
American edition, 1844, p. 106. 186 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
ments of Sir Astley and of Mr. Key that the operation of ex- 
cision of an enlarged or otherwise diseased omentum is not 
only proper, but generally unaccompanied with danger. It 
will be observed in these reports, also, that most of the pa- 
tients have died in which the omentum has been returned 
(XXXVII., XLI., XLIL, etc.). 
Case XXXIX.-Indirect inguinal hernia ; traumatic; re- 
cent ; not congenital ; omental; strangulated three days ; 
operation under chloroform and ether ; cut stricture with- 
in sac • death on third or fourth day. 
Mr. Bigelow, of Williamsville, Erie County, N. Y., aged 
seventy-seven. Had an oblique hernia on left side for several 
years. March 10, 1859, he was kicked by a horse, causing an 
oblique hernia on the right side, which at once became stran- 
gulated. March 13th, the third day after this accident, I 
found him very much prostrated, and vomiting. The hernia 
was large and very tender. His surgeon, Dr. Van Pelt, of 
Williamsville, had employed every proper means to accom- 
plish reduction, but had failed. I repeated the taxis with the 
same result; and, after placing the patient under the influence 
of a mixture of ether and chloroform, I at once proceeded to 
operate. 
The sac contained no intestine, and only a little serum; 
but it was completely filled with omentum, which was en- 
gorged and already attached to the sac by adhesions. Having 
released the stricture and broken up the adhesions, the omen- 
tum was returned into the cavity of the abdomen, and the 
wound closed by sutures. The pain, which had been great 
before the operation, did not return with the same degree of 
intensity. 
A few hours later, I left him in charge of his surgeon, and 
of the result I have only been informed that he died on the 
third or fourth day, probably of peritonitis. 
Remarks.-It is probable that, in this case, the death was 
quite as much due to the severe injury to the abdominal pari- 
etes, occasioned by the blow, as to the strangulation and 
operation. Such cases always offer an unfavorable prognosis. ABDOMINAL HERNIA. 
187 
Case XL.-Indirect inguinal hernia', entero-epiplocele ; 
strangulated about twenty hours ; very little taxis ; opera- 
tion without any anesthetic, except whiskey; sac opened, 
and hernia reduced without cutting the stricture', re- 
covery. 
Michael Braun, aged about fifty. Had a hernia from child- 
hood. Indirect inguinal, left side. The hernia had been 
strangulated several times before. July 27, 1866, after a de- 
bauch on the previous night, he found himself unable to re- 
duce it. About eighteen hours later he sent for a Dispensary 
physician, but the messenger was unable to procure one. On 
my arrival I found the hernia very large, tense, but not very 
tender. He had vomited some, but whether from the strangula- 
tion or from liquor could not be decided. He had taken sev- 
eral glasses of liquor during the last few hours, and was quite 
drunk at the time. Taxis was attempted for half an hour, 
but without success. With no assistance but a woman with 
two or three children, and without anaesthetics, I proceeded at 
once to operate, tying the vessels carefully as I progressed. 
The sac contained a large coil of the small intestine, a small 
portion of omentum, and much serum stained with blood and 
of an offensive odor. The ring was very large, but completely 
occupied by the protruded mass. Pressing with moderate 
force upon the piece of omentum, I found it beginning to re- 
cede, and in a few seconds it retired completely. With not 
much difficulty I now reduced the intestine. The reduction 
was therefore completely accomplished without cutting the 
point of stricture. 
The wound was closed by sutures, and his recovery was 
rapid and complete. 
Remarks.-Taxis, which failed before the operation, was 
successful after the sac was opened. It was now possible to 
bring the pressure to bear more effectively upon the protrud- 
ing viscera, and especially upon the small piece of omentum. 
It is probable that this experiment would succeed pretty often 
if the trial were more frequently made. The advantages to 
the patient from not cutting the stricture, both immediate 
and remote, are apparent, and need not be stated. 
SECOND.- ENTERO-EPIPLOCELE. 188 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Case XLI.-Indirect inguinal hernia ; become scrotal } entero- 
epiplocele • strangulated forty-eight hours', operation after 
protracted taxis, under influence of ether; death from 
abscess opening into peritoneal sac. 
Jacob Vanderhoff, aged fifty-eight, shoemaker, admitted 
to Bellevue Hospital, August 14,1866. Patient was intoxicated 
at the time of admission, and was sent to a medical ward 
by mistake. He was not seen by the house surgeon until the 
following morning. He then gave the following history: 
When forty-four years old, while in the act of shovelling coal, 
a swelling made its appearance suddenly in the left groin, 
from which time it had gradually increased until it occupied 
the scrotum. He had worn a truss, but the hernia had been 
imperfectly retained, so that he had often occasion to return 
it himself. On the 13th of April a larger mass than usual 
descended, and he was unable to reduce it. The strangulation 
had continued, therefore, when he came under my notice, 
forty-eight hours and perhaps longer, yet his bowels had 
moved once or twice during this time. The tumor now, on 
the 15th, of very great size, was tender and painful, especially 
near the neck of the sac. The house surgeon applied ether 
over the tumor, and tried taxis, but failed. I then attempted 
to reduce the mass by taxis, with the same result. Ether was 
now administered, and taxis was repeated, while the lower ex- 
tremities were very much elevated by placing the feet of the 
bedstead upon a table. This having failed also, I immedi- 
ately proceeded to operate. A large mass of omentum was 
found in the sac, behind which was a loop of intestine of sev- 
eral inches in length. After dividing the stricture, consider- 
able difficulty was experienced in returning the hernia. This 
was, however, finally accomplished, and the wound was closed 
with sutures, compress, and bandages. 
Peritonitis ensued, and the patient was placed under the 
influence of opiates. No cathartic was administered. 
August 21st, he had a spontaneous movement of his bow- 
els, and his condition seemed to warrant an expectation of his 
speedy recovery. On the 22d he had a second movement, af- 
ter which a dose of castor-oil was administered, but not by my ABDOMINAL HERNIA. 
189 
order, which was followed by four evacuations. On the fol- 
lowing morning he was suddenly seized with violent pains in 
the left iliac region, accompained with tremors, vomiting, etc., 
and he died on the morning of the 24th, having survived the 
operation nine days. 
The autopsy disclosed the usual signs of acute peritonitis, 
caused by the opening into the peritoneal cavity of a small 
abscess which had formed outside of the seat of the stricture 
and in the vicinity of the internal ring. 
Death occurred plainly as a consequence of the abscess 
which formed outside of the stricture, and which opened inter- 
nally ; from which circumstance the suggestion naturally 
arises, whether this might not have been avoided by main- 
taining a free channel for the exit of pus toward the surface. 
The full dose of castor-oil, given on the 22d, was injudi- 
cious, but was not the direct cause of death. 
Case XLII.-Indirect inguinal hernia in a female ; entero- 
epiplocele ; strangulated two days ; operation ; stricture 
at internal ring; divided outside of sac ; death six days 
after operation; autopsy; portion of the omentum still 
strangulated. 
Ann Kean, aged fifty-two. Admitted to Bellevue Hos- 
pital, ward 28, July 18, 1866. Had an inguinal hernia for 
three years; it first appeared after she had lifted a heavy 
weight; the tumor at this time was about the size of an 
egg. It remained of nearly the same size and perfectly re- 
ducible until Monday, the 16th inst. Sunday afternoon, 15th 
inst., wTas taken with vomiting. Monday morning, noticed 
that the tumor was twice its original size and very painful; 
she was now unable to return, the gut into the abdomen. 
She has had continual vomiting, and no passage from her 
bowels since Monday evening. Dr. saw the case about 
2 p. m., and found that the hernia could not be reduced 
by taxis. The vomiting, constipation, and pain indicated 
that the gut was strangulated. He operated immediately. 
All the tissues about the sac and its contents were lifted 
w'ith the fino-ers of the left hand and transfixed with a 
curved, sharp-pointed bistoury, and cut through from within 190 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
outward; the incision divided all the tissues down to the peri- 
tonaeum. The strictured portion of the ring (internal) was 
then divided, and the gut returned into the cavity of the ab- 
domen. The sac was not opened. The wound was closed 
with sutures, and a compress and spica bandage applied: sol. 
sulph. morphia (IT. S.) 3 ss. given. 
July 19th.-Since the operation, patient has kept nothing 
on her stomach : complains of but little pain in the abdomenr 
Patient was put under the influence of opium immediately. 
July 20th.-Vomited constantly to-day until about 8 in 
the evening, when she ceased for a few minutes. Was given 
an enema of brandy and egg. Commenced to vomit again. 
July 22d.-10 a. m., pulse, 130; respiration, 27. Died at 
7.30 p. m. 
Post-mortem eighteen hours after Death.-The peritonaeum 
covering intestines w'as congested. There was very little se- 
rum or lymph. The two rings preserved their normal relation 
to each other. The ilium, about three inches from the ileo- 
csecal valve, was found adherent to the internal ring; on tear- 
ing this away, its adherent surface presented a livid color, and 
was quite soft. The hernial sac and a quantity of omentum 
were found protruding through the ring and lying in the in- 
guinal canal; both were strangulated and of a dark-purple 
color. The inguinal canal was distended into a large sac, 
which extended down behind the pubes for a distance of three 
or four inches. The amount of omentum extending through 
the ring was considerable, and with the hernial sac quite 
filled up the dilatation of the inguinal canal. Reported by 
T. B. Cross, II. D., House Surgeon. 
B.-Indirect Inguinal Hernia ; strangulated ; reduced 
without Operation. 
Case XLIIL-Indirect inguinal hernia ; strangulated about 
twenty hours; reduced by taxis aided by posture, after 
simple taxis had failed. 
A male convict, in the Blackwell's Island Penitentiary, had 
an indirect inguinal hernia, which had become strangulated. 
This occurred in the summer of 1865, and one of the house ABDOMINAL HERNIA. 
191 
surgeons of the Charity Hospital had been trying all night to 
accomplish reduction by taxis alone. When I was called to 
see him I found the hernia very large and tender, and the 
condition of the patient alarming. The patient himself wished 
me to give him an emetic, by which means, he said, it had 
once been reduced when it was strangulated. I did not think 
it best to do so ; but directed that, while the house surgeon was 
making preparations for the operation, an attempt should be 
made to reduce the hernia by posture. Accordingly, the foot- 
legs of the bedstead were lifted, and placed upon the top of a 
table, and, while the patient was lying upon this inclined plane, 
with his head down, moderate pressure was made upon the 
hernia. It began to diminish in size almost immediately, and 
in about ten minutes it disappeared altogether. 
Case XLIY.-Some years ago I had a similar case, but of 
which I have preserved no notes. The patient was a German, 
of middle age, living a few miles from Buffalo, N. Y., and was 
under the care of Dr. Ernst Pupikofer, who sent for me to 
operate. After ordinary taxis had failed, by adopting the 
method above described we succeeded in effecting reduction. 
Case XLV.-Indirect inguinal hernia' strangulated eight 
hours; reduced by application of ice, aided by posture, 
and the internal administration of morphia. 
Wm. Thomas, set. 25, came to my office September 14, 
1855, with a strangulated indirect inguinal hernia; enterocele; 
right side. It was an old hernia. The strangulation occurred, 
eight hours before he called upon me, from lifting. He was 
quite sick at his stomach, and was suffering acute pain. As- 
sisted by my pupil, he was at once put completely under 
the influence of chloroform, and reduction attempted by taxis, 
but without success. He was sent to his home, and, two hours 
later, I called and gave him half a grain of morphia and applied 
a bladder filled with ice. In about three hours it retired spon- 
taneously. 192 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Case XLVI.-Indirect inguinal hernia; strangulated three 
days ; reduction by posture and application of ice, after 
taxis had failed. 
July 14, 1853, I was requested by Dr. Nott, of Buffalo, 
to see a man, about fifty years of age, who had an indirect 
inguinal hernia on his left side, which had existed many 
years, but which two days before had become strangulated, 
lie was suffering considerably from pain at the seat of stric- 
ture, and had vomited occasionally. Attempts had been 
made to reduce the hernia, but without success. I was also 
unable to reduce it. 
As the symptoms were not very urgent, we decided to keep 
him on his back, with his knees elevated by pillows, and apply 
ice in a beef-bladder. During the night the hernia gradually 
diminished in size, and on the following morning it had disap- 
peared. 
Case XLVII.-Indirect inguinal hernia ; recent; strangu- 
lated twelve hours ; reduced by careful taxis, continued 
half an hour. 
G. S., Engineer on the State Line Railroad, had an indirect 
inguinal hernia on the left side, which had existed only a few 
weeks when it became strangulated. 
I was called to see him by Dr. Lockwood, a gentleman of 
large experience in Buffalo, N. Y., on the 25th of July, 1854. 
The hernia, apparently intestinal, had been strangulated about 
twelve hours, and Dr. L. had attempted to reduce it by taxis. 
The usual symptoms of strangulation were present. 
Placing him upon his back, with the knees elevated, I 
seated myself beside him, and, grasping the tumor with the four 
fingers and thumb of my left hand, allowing the fundus of the 
tumor to rest in the palm of the hand, I made moderate but 
steady and continuous pressure for half an hour. The hernia 
began to recede after a few minutes' pressure, and at the end 
of the half hour it had disappeared altogether. ABDOMINAL HERNIA. 
193 
Case XLVIII.-Indirect inguinal hernia in a female ; stran- 
gulated at least twenty-four hours ; failure to reduce by 
ordinary taxis ; reduction effected by Dr. Vance by taxis, 
aided by posture ; recovery. 
Catherine Taylor, aet. 32. Admitted to Bellevue Hospital, 
ward 18, August 20,1868. Was confined one year ago; had an 
easy and natural labor, although her convalescence was slow. 
Two weeks after her child was born, she first noticed a small 
tumor in her left groin. At intervals she suffered sharp pain in 
her abdomen, but it generally passed away in a short time. Two 
weeks ago she had a severe dysentery, from which she partially 
recovered and resumed her daily avocation. During this attack 
the hernia gave her intense pain. August 19th, was seized 
with pain and vomiting, and was greatly prostrated. Having 
sent for a surgeon, who tried taxis for an hour and a half with- 
out success, she was brought to the hospital. On admission 
she was very much prostrated; pulse very feeble and quick, 
eyes sunken, and countenance anxious. Had had no stool for 
forty-eight hours. On examination, there was found a small 
tumor in the left groin, above Poupart's ligament, oval in 
shape, one and a half inches in length, hard and resisting to 
the touch, and exceedingly tender upon pressure. Dr. Vance, 
house surgeon, immediately put the patient under the influence 
of chloroform, raised the foot of the bed, to gain the effect of 
gravitation, and employed taxis. After half-an-hour's manip- 
ulation, succeeded in reducing the hernia, which had been 
strangulated over twenty-four hours. Her recovery was rapid 
and complete. Discharged September 4th, with a truss. De- 
ported by T. B. Cross, H. D., House Surgeon. 
Case XLIX.-Inguinal hernia, probably indirect; strangu- 
lated several hours ; successf ul taxis by Dr. Stoddard ; 
recovery. 
Charles McBruen, aet. 39. Admitted to Bellevue Hos- 
pital, ward 13, April 16, 1868. Has had double inguinal 
hernia several years. Has worn a truss constantly-the 
hernia on the left side being the larger-during sleep; 
the night before his admission, his truss slipped off, and 194 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
on awaking he found himself unable to reduce the hernia. 
On admission a large tumor was found in the left groin, 
which was hard, painful, and tender on pressure. There 
were no other symptoms of importance. Taxis was imme- 
diately employed, but without success. Cloths wetted in hot 
water were constantly applied to the tumor, and the patient 
put under the influence of ether. Taxis was again resorted 
to, and, after continued efforts for twenty minutes, a small 
mass of hardened faeces passed through the constriction, and 
the gut was immediately returned by Dr. Stoddard. A com- 
press and a spica bandage were applied. The patient was dis- 
charged April 18th, having had no bad symptoms whatever. 
Reported by T. B. Cross, JI D., House Surgeon. 
Case L.-Indirect inguinal hernia ; strangulated ; probably 
never completely reduced; no operation; death on four- 
teenth day. 
Bernard Ruin, jet. 36. Admitted to Bellevue Hospital, 
Angust 25, 1868. Has had a hernia for eight years, which 
came on immediately after violent exertion. At first it was 
very small, and, as the patient constantly wore a truss, it caused 
him little or no inconvenience. Two days before admission, 
August 23d, however, the tumor grew very large, and, being 
unable to reduce it, he called a surgeon, who supposed he had 
succeeded after two hours' taxis. After the reduction, however, 
he suffered severely from pain in the abdomen and vomiting. 
He* was brought to Bellevue Hospital, ward 5, and, on exami- 
nation, a large scrotal hernia was found on the left side, which 
could be easily reduced, but not retained. The external ring 
was very large. Patient still continued to suffer pain, accom- 
panied with retching and vomiting. The testicle could be 
detected within the external ring.-August 28. Patient more 
comfortable to-day; vomits, and has pain occasionally.-August 
31st. Has had no passage from his bowels for two days; ab- 
domen very tympanitic. Turpentine stupes and hot fomen- 
tations applied.-September 1st. Materials ejected from the 
stomach of a green color. Bowels wTell moved by Croton oil.- 
September 2d. Tenderness, tympanites and vomiting have dis- 
appeared.-September 3d. Appetite returning, respiration in- ABDOMINAL HERNIA. 
195 
creased in frequency.-September 4. Passed a lumbricoid this 
morning; vomits now and then; at 7 p. m., patient delirious 
and bathed in perspiration; pulse very feeble ; respiration 
oppressed ; eyes sunken and features pinched. Given brandy 
and laudanum ; pain in back; at 10 p. m. very weak; pupils 
did not respond to light; convulsive movements of muscles of 
the face, and slight opisthotonos. Died at 10.30 p. m. No 
autopsy. Reported by T. B. Cross, II. I)., House Surgeon. 
C.-Incarcerated Indirect Inguinal Hernia. 
Case LI.-Indirect inguinal hernia; probably omental ; 
incarcerated thirty days ; reduced in ten days, after taxis 
had failed, by rest, laxatives, and cool water dressings. 
Michael O'Hara, set. 29, admitted to the Buffalo Hospital 
of the Sisters of Charity, October 5, 1850, with an irreducible 
oblique hernia. He had discovered the hernia first about 
eighteen months before admission. It had often been down, 
but he had reduced it always easily; but it had now been down 
twenty days, and he was unable to get it back. The tumor 
felt solid, and was flat on percussion. It was tender and 
somewhat painful. His bowels had moved several times 
since it became incarcerated. He had no nausea or vomiting. 
It was diagnosticated as an incarcerated omental hernia. We 
made repeated efforts to reduce it, but without success. 
I then directed that he should remain in bed, with the hips 
and thighs somewhat elevated-that his bowels should be kept 
gently open, and cool water lotions applied to the tumor. 
From this day it gradually receded, and on the tenth day after 
admission it had disappeared entirely. Its disappearance was 
throughout gradual, at least so the patient informed us. 
Remarks.-In this case the incarceration was probably not 
due to any adhesions, but only to the congestion of the omen- 
tum, and possibly also to some swelling of the neck of the sac. 196 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
CHAPTER II.-DIRECT INGUINAL HERNIA. 
A.-Enterocele. 
Case LII.-Direct inguinal hernia ; enterocele ' strangula- 
ted six hours ; operation under ether ; division of stricture 
within the sac ; reduction; recovery. 
Michael McCarty, set. 42. Admitted to the Buffalo Hos- 
pital of the Sisters of Charity, November 3, 1852. A direct 
inguinal hernia had existed upon the left side several years, 
lie had generally worn a truss, but it had never been well re- 
tained. On the morning of November 3d, while lifting, it sud- 
denly protruded below the truss, and at once gave him great 
pain. He tried himself to reduce it, but was unable to do so. 
He walked to the hospital within an hour after the accident, 
and attempts were immediately made by the house surgeon to 
accomplish its reduction, but without success. When I saw 
him, six hours after the strangulation occurred, he was vomit- 
ing, and was suffering great pain, both at the point of stricture 
and in the abdomen. After about twenty minutes' trial of 
taxis by myself, he was put under the influence of chloroform, 
and the operation made. The sac contained intestine only, 
filled with gas and hardened faeces. It was much congested, 
but not adherent. The stricture was divided-after a careful 
examination as to the character of the hernia-by cutting in- 
ward toward the pubes. The intestine was then easily reduced. 
After the reduction I introduced my finger into the cavity of 
the abdomen, and, by hooking it over the outer margin of the 
ring, I could distinctly feel the pulsation of the internal epigas- 
tric artery. 
The wound was closed by sutures, and compress-except 
at the most depending point. His recovery was rapid and com- 
plete. 
C.-Incarcerated Direct Inguinal Hernia. 
Case LUI.-Direct inguinal hernia', entero-epiplocele ; in- 
carcerated seven days hy adhesions ; operation ; adhesions 
hrohen up with the fingers, and ring enlarged with the 
hnife ; reduction and recovery. 
September 14, 1858, John Murphy, set. 43, was admitted 
into the private wards of the Buffalo Hospital of the Sisters of ABDOMINAL HERNIA. 
197 
Charity, with a direct inguinal hernia of very great size, and 
which during the last seven days lie had been unable to reduce. 
Ue stated that the hernia had existed twenty years, but that 
he had never worn a truss-it had been frequently down in 
the scrotum, as it was now-and that he had always reduced it 
easily. He had no vomiting or other signs of strangulation, 
but I was unable to reduce it. I determined therefore to op- 
erate. Having carefully laid open the sac, I found it to contain 
a large mass of intestine, with a small portion of omentum ; 
considerable serum also escaped. The intestine was quite 
firmly adherent, throughout most of its surface, to the sac. 
These adhesions required considerable force to break them up ; 
but this was finally accomplished, some portions having re- 
quired the knife. The canal through which the hernia had 
escaped was narrow, but did not actually strangulate the vis- 
cera. It was enlarged by cutting upward and inward, and 
the hernia was then reduced. The wound having been closed 
by sutures, etc., the recovery took place in a short time, and he 
was discharged cured. 
Remarks.-Most of the notes of this case have been fur- 
nished to me by my friend Dr. Lucien Damainville, who was 
present, and assisted in the operation. 
It is probable that, if the operation had been delayed much 
longer, strangulation would have occurred; and that, in any 
event, the adhesions, which were certainly now not more than 
a week old, would have become much more extensive and firm, 
so as to have rendered it both more difficult and more danger- 
ous to break them up. It is worthy of note that, within a pe- 
riod of seven days, the adhesions were so strong that they 
could not be easily torn with the Unger, certainly not without 
considerable risk of tearing the intestines. 
Case LIV.-Direct inguinal hernia ; incarcerated loy adhe- 
sions ten days ; patient suffering under Bright's disease ; 
operation ly Dr. Sayre ; reduction of hernia ; recovery. 
Francis McHugh, set. 54, admitted to ward 5, male, Char- 
ity Hospital, in 1868. Direct inguinal hernia on left side; had 
existed something more than one year. Caused by a strain. 
Ten days before the operation it came down and could not be 198 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
reduced : not strangulated. Dr. Lewis A. Sayre, visiting sur- 
geon, operated in August, 1868, breaking up the adhesions and 
returning the hernial protrusion. His recovery was complete : 
but one year later the hernia is found still descending freely 
into the scrotum, yet easily reduced. He is still confined to 
his bed from Bright's disease. 
CHAPTER III.-FEMORAL HERNIA. 
A.-Strangulated, and reduced by Operation. 
Case LV.-Femoral hernia; enterocele ; strangulated four 
days; doubts as to diagnosis ; moderate taxis ; operation 
under ether; cut Gimbernatfs ligament within the sac; 
reduction and recovery. 
Mrs. Catherine Corbert, aet. 40, admitted to ward 18, Belle- 
vue Hospital, January 19, 1867, with a strangulated femoral 
hernia on the left side. She said the swelling had been coming 
gradually during the last live years. Two days before admis- 
sion she lifted a heavy weight, and it suddenly became larger 
and gave her pain. She began to vomit soon after, and the 
vomiting continued occasionally until relieved by the operation. 
The tumor on admission was tense, tender, red, and painful. 
It was not resonant on percussion, nor was any impulse com- 
municated to it on coughing. Mrs. C. was the mother of sev- 
eral children, and had a free leucorrheal discharge. A sus- 
picion arose in the mind of the house surgeon that the swelling 
was a bubo, and indeed it had very much that appearance. 
I expressed an opinion, however, that it was a hernia, but that 
the case admitted of a doubt. Accordingly, after having- at- 
tempted its reduction by taxis, and cold water applications 
having been made steadily for two days, I brought her before 
the class for an operation. I stated to the gentlemen that the 
diagnosis was not positive, but that I believed it to be a hernia. 
Having placed her under the influence of ether, the incisions 
were carefully made, through a large mass of swollen and infil- 
trated tissue, down to the hernial sac. The depth of this infil- 
trated tissue led me at one time, during the progress of the 
FIRST-ENTEROCELE. ABDOMINAL HERNIA. 
199 
incisions, to suspect that after all it might prove to be a 
bubo; but at length the sac was opened and the intestine dis- 
closed. We were not able to recognize at any step of the 
operation a distinct fascia. The knuckle of intestine was 
small, but intensely strangulated, it having assumed over a 
large portion of its surface a greenish hue, and there were 
points which presented a superficial ulceration. It was adhe- 
rent to the sac, and its anterior surface was covered with fresh 
lymph. The amount of serum in the sac was not large. 
I relieved the strangulation by a slight incision of the 
margin of Gimbernat's ligament; the edge of a probe-pointed 
knife, directed obliquely upward and inward, being pressed 
against the ligament so as to divide only the fibres on its con- 
cave margin. The adhesions having been torn up by my 
fingers, the intestine was now easily returned within the cavity 
of the abdomen, but could not be removed from the abdominal 
side of the ring, owing to certain firm adhesions which bound 
it to the mouth of the sac. The wound was then closed and 
the patient was returned to her bed. 
During the first twenty-four hours after the operation, one 
grain of opium was given every four hours. On the second 
day, the same quantity was given every six hours. On the 
third day the opium was discontinued. 
Vomiting occurred only once after the operation, and the 
bowels moved spontaneously on the third day. 
February 25th, a little more than one month from the date 
of the operation, the wound was closed, and she was able to 
sit up. 
Soon after this she was discharged cured. One year later 
an examination of the wound showed a firm cicatrix, and, 
although she was wearing a truss, I could discover no tendency 
in the hernia to protrude. 
Remarks.-In relation to the difficulty of diagnosis in 
this case, the reader is referred to the remarks upon case LX. 
The large size of the swelling was due not so much to the 
amount of intestine protruded, and to the serum in the sac, as 
to the engorgement of the tissues outside of the sac, and this 
circumstance, especially, led those who first examined it to the 
conclusion that it was a bubo. The result is another confirma- 200 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
tion of the soundness of the principle to operate in all cases of 
doubt. 
I have not stated, I think, that this patient said the tumor 
in her groin was at first, and for a long time, movable. She 
could move it about, she said. The same fact has been noted 
in other cases of femoral hernia, especially in women, in whom 
the cellular tissue is more loose, usually, in this region than 
in men. Such a statement made by the patient must not be 
considered, therefore, as proof that the tumor is an enlarged 
gland. 
Case LVI.-Femoral hernia ; enterocde; incarceratedlnj old 
adhesions ; strangulated by Iley's ligament; inflammation 
and suppuration of sac ; operation ; death. 
Mrs. Frederick, aet. 53, of Buffalo, N. Y., had a femoral 
hernia on the right side since she was about 33 years of age, 
caused originally by lifting, but it never disappeared after she 
first discovered it. It slowly but steadily increased in size. 
April 16, 1853, it suddenly became much larger, while lifting, 
causing abdominal pains and vomiting. Dr. Weiss was called 
and attempted to reduce it by taxis, cold applications, etc. 
April 18th, two days after the strangulation commenced, I saw 
the patient, with Dr. Weiss. She was then vomiting stercora- 
ceous matter ; bowels had not moved in forty-eight hours ; and 
she was suffering acute pain in the tumor and in the abdomen 
generally. The hernia had escaped from the saphenous open- 
ing and lay upon the fascia lata, its long axis being directed 
upward and outward, almost parallel with and only slightly 
below Poupart's ligament. 
Having no anaesthetic, and the necessity for the operation 
seeming urgent, I at once proceeded to operate, assisted by 
Drs. Weiss, Daniels, Cotes, etc. Ice having been applied to 
the skin for about three hours, its sensibility was found some- 
what diminished. No vessels required the ligature. The sac 
was inflamed, thickened, and filled with offensive pus; over 
more than half its surface it was firmly adherent to the intes- 
tine, which alone constituted the hernial protrusion. These 
adhesions were too close and too strong to be separated by 
either the knife or the fingers. The knuckle of intestine was of ABDOMINAL HERNIA. 
201 
a dark-brown color, but neither ulcerated nor sloughing. 
Having divided Iley's ligament, I carried my finger up to the 
crural ring, and found there was no stricture at this point, the 
finger passing easily into the cavity of the abdomen, but, as the 
adhesions could not be divided, the hernia could not be reduced, 
except partially, a small portion still remaining in the crural 
canal. Leaving the intestine in this position, the 'wound was 
closed by compress and bandage. 
Four days later the patient died, the vomiting having con- 
tinued after the operation as before, and the bowels not having 
been moved. 
The autopsy, made on the following day, showed the intes- 
tine still in the crural ring, and so firmly adherent to the sac 
that in the attempts to tear it away, the intestine was ruptured. 
There was not the slightest strangulation at the crural ring. 
The whole surface of the peritonaeum, below the umbilicus, was 
covered with lymph, which had been recently deposited. It 
was apparent, therefore, that this patient had died of peritoni- 
tis, and of intestinal obstructions, caused by the displacement 
and attachment of the gut in the canal. 
Case LVII.-Femoral hernia; recent; strangulated; ope- 
ration; recovery. 
Mary Carney, set. 45, fell, while intoxicated, down a cellar 
stairway, striking her belly upon the top of a barrel. Dr. 
Wilcox, of Buffalo, was called the following morning, Sep- 
tember 5, 1856, and found her suffering from the contusions 
in her belly and groin, but, as she had never spoken of a hernia, 
and as no positive symptoms of a strangulation were present, 
the nature of the accident was not suspected. 
On the following day I was requested to see her in consul- 
tation. There was much contusion and swelling in the right 
groin, but it was diffused and undefined in its limits. Pressure 
over any portion of the lower part of her abdomen caused pain, 
but she was especially sensitive over the region of the external 
crural ring. The swelling at this point was the greatest, and 
had a feel of elasticity. The tenderness was too great to allow 
of any pressure equal to taxis. She had acute, paroxysmal 
pains in the umbilical region, accompanied with vomiting and 202 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
great prostration. The existence of a femoral hernia was sus 
pected, but not confirmed. We ordered cold water applica- 
tions, and rest in the horizontal posture, with half a grain of 
morphine. 
We saw her again the next day, and found no improve- 
ment. Her bowels had not moved since the occurrence of the 
accident. 
The suspicion was now so strong that we had to deal with 
a strangulated femoral hernia, that it was decided to operate. 
She was at once placed under the influence of ether, and the 
operation made by myself, assisted by Dr. W. 
The superficial structures, when exposed by the knife, were 
seen to be much infiltrated with blood and serum; and the sac 
was found lying directly over the external crural ring, of a 
globular form, and not thrown upward, as in most cases of slower 
development. The sac was opened, bringing into view a 
knuckle of intestine of considerable size, dark with venous 
congestion, and covered with some flakes of lymph. Taxis 
was attempted, but without success. I then cut carefully the 
free margin of Gimbernat's ligament, to the extent of about 
one line, and, forcing my index finger in between the ligament 
and the intestine, I enlarged the opening by tearing. The 
hernia was now easily reduced. Her recovery was slow but 
complete, and a few months later she applied to me for a truss. 
SECOND.-ENTERO-EPIPLOCELE. 
Case LVIII.-Femoral hernia; entero-epiplocele ; strangu- 
lated nine days ; vomiting of stercoraceous matter ; opera- 
tion under chloroform ; stricture at Hey's and Gimbernat's 
ligaments ; division of both ; extensive adhesions ; excision 
of large portion of omentum ; reduction and recovery. 
Mrs. Catherine Welch, set. 50, much emaciated and feeble, 
was admitted to Buffalo Hospital of the Sisters of Charity, Oc- 
tober 7,1856. Mrs. W. had a femoral hernia on the right side 
many years, which never disappeared entirely, but at some 
times was larger than at others. She had always been able to 
reduce it by pressure, however, when it enlarged. Nine days 
before admission it was forced down by an effort in lifting, and 
she could not reduce it. A surgeon was called, but he failed ABDOMINAL HERNIA. 
203 
also. The symptoms of strangulation were at first moderate, 
but they gradually increased in severity, the bowels did not 
move, vomiting occurred, and on the eighth day she began to 
vomit stercoraceous matter. On the following day she was 
brought to the hospital. She was now exceedingly prostrated. 
The hernia, having passed the saphenous opening, was reflected 
upward, over the falciform process of the fascia lata, and lay 
fairly upon Poupart's ligament, inclining upward and inward 
toward the pubes. It was oblong in shape, and measured 
about six inches in its longest diameter, by about three in its 
shortest. 
Having administered chloroform, assisted by my house 
surgeon, Dr. Lemon, I divided the integument over the long 
diameter of the tumor. The fasciae and peritoneal sac were 
thickened. A copious discharge of straw-colored serum fol- 
lowed the incision into the sac, bringing into view a large mass 
of omentum, of a pink color, and firmly adherent to the sac at 
many points. The superficial veins of the omentum were 
large and full of blood. Posteriorly, and to the inner side of 
the omentum, was a still larger mass of intestines, of a dark- 
claret color, covered here and there with exudations of lymph. 
The intestines were not adherent to the sac, bul the convolu- 
tions were glued together by recent deposits. 
Both the omentum and intestine were strangulated over 
the falciform margin of the fascia lata, and this was cut upward 
and outward by a probe-pointed bistoury. Attempts to tear 
the adhesions between the omentum and sac having proved 
unsuccessful, I cut away a large portion of the omentum, which 
was found to be quite solid, and no bleeding of consequence 
occurred from the cut surface. Finding still that neither the 
intestine nor the remnant of the omentum could be returned, I 
examined the crural ring, and found a second point of constric- 
tion at Gimbernat's ligament. The crescentic margin of this 
ligament was then divided by a slight incision, and now the 
intestine was easily returned, and the omentum followed spon- 
taneously. No attempt was made to confine the omentum at 
the orifice of the ring, and indeed I think it was retained near 
this point by adhesions at the neck of the sac. 
The wound was closed with sutures. A pledget of lint 204 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
moistened with cold water was applied, and half a grain of 
morphine administered by the stomach. 
Soon after the operation was completed, the bowels moved 
spontaneously, evacuating a large quantity of liquid fecal 
matter. She took half a grain of morphine again at night, and 
during the following three days she took half a grain daily. 
Fomentations of warm water were also applied to the bowrels 
constantly after the first day. Her bowels did not move again 
until the fifth day, when she was ordered half an ounce of 
castor-oil. This not having caused a movement, she took half 
an ounce of sulphate of magnesia on the sixth day, from which 
a free movement was obtained ; most of the wound had closed 
by first intention on the fifth day. The sutures were removed 
on the seventh, and, on the twenty-fourth day, the wound having 
entirely closed, and her recovery being considered complete, 
she was discharged from the hospital. 
^Remarks.-In this case, as in Cases XXXVIII. and LIX., 
the omentum had been incarcerated by adhesions, probably 
some years before the strangulation occurred, and it is 
doubtful whether the symptoms which finally created the 
necessity for the operation wrere not due altogether to the 
escape and strangulation of the intestines. 
The excision of the omentum, practised also in Cases 
XXXVIII. and LIX., was followed by no bleeding from the 
cut surface, although the surface had a pink color, and it might 
have been supposed that the interior would prove to be unu- 
sually vascular. A stricture was found at two points, namely, 
at the saphenous opening and at the crural ring, requiring a 
division of both before the mass could be returned, although 
it had been previously reduced in size by excision of a portion 
of the omentum. 
Case LIX.-Femoral hernia ; entero-epiplocele ; strangu- 
lated ; operation and removal of portion of omentum ' 
complete recovery. 
A woman, about fifty-five years of age, was admitted to 
ward 9, Charity Hospital, Blackwell's Island, in February, 
1865, with a strangulated femoral hernia of the right side. 
Having placed her under the influence of ether, I operated, and ABDOMINAL HERNIA. 
205 
found the stricture at the femoral ring. The sac contained 
both intestine and omentum. The omentum was quite firmly 
adherent to the sac at its neck. I divided the stricture with 
a long, narrow, probe-pointed bistoury, by cutting upward and 
inward toward Gimbernat's ligament. The intestine was then 
easily reduced, but the omentum could not be made to retire, 
on account of the adhesions. I therefore cut away a large 
portion of the omentum, and left the remainder in situ. No 
vessels in the omentum required ligatures. The wound was 
closed without sutures, by adhesive plaster, compress, and 
bandage. 
A few days later I found the wound open, and a knuckle 
of intestine plainly in sight, but not protruding. It had al- 
ready become adherent to the sac near its neck, and was not 
in the least strangulated, therefore I permitted it to remain. 
The wound gradually closed, and finally, after several weeks' 
confinement, the cure was complete. 
Remarks.-The frequency of adhesions of the omentum to 
the sac, in femoral hernia, will be referred to more particularly 
hereafter. 
Excision of the omentum with a favorable result, was prac- 
tised also in cases XXXVIII. and LVIII. In neither case 
were ligatures required. 
The gaping of the wound, and consequent exposure of the 
intestine, would probably have been prevented had the wound 
been closed, as is my usual practice, with sutures. 
Case LX.-Femoral hernia ; entero-epiplocele ; strangula- 
ted; operation', death. 
Mrs. Elizabeth Craigie, jet. 48, of Rochester, N. Y., was 
seized November 4, 1840, with a severe pain in her abdomen, 
near the umbilicus, unattended writh soreness, and which she 
considered an attack of colic. No cause could be assigned by 
herself for this sudden attack, nor was her physician, Dr. Arm- 
strong, a gentleman of large experience, able to find an expla- 
nation. She was bled from the arm, and a dose of laudanum 
was administered; after which the severity of the pain was 
considerably abated. On the following day, November 5th, 
the attention of Dr. Armstrong was called to a small tumor 206 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
in the left groin, of the size of a hazel-nut, which upon exami- 
nation he believed to be a femoral hernia. Later in the day, 
Dr. Moore, a distinguished surgeon of Rochester, and myself, 
were called in consultation. After a careful examination, we 
expressed to Dr. Armstrong our opinion that it might be an 
enlarged gland. At least, it did not seem to us quite certain 
that it was a hernia. The grounds for this opinion were as 
follows: First. When a girl, a similar swelling existed at this 
point for several years, which was unaccompanied with pain, 
did not appear and disappear at intervals, but remained per- 
manently for a long time, and then gradually went away. She 
had always spoken of this as a " kernel." Second. She had 
never seen any other swelling in the groin until she discovered 
this to-day. Third. This tumor was not tender or painful, 
all the pain which she now suffered being referred to the belly, 
and especially to the umbilical region. Fourth. The tumor 
was small, hard, and could not be reduced or diminished, after 
we had made prolonged taxis. Fifth. She had long been 
subject to similar attacks of pain, etc., in her bowels, which 
never, to her knowledge, had been accompanied with a simi- 
lar swelling, but which had always been called colic, inflam- 
mation of the bowels, cholera-morbus, etc. Sixth. This pres- 
ent attack was preceded by a similar attack only a week or 
two before, of which she recovered without any medical aid. 
For all these reasons she was herself convinced that the swell- 
ing in the groin had nothing to do with her present symptoms. 
Her mother had died of a strangulated femoral hernia; and 
she was herself an intelligent Scotchwoman, having a full 
appreciation of what a hernia signified. 
Dr. Moore and myself concurred fully in the opinion that 
it was probably an enlarged gland, but that, after all, it might 
prove to be a hernia; but the symptoms had abated very much 
in severity, and we determined to delay surgical interference, 
advising her that, if the tumor should increase in size, or the 
pain and vomiting should return, we should be immediately 
notified. 
On the following day (November 6th) we saw her again, 
and no change had occurred in the swelling, but her abdominal 
symptoms had still further improved. ABDOMINAL HERNIA. 
207 
During the evening of November 7th the pain returned 
with severity, and the tumor in the groin was found enlarged ; 
but I was not called until the morning of the 8th, when I found 
the tumor quite large, elastic, tender, and painful. The vom- 
iting and abdominal pains had returned, her pulse was very 
feeble, and her general system was greatly prostrated. The 
fact that we had to deal with a strangulated hernia was now 
settled beyond doubt. 
In the presence of Drs. Armstrong, Dean, Moore, Pope, 
Ford, and others, I proceeded at once to operate. A crucial 
incision was made over the tumor. The integuments with fat 
and areolar tissue were nearly one inch in thickness. The sac 
contained, first, about half a gill of pus, with a little serum 
and lymph; second, omentum, considerably adherent to the 
sac at various points, and presenting here and there upon its 
surface minute points of ulceration; third, behind the omen- 
tum a small knuckle of intestine, of a dark-brown color. 
The stricture was found to be at Gimbernat's ligament. This 
was divided by directing tlie cutting edge of the knife inward. 
Cutting the stricture caused a sharp and severe pain. The 
intestine was then easily reduced, but the omentum was re- 
turned with difficulty, owing to the existence of quite firm 
adhesions at the situation of the internal opening. 
The pain caused by cutting the stricture continued and 
steadily increased after the operation was completed, extend- 
ing up to the epigastric region. The vomiting also continued 
unabated. The bowels did not move, and the patient died in 
about twenty hours. 
Autopsyy a few Hours after Death.-The omentum and 
intestine were completely within the abdominal cavity, and in 
no way constricted. The omentum was, however, still firmly 
adherent to a portion of the crural ring by both short and long 
bands, some of which -were evidently ancient. The intestine 
which had been strangulated was of a dark-purple color, but 
not gangrenous ; over a large portion of the peritoneal surface 
there were patches of lymph, with recent adhesions. The 
cavity of the abdomen contained no pus or blood. 
Remarks.-The history of this unfortunate case is full of 
instruction. We cannot doubt now that the "kernel" which 208 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
this woman had first noticed many years before, at the pre- 
cise point where we finally proved the existence of a hernia, 
was in fact incarcerated omentum, which gave her at the time 
no trouble, but which gradually receded and disappeared from 
the surface. At a later day, when she became subject to at- 
tacks of " colic," etc., it was this same omental hernia, still 
lying within the internal ring, held fast by adhesions, which 
did not permit it to descend through the external saphenic 
opening, and which piece of omentum occasionally became 
strangulated; or, what is quite as probable, a small knuckle 
of intestine occasionally descended behind the omentum a 
short distance, and then became strangulated, of which stran- 
gulation it was after a time relieved by the spontaneous with- 
drawal of the intestine; which withdrawal is, I believe, some- 
times effected by the mere act of vomiting. 
Iler mother had died of a strangulated femoral hernia, 
illustrating the occasional hereditary anatomical formation pre- 
disposing to hernia. 
We cannot be certain of this fact, but the sudden increase 
in the size of the tumor, and the aggravation of all' the symp- 
toms, during the night of the 7th of November, may imply 
that up to this moment only omentum was engaged in the 
stricture, and that these added phenomena indicated the first 
protrusion of the intestine. The fact, also, that the intestine 
was not adherent at any point, would tend to confirm this 
view. 
We do not attach to ourselves so much blame for the un- 
certainty of our diagnosis, as for the omission to operate when 
we admitted the possibility of its being a hernia. The rule 
ought to be inviolable, that an explorative incision should al- 
ways be made if the surgeon entertains a doubt; especially 
since experience has generally shown that, whenever intelligent 
surgeons have entertained a doubt whether it is a femoral her- 
nia, or an enlarged inguinal gland, the result has proved that 
it was a hernia. I shall relate one other case, which has come 
under my own observation at Bellevue Hospital, illustrating 
this statement, and many more have been recorded. Samuel 
Cooper says: " It is frequently mistaken for an enlarged 
gland." Gibson has said the same. See also Dunsjison's 
O o ABDOMINAL HERNIA. 
209 
Medical Library, vol. iv., p. 38. Sir Astley Cooper men- 
tions two fatal cases of this kind in his great work on Hernia, 
American edition of 1844, pp. 203, 204. 
Four unfortunate cases are related by Anderson, in his 
book on Hernia, p. 159. A case reported by Prof. D. 
Palmer, of Woodstock, Vt., in the Boston Medical and Sur- 
gical Journal, August 28, 1839, is so nearly a counterpart of 
my own case, that I think proper to quote it at some length. 
A woman, fifty-three years old, was under the care of her 
physician ten or twelve weeks, for what he considered inflam- 
mation of some portion of the abdominal viscera. At the end 
of this period, Dr. Palmer, being called in consultation, dis- 
covered a swelling in the groin. This swelling the patient 
said had been there two years-sometimes as large as at pres- 
ent, but never wholly absent. It had never caused any dis- 
comfort, and was never suspected of being a hernia. On the 
day preceding Dr. Palmer's visit, it had suddenly increased in 
size, and the signs of a strangulation became apparent. An 
attempt was made to reduce it, but without success. The 
operation was then made, and a piece of omentum was found, 
tolerably healthy in appearance, behind which was a knuckle 
of intestine of a dark color. After relieving the stricture, the 
intestine was easily returned, but, owing to adhesions between 
the sac and omentum, the latter was returned with difficulty. 
The patient died the following morning, and, on examination 
after death, the portion of intestine which had been stran- 
gulated was " black," and a part of the omentum was firmly 
adherent to the neck of the sac. Over a large portion of the 
peritoneal surfaces were deposits of fibrin, with pus, and other 
traces of both chronic and recent inflammation. 
Dr. Palmer, in the same communication, relates a second 
case in which the strangulation of a femoral hernia existed 
twenty-four hours before it was discovered, " the symptoms 
resembling those occasioned by the passage of a gall-stone 
rather than those of a strangulated hernia." 
There is one point in the history of most omental, femoral 
hernise which, if mentioned by surgical writers, has certainly 
not been given sufficient prominence, namely, that when small, 210 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
and at an early period of its progress, it generally feels quite 
as solid to the touch as an enlarged gland. 
The frequency with which we meet with irreducible femo- 
ral hernia, as a consequence of such adhesions as existed in 
this case, has been noticed by Mr. Birkett, in Holmes's Surgery ; 
and he has referred also to Pott, Sir Astley Cooper, and es- 
pecially Mr. Bryant, as having observed how often recent 
enteroceles, in this situation, have been found irreducible and 
strangulated, although they are not generally adherent. 
Case LXI.-Femoral hernia ; entero-epiplocele ; strangu- 
lated; operation ; ligation and excision of omentum; 
death. 
Irishwoman, aged about fifty years, admitted to ward 18, 
Bellevue Hospital, June 27,1865, with a strangulated femoral 
hernia of the right side. The hernia had existed many years, 
but it had been very well retained with a truss. She is 
the mother of eight children. The hernia came down six 
days before admission, and two surgeons tried, but failed, to 
reduce it. The tumor was now three and a half inches in 
length, extending from the external saphenous opening up- 
ward and outward. No impulse communicated to the tumor 
on coughing. 
Operation, at twelve o'clock at night, under influence of 
ether. Reached the sac in four or five incisions ; tissues much 
infiltrated; could not recognize the fasciae, owing to the great 
infiltration of the tissues with serum. A large mass of omen- 
tum occupied the sac, beneath which was a small knuckle of 
intestine. The intestine was congested, and of a brown or 
brick-dust color. It was not adherent. The omentum was 
hypertrophied, but not ulcerated. It was attached to the in- 
ternal ring, and to the peritonaeum a little above the ring, by a 
single, firm band, which was evidently an old adhesion. The 
remainder of the omentum was attached everywhere to the 
sac by short and recent adhesions. There was no serum in 
the sac. 
I tore away the recent adhesions, and cut that portion of 
the old fibrous band which was within the neck, before I was 
able fairly to reach the point of stricture at the internal ring. ABDOMINAL HERNIA. 
211 
I then cut upward and inward against Gimbernat's ligament, 
and enlarged the small opening thus made by tearing it with 
my finger. I now reduced the intestine easily. The omen- 
tum was too large to be returned with safety; I therefore 
placed a strong ligature about the omentum, near the inter- 
nal ring, and cut it off. Pushing the stump well up, I left the 
ligature hanging out of the wound. 
No vessel required a ligature during the operation. A 
compress and bandage were then applied. Iler bowels, which 
had not been moved in six days, were relieved, soon after the 
operation, by a copious and very offensive evacuation. This 
was not occasioned by physic, at least not by physic taken 
after the operation, but was spontaneous. Other movements 
of the bowels soon followed, and these continued to recur in 
spite of opiates, causing great prostration, until about forty- 
eight hours after the operation, when she died. No nausea 
followed the operation, and I am disposed to ascribe the severe 
and persistent diarrhoea to the ether; an effect which I have 
observed several times before, especially when nausea and 
vomiting do not occur. There was at no time following the 
operation any sign of peritonitis. The friends would not allow 
an autopsy. 
B.-Femoral Hernia, strangulated; reduced without a 
Surgical Operation. 
Case LXIL-Femoral hernia ; enterocele ; strangulated eight 
hours ; reduced hy taxis, aided hy posture, after simple 
taxis had failed. 
September 22,1855.-Mrs. P., of Buffalo, aged forty. First 
discovered the hernia eighteen months before. One year pre- 
vious it had become strangulated, and her physician, Dr. Doo- 
little, applied over the hernia a tobacco-poultice, which caused 
nausea, and the hernia retired. When seen by me, it had 
been strangulated eight hours. It was very painful. She 
had tried to reduce it herself, and had applied tobacco, but 
to no purpose. She was much nauseated, but whether from 
the strangulation or the tobacco could not be determined. 
Taxis was first attempted as she lay upon the bed, but 212 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
without success. We then lowered her head and shoulders, 
and raised her legs and hips with blankets and pillows, and in 
about five minutes the reduction was accomplished. 
Case LXIII.-Femoral; strangulated ; reduced by taxis. 
Mrs. Maria O'Rourke, aged sixty. Had a hernia for many 
years, which had often been slightly strangulated, causing 
severe colic pains. May 26, 1851, became strangulated, and 
she was unable to reduce it. Found her, after the lapse of 
several hours, vomiting and suffering severe pain about the 
umbilical region. Some pain and tenderness in the region of 
the hernia. She had taken physic, but her bowels had not 
been opened. I placed her in bed, in the usual position for 
the reduction of femoral hernia, and by steady taxis the hernia 
was reduced in about ten minutes. 
Case LXIV.-Strangulated femoral hernia ; supposed reduc- 
tion by manipulation, resulting in artificial anus ; cure. 
In January, 1860,1 was requested to go to the town of 
Alden, Erie County, to see-in consultation with Dr. Den- 
nison-Mrs. J. R , aged sixty, who had a strangulated 
femoral hernia. It had been strangulated two weeks. I was 
unable to go, and another surgeon, of large experience, went 
in my place. 
Subsequently I was consulted in relation to the same case, 
and learned that it had been reduced by manipulation. Ten 
days after the supposed reduction, she had a spontaneous dis- 
charge of fecal matter by the rectum. About two weeks later, 
a slough formed at the seat of the hernia, and the contents of 
the bowels escaped by the opening thus made. 
The fteces continued to discharge by the artificial anus 
several weeks, but it gradually closed, and the contents of the 
bowels resumed their natural channel. 
When I last heard from this patient, the artificial anus 
had been closed six weeks, and she considered herself well. 
Case LXV.-Femoral hernia', strangulated ; partly reduced 
by taxis ; patient refused to be operated upon ; death on 
the twelfth day. 
August 15,1853, in consultation with Dr. H., of B . Pa- 
tient a German woman, who had a femoral hernia on the right ABDOMINAL HERNIA. 
213 
side ten years. At the time of our visit the hernia had been 
strangulated nine days, and we were informed that, after the 
bleeding and taxis, which had been performed the previous 
day, the size of the tumor was somewhat reduced, and she had 
experienced no pain. Slight vomiting, however, continued. 
The hernia was not tender to the touch. 
No further attempt was made to reduce the hernia, but 
she was advised to submit at once to an operation. This she 
declined, for the reason that she felt much better. 
August 18th, twelve days after the strangulation com- 
menced, she died. No autopsy was obtained. 
Case LXVI. - Femoral hernia; probably intestinal and 
adherent; strangulated; partially reduced by taxis ; a/r- 
tificial anus; death on the fourteenth day, without 
operation. 
Mary Maddox, aged twenty-eight, admitted to Bellevue 
Hospital, ward 28, June 25, 1868. Had a femoral hernia on 
the left side eight years. Never wore a truss, nor had the tumor 
ever been reduced. Three days before admission, while ex- 
erting herself, was seized with pain and vomiting, which con- 
tinued up to time of admission. On admission, June 25th, 
patient was nervous, restless, and occasionally vomited a small 
quantity of stercoraceous matter. Had passed nothing from 
her bowels for three days, nor could she retain any food. 
The tumor was about the size of a hen's egg, with an indurated 
base, tympanitic and crepitant. Taxis was immediately ap- 
plied by the house surgeon, Dr. Lock wood, without suc- 
cess. The visiting surgeon came, and employed taxis, and 
reduced a portion of the tumor. No crepitation felt afterward. 
Patient's skin now cold and clammy, but she felt less pain.- 
June 26th, retained some brandy. No perceptible improve- 
ment.-June 27th, is better; pulse 100, surface warm, no 
vomiting; takes brandy, beef-tea, and ice-water. Breath very 
offensive; has had no passages from her bowels.-June 28th, 
some tenderness over the abdomen, with tympanites, pulse 
104, breath has a fecal odor, no tenderness, nor crepitation in 
the tumor.-June 29th, pulse 112, very restless, flatulent.- 
July 1st, pulse 130. Patient more quiet, has a desire to defe- 214 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
cate, breath still very offensive, surface warm, retained her 
nourishment, tumor red, fluctuating, and increased in size. 
Patient continued to grow weaker until July 6th, when she 
died. Reported by T. Cross, House Surgeon. 
Remarks.-The fact does not appear in the records, but the 
surgeon states that, prior to the death of the patient, it being 
suspected that there was an escape of the contents of the her- 
nial sac, he opened the tumor, and gave exit to fecal matter, 
forming thus an artificial anus. 
The autopsy gave no additional information. 
Median Ventral Hernia. 
Case LXVH.-Median ventral hernia, consequent upon 
atrophy of the rectus abdominis, in a woman laboring 
under cancer of the uterus. 
Mrs. Angeline Edler, aged thirty years, admitted to Buf- 
falo Hospital of the Sisters of Charity, October 17, 1850, with 
cancer of the neck of the womb. March 28, 1851, discovered 
that she had a hernia in the median line of the abdomen, ex- 
tending from the ensiform cartilage to the pubes, elliptical in 
form, being several inches in width a little below the umbili- 
cus, at which point it attained its greatest breadth, and ter- 
minating in a sharp angle above and below. The hernia 
occupied the situation of the rectus abdominis, and seemed to 
be due alone to an atrophy of the muscular and tendinous 
fibres. She said she had noticed this first about three months 
before. The uterus was not appreciably enlarged, nor was 
her abdomen tumid. She had given birth to two children some 
years before. Before admission to the hospital, she had ac- 
cidentally fallen against the corner of a table, striking the 
belly, and thus had caused a miscarriage at three months. 
On the 11th of June following her admission, she died, and 
the autopsy confirmed the existence of cancer of the neck of 
the uterus, with moderate enlargement of the body of the 
uterus. The rectus-abdominis muscle had nearly disappeared, 
and the oblique muscles were also somewhat atrophied. Her 
whole body was much emaciated. ABDOMINAL HERNIA. 
215 
Case LXVIII.- Ventral hernia, probably caused by lacera- 
tion of the linea alba during labor, extending from the 
ensiform cartilage to the pubes. 
Mrs. Wilson, aged thirty-three, a large muscular woman, 
and the mother of five children. She was in labor with her 
last child about three hours. Three days after the birth of 
the child she left her bed, and then discovered the protrusion. 
She consulted me seven weeks after the birth of the child. 
I found an elliptical hernia, extending from near the ensi- 
form cartilage to the pubes, not so wide as in the preceding 
case at its centre, but with its margins more sharp and more 
clearly defined. It was evidently due, not to atrophy of the 
rectus abdominis, but to a laceration of the tendinous struc- 
ture of the linea alba. She stated, however, that she was not 
unusually large before the birth of the child, her labor was 
not unusually severe, and she had not felt at the time any 
yielding or tearing of these parts. 
I recommended that she should wear a band, constructed 
with gores, so as to fit the surface of the abdomen perfectly, 
stayed along the sides and back with whalebone, secured in 
place by a strong cord laced along the back; the centre of 
the stay, where it came together posteriorly, being one or two 
inches on one side of the spine-and, if found necessary, to add 
shoulder-straps, to prevent its sliding down. 
I have thought it proper to designate the form of ventral 
hernia described in the two preceding cases, " Median Ven- 
tral." Such herniae are not very infrequent, as the result of 
laceration of the tendinous structure of the linea alba, in con- 
sequence of severe labor; but I think it is unusual to find it of 
such great length, and occasioned by a labor so easy and short 
as in the case of Mrs. Wilson. 
Cases not classified. 
Case LXIX.- Varicose veins in vagina, simulating vaginal 
hernia. 
August 29,1854, Mrs. AV. S. consulted me in relation to a 
supposed vaginal hernia. She was a young married woman, 
in excellent health, and eight months gone with her first child. 
About two months before, she began to feel something descend 216 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
in her vagina when she stood erect, and especially when she 
lifted. Examining her in the erect posture, a tumor was dis- 
covered in the vagina, on its posterior and left lateral wall, 
occupying the upper two-thirds of the canal; pyriform in 
shape, being about three inches in length by one inch and a 
half at its widest part; its neck terminating above posteriorly, 
and to the left side of the vaginal cul-de-sac. It was tense, 
elastic, but, being grasped firmly, the interior felt like a bun- 
dle of large earthworms. Upon the surface of the left labium 
a number of large varicose veins were discovered. 
Pressing upon the tumor more firmly, while she was still 
standing, it was made gradually to retire, and finally to disap- 
pear altogether; but its disappearance was not accompanied 
with any gurgling sensation, nor was I able at this time, or in 
my subsequent examinations, to find any orifice through which 
it had escaped. 
In the recumbent posture it retired very slowly, without 
pressure. 
I attended this lady in her confinement, October 10,1854. 
Her labor was natural and rapid. As the head descended in 
the superior strait, I thrust the tumor back with my fingers. 
It would, however, occasionally get in front of the head; but 
it was always easily replaced by the finger; and at other 
times the descent of the head would alone seem to reduce it. 
Finally, when the head fairly entered the inferior strait, it 
ceased to protrude altogether. 
In June, 1857, I attended Mrs. S. in her second labor, at 
the full period. The tumor had increased some since the 
first examination, and had annoyed her considerably during 
the period of gestation; but the labor was again rapid, and 
accomplished with no more difficulty than in the first instance. 
In the period which intervened between the gestations of 
the first and second child, she had experienced occasional in- 
convenience from its descent, and for a portion of the time 
she had worn, at my suggestion, and with comfort, a simple, 
broad perineal band, made fast behind and in front to a broad 
pelvic band. 
Remarks.-I have thought it proper to introduce this case ABDOMINAL HERNIA. 
217 
because I at one time supposed it was a hernia, but subse- 
quently my opinion was changed. 
Its peculiar feel, the existence of varicose veins in the cor- 
responding labia, and the fact that it always retired without 
the sensations which are usually felt on the recession of a 
hernia, and my inability to find any opening after its reduc- 
tion, are conclusive as to its character. Moreover, vaginal 
hernias, containing either intestine or omentum, seldom, if 
ever, occur, except low down in the vaginal canal. 
Case LXX.-Traumatic ventral hernia, containing intestine 
and the hidney • no operation ; death in twenty-four hours. 
John Bradley, aged 25, admitted to Bellevue Hospital, 
ward 5, April 25, 1867. While riding on a street car, the 
car came in collision with a truck, the shaft of which struck 
him in the abdomen, and forced him through the window 
and woodwork of the back of the car. He was immediately 
brought to Bellevue Hospital, and on admission complained 
only of general pain. Upon examination, a large tumor was 
found in the umbilical region, about six inches in diameter, 
with a broad base, apparently fluctuating, non-pulsatory, 
dull on percussion, and having very thin walls. Its centre 
was very greatly ecchymosed, and the whole surface more 
or less discolored. The tumor was situated a little to the 
left of the median line, below the level of the umbilicus, in 
the course of the epigastric artery. Auscultation revealed 
no murmur. In view of these points it seemed reasonable 
to suspect rupture of the epigastric artery, with diffuse aneu- 
rism. Most of the surgeons who examined it were of the 
same opinion. At 7 p. m., an hour and a half after admission, 
the patient had rallied ; the pulse became full and regular, and 
the temperature of the body normal. He now complained of 
intense pain in the abdomen, and lay in a semi-supine position, 
with legs drawn up. The tumor seemed to be increasing in 
size, and was still dull on percussion. Sol. snip, morph. (U. S.) 
^ss. was given at 9 p. m. Magendie's sol., tti xx, was admin- 
istered hypodermically, Friday morning, April 26th. The 
patient's expression was that of one suffering great pain. 
Tenderness was now diffused over the whole abdomen ; skin 218 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
was moderately hot; respiration increased in frequency, and 
entirely thoracic; pulse 120. There was obstinate vomiting 
of yellow, curdlike material. The whole of the tumor was now 
discolored, being of a dark-purple hue, while the integument 
around it was of a copper tint. The discoloration of the in- 
tegument of the right side extended from the axilla to Pou- 
part's ligament. At this time the whole of the tumor, as well 
as the abdomen, was tympanitic, the former crepitating on 
pressure. At 12 m. the discoloration had diffused itself, and 
the patient was gradually failing. He had hiccough, and 
vomited material resembling coffee-grounds Died, at 8 p. m., 
April 26th, twenty-eight hours after admission. 
Autopsy, eighteen hours after death. 
Rigor mortis well marked. Upon removing the integu- 
ments of the abdomen, a large tumor, composed of intestines, 
presented itself. The intestines were adherent to the integu- 
ment ; and the cellular tissue, for a considerable distance, was 
gangrenous from infiltration of intestinal fluids. Upon more 
careful examination, the tumor was found to be external to all 
the muscles and fasciae, and to extend nearly to Poupart's liga- 
ment on either side. In tracing the muscles downward by 
dissection, under the tumor, a large rupture of the abdominal 
walls, of ovoid form, was found, 2| by 3 inches in diameter, 
situated a little below the umbilicus, and just outside of the 
left rectus muscles, the border of which could be plainly seen. 
The abdomen being now laid open, the tumor was found to 
consist of three feet of ileum, which had been ruptured at a 
point five feet from the ileo-caecal valve, the rupture giving 
exit to a large amount of fluid contents of the gut, and some 
solid fecal matter. The left kidney had escaped through the 
opening in the abdominal wall. Some fluid was found in the 
cavity of the peritonaeum, and the peritonaeum itself was cov- 
ered with lymph, causing adhesions between the folds of the 
intestines. Most of the remaining viscera were normal. The 
lungs contained a few tubercles; the kidneys were enlarged, 
but uninjured. Just behind and internal to the left kidney, 
the psoas muscle was ruptured, and coiled up into a globular 
mass. The epigastric artery was intact, though one of its 
small branches was ruptured. ABDOMINAL HERNIA 
219 
The points of interest in this case are: 1, the difficulty in 
diagnosis of the precise nature of accident; 2, the escape of 
the kidney; 3, the rarity of the accident. Reported by T. 
Cross, M. D., House Surgeon. 
ANALYSIS OF PRECEDING CASES, AND OBSERVATIONS. 
Indirect inguinal, congenital, strangulated, and reduced hy surgical 
operation, p. 147. > 
Case I.-Concealed, funicular, enterocele, abnormal formation of ring; 
ether employed; stricture at internal ring; division inside of sac. Re- 
covery. 
Case II.-Enterocele ; scrotal; chloroform employed; stricture at ex- 
ternal ring; division of stricture outside of the sac after the sac was opened. 
Recovery. 
Case III.-Enterocele; chloroform and ether ; stricture at both rings; 
division within sac. Recovery. 
Case IV.-Whether enterocele or epiplocele is not known: scrotal ; 
reduction of hernia by taxis; followed by suppuration of sac; operation 
under chloroform. Recovery from immediate effects of operation, and 
death after six months. 
Indirect inguinal hernia, congenital, strangulated, and reduced without 
an operation, p. 155. 
Case V.-An infant; failure of taxis, and reduction by application of 
ice. Recovery. 
Case VI.-An infant; failure of taxis, and spontaneous reduction. Re- 
covery. 
Case VII.-An infant; failure of taxis alone, and reduction by taxis, 
aided by posture, the legs and body being held higher than the head. 
Recovery. 
Case VIII.-Infant, thirteen days old; failure of taxis ; reduction by 
posture while under the influence of chloroform, the child being held up 
by its legs. Recovery. 
Case IX.-Congenital hernia mistaken for a hydrocele; illustrating a 
frequent error of diagnosis. 
Congenital indirect inguinal hernia in a female, p. 159. 
Case X.-Occurring six weeks after birth, and descending through the 
canal of Nuck into the pouch of Broca. Reducible. 220 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Inguinal and femoral hernia, containing the ovaries, Fallopian tubes, etc., 
p. 159. 
Case XI.-Congenital inguinal ovarian hernia; suppuration of the ovary. 
Case XII.-Pott's case of double ovarian inguinal hernia, in which he 
removed both ovaries by excision. Recovery, with loss of sexual traits. 
Case XIII.-Guersant's case of ovarian, probably congenital inguinal 
hernia; mistaken for a cyst; excision of the ovary. Death on third day. 
Case XIV.-Deneux's case of ovarian inguinal hernia; mistaken for an 
ordinary hernia; operation ; excision of the ovary. Recovery. 
Case XV.-Neboux's case of incarcerated, ovarian, inguinal hernia; 
operation, and return of the ovary (incarcerated by adhesions) into the 
cavity of the belly. Recovery. 
Case XVI.-Mulert's case of strangulated ovarian hernia; occurring 
below Gimbernat's ligament, without distinct hernial sac; operation and 
replacement of the ovary. Recovery. 
Case XVII.-Mulert's second, strangulated, ovarian, inguinal hernia; 
reduced by taxis. Recovery. 
Case XVIII.-'Krieger's case of strangulated, inguinal, ovarian hernia; 
operation; the sac contained serum, fat, intestine, an ovary, and a portion 
of the tube; Krieger ruptured the stricture with his fingers, cut away the 
fat and a portion of the sac, and then reduced the intestine, ovary, and 
tube. Recovery. 
Case XIX.-Berard's case of irreducible, inguinal, Fallopian hernia; 
mistaken for a serous cyst; sac opened by a trocar; operation followed by 
suppuration of the sac and peritonitis. Death on the seventh day. 
Case XX.-Loeper's case of inguinal, ovarian hernia; operation, re- 
duction of the ovary, and recovery. 
Case XXL-Billard's case of congenital, inguinal, irreducible ovarian 
hernia; discovered at the autopsy of a child, who died when seventeen 
days old. 
Case XXII.-Dr. J. 0. Nott's case of inguinal, ovarian hernia; reduced 
by prolonged taxis. Recovery. 
Case XXIII.-Dr. Willard Parker's case of femoral hernia, containing 
intestine, the ovary, and the fimbriated extremity of the Fallopian tube; 
excision of the extremity of the Fallopian tube, and return of the ovary and 
intestine. Recovery. 
Fallopian tube and ovary in an obturator hernia, p. 166. 
Ovarian, vaginal hernia, p. 166. 
Indirect inguinal hernia, not congenital, p. 166. 
Case XXIV.-Enterocele; strangulated; operation under ether; stric- 
ture at internal ring; division within the sac. Recovery. 
Case XXV.-Enterocele; strangulated; division of stricture within 
the sac. Recovery. ABDOMINAL HERNIA. 
221 
Case XXVI.-Enterocele; strangulated ; operation without anaasthet- 
ic; stricture at internal ring; division within the sac; secondary hemor- 
rhage from vessels of scrotum. Recovery. 
Case XXVII.-Enterocele; strangulated ; ether employed; stricture 
at internal ring; division within the sac. Recovery. 
Case XXVIII.-Enterocele; laceration of fascia transversalis in conse- 
quence of a severe injury; strangulated; operation without anaesthetic; 
stricture at external ring. Death in a few hours, from shock of the original 
injury. 
Case XXIX.-Enterocele; strangulated; prolonged taxis, and internal 
exhibition of tobacco; operation without anaesthetic ; stricture the whole 
length of canal; divided within the sac; severe pain caused by incision, 
and consequent prognosis. Death. 
Case XXX.-Enterocele; strangulated; violent and repeated taxis; 
operation under chloroform; stricture at both rings; divided within the 
sac. Death from lesions caused by taxis. 
Case XXXI.-Enterocele; strangulated; operation under ether; mes- 
entery incised through mistake; stricture at external ring; divided within 
the sac. Death. 
Case XXXII.-Enterocele; strangulated; the sac being laid open, the 
intestine was reduced without dividing the stricture. Death. 
Case XXXIII.-Enterocele ; recent; strangulated ; stricture at exter- 
nal ring; operation. Death in twenty-nine hours. 
Case XXXIV.-Enterocele; strangulated; stricture at external ring; 
operation. Death in 60 hours. 
Case XXXV.-Enterocele; strangulated thirty-six hours; failure of 
taxis; operation ; sac opened, and spontaneous reduction of the hernia be- 
fore division of stricture. Recovery. 
Case XXXVI.-Strangulated four days; operation. Death in fifteen 
minutes. 
Case XXXVII.-Entero-epiplocele; strangulated one hundred and 
twenty-five hours; operation; stricture at internal ring; division within 
the sac; return of both omentum and intestine. Death on twenty-fifth 
day. 
Case XXXVIII.-Omental; strangulated six days; tobacco injections 
and taxis; operation without anaesthetic; large number of fasciae; exci- 
sion of omentum. Recovery, and subsequent descent of the omentum. 
Opinions and practice of Gibson, Sir Astley Cooper, and Mr. Key. 
Case XXXIX.-Traumatic; omental; strangulated three days; opera- 
tion ; divided stricture within the sac. Death on the third or fourth day, 
due rather to the original injury than to the operation. 
Case XL.-Entero-epiplocele; strangulated twenty-four hours ; whis- 
key as an anaesthetic; operation; hernia reduced without dividing the stric- 
ture. Recovery. 
Case XLI.-Entero-epiplocele; strangulated forty-eight hours; opera- 222 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
tion after prolonged taxis; division of stricture within the sac. Death on 
tenth day, from peritonitis, and discharge of the contents of an abscess 
into the peritoneal cavity. 
Case XLII.-Indirect inguinal hernia in a female; entero-epiplocele; 
strangulated two days; operation; division of stricture at the internal 
ring outside of sac. Death six days after operation; strangulation not 
relieved. 
Indirect inguinal hernia ; strangulated, but reduced without an operation, 
p. 190. 
Case XLIII.-Strangulated twenty hours; reduced by taxis, aided by 
posture-elevating the foot of the bed several feet-after simple taxis had 
failed. Recovery. Reduction of a previous hernia by an emetic. 
Case XLIV.-Similar to Case XLIII. Recovery. 
Case XLV.-Strangulated ten hours ; spontaneous reduction under ap- 
plication of ice, and after administering morphine, aided by posture. Re- 
covery. 
Case XLVL- Strangulated three days; reduced by posture, aided by 
ice, after taxis had failed. Recovery. 
Case XLVII.-Strangulated twelve hours; reduced by prolonged 
taxis. Recovery. 
Case XLVIII.-Indirect inguinal hernia in a female; strangulated 
twenty-four hours; failure of taxis; reduced under chloroform by taxis 
aided by posture-elevating the foot of the bed. Recovery. 
Case XLIX.-Strangulated several hours; reduced by taxis under 
ether. Recovery. 
Case L.-Strangulated: surgeon supposed he had reduced it before 
admission, but probably he had not. Death on fourteenth day. 
Incarcerated indirect inguinal hernia, p. 195. 
Case LI.-Probably omental; incarcerated thirty days; thilure of 
taxis; spontaneous reduction in ten days, by posture, rest, laxatives, and 
cool lotions. Recovery. 
Direct inguinal hernia, p. 196. 
Case LIL-Enterocele; strangulated six hours; operation under ether; 
division of stricture within the sac; reduction. Recovery. 
Case LIII.-Incarcerated entero-epiplocele; adhesions; operation; 
adhesions broken up by the fingers, and ring enlarged by the knife; re- 
duced. Recovery. 
Case LIV.-Incarcerated by adhesions; patient suffering under Bright's 
disease; operation; reduction. Recovery. ABDOMINAL HERNIA. 
223 
Femoral hernia, p. 198. • 
Case LV.-Enterocele; strangulated four days; doubtful diagnosis; 
operation under ether; division of Gimbernat's ligament from within the 
sac. Reduction and recovery. 
Case LVI.-Enterocele; incarcerated by adhesions; strangulated by 
Iley's ligament; inflammation and suppuration of sac; operation without 
anaesthetic, after prolonged application of ice; adhesions prevented com- 
plete reduction. Death on fourth day. Autopsy showed that the strangu- 
lation was completely relieved, and that the intestine could not have been 
separated and reduced without laceration of its coats. 
Case EVIL-Enterocele; recent; traumatic; doubtful diagnosis; 
operation under ether; division of Gimbernat's ligament. Recovery. 
Case LVIII.-Entero-epiplocele ; strangulated nine days; operation 
under chloroform; removal of a large portion of omentum ; return of in- 
testine, after dividing stricture at falciform margin of the fascia lata, and at 
Gimbernat's ligament. Recovery. 
Case LIX.-Entero-epiplocele; operation ; return of intestine, and re- 
moval of a portion of the omentum. Recovery. 
Case LX.-Entero-epiplocele; strangulated; doubtful diagnosis; opera- 
tion without anaesthetic; stricture at Gimbernat's ligament divided; pain 
when the stricture was divided. Death in twenty hours. Reference to 
similar cases by Samuel Cooper, Astley Cooper, Dunglison, Gibson, Palmer. 
Frequency of adhesions in femoral hernia. 
Case LXI.-Entero-epiplocele; strangulated; ligation and excision of 
omentum; cut Gimbernat's ligament; reduction of intestine. Death in 
forty-eight hours. 
Case LXII.-Enterocele; strangulated eight hours; taxis and tobacco- 
poultices failed; succeeded by taxis, aided by posture-elevating the lower 
extremities and body. Recovery. 
Case LXIII.-Strangulated and reduced by taxis. Recovery. 
Case LXIV.-Strangulated; supposed reduction by taxis; formation 
of artificial anus ; spontaneous cure of artificial anus. Recovery. 
Case LXV.-Strangulated; partly reduced by taxis; patient refused an 
operation. Death on the twelfth day. 
Case LXVI.-Strangulated; partly reduced; artificial anus formed. 
Death on fourteenth day. 
Median ventral hernia, p. 214. 
Case LXVIL-Consequent upon atrophy of the rectus abdominis, in 
a woman laboring under cancer of the uterus ; no operation. Death and 
autopsy. 
Case LXVIII.-Consequent upon laceration of the linea alba during 
pregnancy; no operation. Recovery. 224 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Cases not classified, p. 215. 
Case LXIX.-Varicose veins in vagina; at first supposed to be a hernia; 
behavior of tumor in parturition. 
Case LXX.-Traumatic ventral hernia, containing kidney, intestine, 
etc.; no operation. Death in twenty-four hours. 
Of 31 operations for strangulated inguinal and femoral 
herniae, 15 died and 16 recovered. They are to be classified 
as follows: 4 congenital inguinal herniae, all occurring in 
adults, and all recovered ; 19 non-congenital, indirect inguinal 
herniae, with 12 deaths and 7 recoveries; 1 direct inguinal 
hernia, with recovery; 7 femoral herniae, with 3 deaths and 4 
recoveries. 
If I exclude the cases reported to me from Bellevue and 
Charity Hospitals, and speak only of my own cases, the result 
is a little more favorable; namely, 15 recoveries and 10 
deaths, in a total of 25 cases. The reports from these two 
hospitals include all that can be found upon the records; but 
these records have, until lately, been very imperfectly kept, 
and cannot be considered as a representation of the practice 
or results in either of these establishments. 
It will be noticed that, in the cases of inguinal herniae, the 
strictures have, with one or two exceptions, been cut within 
the sac ; in Case XLII. the sac was not opened, the stricture 
being divided without the sac, and the autopsy showed that the 
strangulation had not been relieved. It is not my intention 
at the present moment to discuss the relative merits of the 
two procedures, for, indeed, I am not fully prepared to do so. 
The recent successful cases of division outside of the sac, re- 
ported by that excellent surgeon, Dr. Erskine Mason, one of 
the visiting surgeons to Charity Hospital, have inclined me to 
make a fair trial of the method adopted by himself and by 
some others, whenever favorable opportunities present. 
The operation was completed without dividing the stric- 
ture in Cases XXXII., XXXV. and XL. 
In the examples of congenital strangulated inguinal herniae, 
the seat of stricture has been found once at the internal ring, 
once at the external ring, and once at both. 
In the examples of non-congenital strangulated inguinal 
herniae, the stricture has been found five times at the internal ABDOMINAL HERNIA. 
225 
ring, four times at the external, once at both rings, and once 
in the whole length of the canal. 
In the examples of femoral herniae, the stricture has been 
found once at Iley's ligament, four times at Gimbernat's, and 
once at both. 
Three cases, in which I cut away the omentum, are re- 
ported as recoveries; but the fourth case, in which I first 
ligated the omentum and then cut it away, died. Most or all 
of the cases, in which an enlarged omentum was returned, 
died also. 
The cases of strangulated herniae actually reduced by taxis, 
posture, or other means than an operation, thirteen in number, 
recovered. Cases L., LXV., and LXVL, were not reduced, 
and died. Case LXIV. recovered with a temporary artificial 
anus. I desire to call especial attention to the value of pos- 
ture as a means of taxis, illustrated by Cases VII., VIII., 
XLIIL, XLIV., XLV., XLVI., and XLVIII.; and particu- 
larly to its value in the cases of children. 
Cases LIII. and LIV. were incarcerated herniae, reduced 
successfully by operations; and Case LI. was incarcerated, and 
reduced by prolonged rest, etc. 
No apology will be required, I trust, for having brought 
together in this paper all the published cases of ovarian herniae. 
They are sufficiently rare and interesting to warrant the spe- 
cial notice they have received. I desire also here to repeat 
my indebtedness to my friend Dr. C. C. Terry, for his aid in 
bringing together the literature of the subject of ovarian 
hernia. 
As this paper is going to press, Dr. Terry has sent me a 
memorandum of an additional case of both ovary and tube in 
an incarcerated femoral hernia ; reported in the St. Petersburg 
Med. Zeit., for Dec., 1868, and quoted in the British and 
Foreign Med.-Chi. Rev., July, 1869, p. 272. IX.-BRIGHT'S DISEASES. 
A Clinical Report based on an Analysis of one hundred and 
two Cases. By Austin Flint, M. D., one of the Attend- 
ing Physicians at Bellevue Hospital, etc., etc. 
My clinical records embrace notes of one hundred and two 
cases of the affections which it has been the custom to include 
under the name Bright's Disease of the Kidneys. Most of 
these notes have been made by myself; a very few have been 
made by others, all the cases having been under my observa- 
tion. The number of cases which I have observed is by no 
means represented by those of which I have notes. For sev- 
eral years past, I have been able to keep notes of a small pro- 
portion only of the cases of different diseases which I have 
observed in hospital and private practice. As regards renal 
diseases, I have noted, of late, chiefly the cases which have 
served as illustrations in clinical teaching, or which have pre- 
sented particular points of interest. 
Of the notes which I have made of these affections, a con- 
siderable proportion are not complete. Many cases came 
under my observation after a considerable lapse of time from 
the commencement of the renal disease, and the previous his- 
tory in these cases is often limited to a few prominent items. 
Other cases were under my observation only for a limited 
period, during the progress of the disease, the subsequent his- 
tory being unknown, and in some cases the patients were not 
seen until at or near the close of life. Of most of the cases, 
the records do not consist of notes made from day to days 
hence they are deficient in full and minute details. For these 
reasons, an analysis will not furnish data for determining, 
numerically, the relative frequency of all or even a consid- 228 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
erable proportion of the events which belong to the clinical 
history of the affections. Notwithstanding these defects, an 
interrogation of the cases with reference to various points of 
inquiry will, it is believed, elicit results which will repay the 
labor of the analysis, and possess value as a contribution to the 
clinical study of a most interesting and important group of dis- 
eases. Much light has been shed on these diseases since the 
labors of Bright; but they furnish still ample scope for clini- 
cal researches, and in the preparation of this report various 
questions will arise which I shall not undertake to answer. 
I have adopted, as the title of this report, " Bright's Dis- 
eases of the Kidney," following the example of Dr. T. Grainger 
Stewart, in his recent work on these diseases;1 the name 
" Bright's Disease," as applied to different renal affections, is 
manifestly incorrect, and it is a simple mode of remedying the 
error, honoring at the same time the memory of Bright, to 
say diseases instead of disease. 
Proceeding to interrogate my cases, the points of inquiry 
will be arranged under the following heads : 1. Morbid appear- 
ances after death; 2. Fatality and cases of recovery; 3. An- 
tecedent circumstances and the previous history ; 4. Symptoms 
and complications; 5. The progress and duration of the dis- 
eases, together with the immediate causes of death ; and 6. The 
treatment. 
1.-Morbid Appearances after Death. 
In 36 of 56 fatal cases, post-mortem examinations were 
made. The points of inquiry under this head relate, first, to 
the lesions seated in the kidneys; second, to lesions in other 
organs, together with the relations between the latter and the 
different forms of renal disease. 
Lesions of the Kidneys.-Without discussing, here or else- 
where in this report, questions concerning the number of 
Bright's diseases, the grounds for considering them severally 
as individual diseases, and the pathological processes involved 
in the different lesions, I shall assume the existence of the 
following distinct affections: 1. Acute tubal nephritis, adopt- 
ing this name, proposed by Dickinson, as the most conven- 
1 Bright's Diseases of the Kidneys, 1868. bright's diseases. 
229 
lent;1 2. The smooth white kidney, the morbid appearances 
due, probably, to the presence of inflammatory products within 
the tubes; 3. The fatty kidney, the presence of fat within the 
tubes constituting the most prominent characteristic; 4. The 
contracted, granular, fibroid, or cirrhotic kidney ; and 5. The 
waxy kidney. 
Of the 36 cases in which post-mortem examinations were 
made, in one case the kidneys were not examined, the body 
being relinquished for dissection, and the only morbid appear- 
ances which were noted relating to the heart. In one case the 
kidneys appeared to the naked eye healthy. In this case 
albuminuria and general dropsy had existed, and the patient 
died from pleurisy, with large effusion, and pericarditis. These 
affections occurred during pregnancy. In one of the cases the 
two kidneys represented different diseases, one being greatly 
contracted, and the other enlarged and fatty. In another 
case one of the kidneys was fatty without cysts, while the 
other had undergone cystic destruction. Exclusive of these 
cases, in all the two kidneys were affected in a similar man- 
ner, and in about an equal degree, thus exemplifying the law 
of parallelism. But in three cases the notes which were made 
of the morbid appearances are not sufficient to determine the 
form of renal disease which existed. 
Eliminating these seven cases, the remaining 29 furnish 
only one example of appearances denoting acute tubal ne- 
phritis. In this case the renal affection was a sequel of scar- 
latina. The cases furnish only two examples of waxy kidneys. 
The fact that but a single example of the former, and but two 
examples of the latter of these affections, occurred in the post- 
mortem examinations, is consistent with the infrequency of 
the fatal termination of acute tubal nephritis, and with the 
infrequent occurrence of waxy disease of the kidneys. In two 
only of the fatal cases was the disease considered to be that 
known as the smooth white kidney. 
In 14 cases the predominant appearances were those of 
fatty kidneys. In eight of these cases the disease was deter- 
mined solely by the characters observed with the naked eye. 
1 Pathology and Treatment of Albuminuria, 1868. 230 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
In six of the cases the microscopical characters were ascer- 
tained. As a rule, the kidneys were more or less enlarged. 
In the case which furnished the maximum of enlargement, the 
weight of both kidneys was a fraction under 25 oz. 
The disease was contracted or cirrhotic in nine cases. This 
disease was determined by the gross characters solely in seven, 
and by the addition of the appearances under the microscope 
in two cases. The minimum of atrophy in these cases was rep- 
resented by kidneys which together weighed three oz. 
The presence of cysts, apparent to the naked eye, is noted 
in five cases, two being cases of fatty kidney, two of contracted 
kidney, and in one case the form of the disease is not deter- 
minable. 
In a case not included in the foregoing enumeration, both 
kidneys had undergone destruction from cysts. The volume 
of the organs was much increased, and the surface of each was 
studded with cysts, varying in size from that of a filbert to a 
large American walnut. The cysts contained a dirty-looking 
brownish liquid. The capsule was closely adherent and could 
not be stripped off. The whole of the cortical portion appeared 
to be destroyed. Uraemia was manifestly the cause of death 
in this case. 
Case of Atrophy of the Kidneys, attributable to Hydro- 
nephrosis ; and Death from Uraemia.-The following case does 
not properly belong in the group of Bright's diseases, and it is 
not included in the collection of cases, the analysis of which is 
the basis of this report. I desire to introduce it as a case of 
interest, and it may be as appropriately introduced here as 
in any other connection : 
Thomas O'Neil, aged forty-two, tinsmith, was admitted 
into Bellevue Hospital, November 7, 1864. He stated that 
his existing illness was that of two years' duration. He com- 
plained of excessive thirst, and of passing a large amount of 
urine. These were the only symptoms of disease of which he 
complained. He had kept at his work until about three weeks 
before his admission, and he came to the hospital on account 
of weakness. He had a rather pallid countenance, and ap- 
peared to be moderately emaciated. He passed daily about 
7£ pints of urine, the specific gravity of which was 1.008; it bright's diseases. 
231 
was tested for sugar with a negative result, and it did not con- 
tain albumen. The bowels were constipated. 
November 21st, fourteen days after his admission, he be- 
came dull and sleepy. He had previously kept about the 
ward, and his disease was considered as diabetes insipidus. 
The bowels on this date were moved by croton-oil. In the 
course of the day he fell into a stupor. The pupils were 
normal, and the pulse was 90. On the following morning he 
was in a state of nearly complete coma. During the night he 
had a convulsion, and another in the morning on this date. 
The coma became complete, and he died at noon. The urine, 
tested shortly before death, was not albuminous. 
The record of the post-mortem examination is as follows: 
"The brain showed a moderate degree of congestion, with 
moderate effusion on the convexity beneath the arachnoid and 
in the ventricles. The lungs and the heart were free from 
disease. The kidneys showed extreme dilatation of the calices 
and pelvis, at the expense of the cortical and the tubular por- 
tion. Very little of the excretory portion of the left kidney 
remained, and the organ presented the appearance of an empty 
sac. The right kidney was in a similar condition, but the 
destruction had not advanced as far. Both ureters were 
much dilated, and contained urine. The muscular walls of 
the bladder were greatly hypertrophied, and the mucous mem- 
brane was thickened. It was thought, by Dr. Flint, that ob- 
struction must have existed, probably at the junction of the 
ureters with the bladder." 
In connection with this case it may be stated that one of 
the kidneys may be destroyed by hydronephrosis, without any 
manifestations of disease. At a meeting of the New York 
Pathological Society, March 10, 1869, Prof. J. C. Hutchison 
exhibited a kidney completely destroyed as regards its paren- 
chyma. The specimen was from a case admitted into the 
Brooklyn City Hospital, on account of an injury of the chest, 
the injury causing death. The other kidney, in this case, which 
was not exhibited, was considered as diseased, and the urine 
removed from the bladder after death contained albumen and 
tubular casts. On inquiry, it was ascertained that the patient, 
up to the time of receiving the fatal injury, was apparently in 232 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
perfect health, daily working as a laborer. His habits were 
intemperate, and he was intoxicated when he received the 
injury, which was caused by his being struck with a street-car, 
when attempting to get on the forward platform. 
Lesions of other Organs.-The greater number of the his- 
tories are incomplete as regards the appearances of organs 
other than the kidneys. In general, the notes contain only an 
account of the liver and spleen, the heart and the lungs. In 
some cases the lesions of the kidneys are alone noticed. The 
important rule, of stating in the records that certain organs 
were healthy, was not observed. For these reasons, the analysis 
with reference to the association with the different diseases of 
the kidney, of lesions elsewhere, must be limited chiefly to the 
organs just named. In the simple case of acute tubal ne- 
phritis, there was considerable hydrothorax on one side, and 
oedema of the lung, without hydrothorax, on the other side. 
The absence of hydrothorax on one side was explained by the 
existence of universal, old pleuritic adhesions on that side; 
there was no pleuritic space in which effusion could take place, 
and the pulmonary oedema occurred in consequence. The 
heart in this case was normal. Nothing is stated of lesions in 
other organs. Death in this case was caused by the hydro- 
thorax, with the pulmonary oedema. 
In the case in which the kidneys appeared healthy to the 
naked eye, there was pleurisy with large effusion in the left 
side, and thoracentesis had been resorted to. There was recent 
pleurisy, without much effusion, on the right side. Recent 
pericarditis also existed. These affections caused death. 
In one of the two cases of the smooth white kidney, lesions 
in other organs are not noted. In the other case, it is only 
noted that the liver was contracted, the weight being only 2 
lbs. 5 oz. 
In each of the two cases of waxy kidney, the liver and 
the spleen were also waxy. In one, the kidneys weighing 9 oz., 
the weight of the liver was 6 lbs. 12 oz., and that of the spleen 
10 oz. The heart, in this case, weighed 11 oz., and the mitral 
valve was slightly thickened ; the lungs contained calcareous 
deposits, and there were emphysematous lobules. In the other bright's diseases. 
233 
case, the kidneys weighing 16 lbs. oz., the liver weighed 
6 lbs. 3 oz., and the spleen 1 lb. In both cases the waxy affec- 
tion was shown by the iodine test. 
Of the fourteen cases of fatty kidneys, in four, neither the 
existence nor absence of cardiac lesions is noted. In seven of 
the remaining ten cases, the heart was normal. Cardiac le- 
sions were noted in three cases, namely: in one case, the walls 
were abnormally soft and flabby, but the valves were healthy, 
and the weight 12 oz.; in another case, the heart was enlarged, 
weighing 20 oz., the valves being sound; and in the third case 
there wras hypertrophy, the weight being 23 oz., the muscular 
structure healthy, the mitral valves presenting patches of athe- 
roma, and the aortic valves vegetations. In the latter case the 
aorta was atheromatous. Atheroma of the aorta is noted in 
one of the cases in which the heart was normal. Old pericar- 
dial adhesions existed in one case in which the heart was other- 
wise sound. 
The condition of the liver is noted in nine of the cases in 
which the kidneys were fatty. In three of these cases the 
liver presented nothing worthy of note. Of the remaining six 
cases, in three it was abnormally fatty in a greater or less de- 
gree, but in none of these cases was the organ notably enlarged. 
In one case the organ was cirrhosed and hobnailed. In one 
case there was contraction, the weight being only 2 lbs., but 
the structure appeared to be normal, and in one case the 
weight was 3 lbs. 2 oz., and the nutmeg appearance was marked. 
Disease of the heart did not exist in the latter case. 
The condition of the lungs is noted in only six cases. In 
two of these cases is it noted that the lungs were healthy. 
This was probably true of most or all of the cases in which 
the condition is not noted. In one case there were small tu- 
berculous cavities, evidently of long standing, with old pleuritic 
adhesions; in one case there were masses of yellow tubercle 
in the left lung, the right lung being free from tuberculous 
disease, and the left pleura contained a pint of inflammatory 
effusion, recent lymph covering the pleural surfaces; oedema 
of lung was noted in two cases, in one moderate, and in the 
other slight. 234 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
(Edema of the glottis existed in one case. The oedema 
was on both sides, and this was the cause of death. 
Morbid appearances within the skull are noted in two cases. 
In one of these cases the brain was congested, and there was 
considerable subarachnoid effusion, but without lymph. In 
the other case there was exudation of lymph beneath the 
arachnoid, on the superior and lateral surfaces of the cere- 
brum. 
Interrogating the notes of the nine cases in which the kid- 
neys were contracted and cirrhotic, in five cases it is noted that 
the lungs were healthy. (Edema of the lungs is noted in one 
case. Contraction of the liver is noted in one case, and in one 
case it is stated that incipient cirrhosis existed. In three cases 
pericarditis existed. In two of these cases the pericarditis 
was recent; in the remaining case it may be said to have been 
chronic, two pints of inflammatory effusion being contained 
within the pericardium, and the pericardial surfaces coated 
with lymph. In one case only is the condition of the heart 
not noted. In five cases the heart was enlarged. The weight 
in these cases respectively was 24 oz., 16 oz., 26 oz., 19 oz., 
and 8^ oz. In the last of these cases the volume of the organ 
was increased, although the weight was within the limits of 
health. Great mitral contraction existed in this case. In two 
of* the cases the valves were normal, the hypertrophy being 
simple. In one case it is noted simply that the aortic valves 
seemed to be attenuated; and in one case there was a calcareous 
deposit at the base of the aortic valves. It is noted in one 
case that the brain was congested, and in one case that turbid 
subarachnoid effusion existed. 
In the case in 'which there was cystic destruction of both 
kidneys, the lieart was hypertrophied, weighing 14| oz., and 
the valves were normal. The liver contained some cysts, but 
was otherwise healthy in appearance. 
In the case in which one kidney was destroyed by cysts, 
and the other kidney fatty without cysts, the heart was en- 
larged, weighing 15 oz., and the valves were normal. (Edema of 
the glottis existed in this case. Of the three cases in which the 
form of renal disease is not determinable, in one the condition 
of other organs is not noted. In one of the two remaining cases, bright's diseases. 
235 
the heart was enlarged without valvular lesions; the liver was 
normal, and there was some subarachnoid effusion. In the 
other case, the heart was enlarged, the aortic vajves were in- 
sufficient, and there • was a small aortic aneurism. In this 
case the lungs were emphysematous. 
Reviewing the facts noted respecting the associated lesions, 
it will be seen that they show the coexistence of certain affec- 
tions in a small proportion of cases, namely, fatty liver, cirrho- 
sis of the liver, subarachnoid effusion, meningitis, pleurisy, 
oedema of the lungs, pulmonary emphysema, oedema of the 
glottis, and pulmonary tuberculosis. The coexistence of most 
of these affections is probably accidental. Considering the 
frequency of their occurrence in other pathological connections, 
this statement may be applied to fatty liver, cirrhosis of the 
liver, emphysema of the lungs, and pulmonary tuberculosis. 
It is worthy of note that the facts do not show any tendency 
in Bright's diseases to the last-named affection, to wit, pul- 
monary tuberculosis. On the other hand, it is probable that 
the renal diseases have a causative relatiorf with meningitis, 
pleurisy, and oedema of the glottis, notwithstanding these com- 
plications are of rare occurrence. 
A reviewal of the facts which were noted in relation to the 
association of cardiac lesions with Bright's diseases, shows the 
number of cases in which the condition of the heart was not 
noted to be ten. Of the remaining 26 cases, in only six was 
the heart or pericardium free from disease, leaving 20 cases in 
which the heart or pericardium was affected. As regards the 
number of cases of the different renal diseases in which the 
heart was unaffected, the facts are as follows: The heart was 
not affected in the case of acute tubal nephritis. It was unaf- 
fected in five of the 10 cases of fatty kidneys, in which the con- 
dition was noted. It was unaffected in none of the seven cases 
of contracted kidneys in which the condition was noted. The 
heart was affected in the case of cystic destruction of the kid- 
neys, in the case of cystic destruction of one, and fatty disease 
in the other kidney, and in the case of contraction of one, and 
fatty disease of the other kidney. It was affected in the case 
in which the kidneys were not examined; in two cases in 
which the form of renal disease was not determinable; in the 236 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
case of waxy disease, in which the condition was noted, and 
in the single case in which the kidneys appeared normal to the 
naked eye. 
As regards the kind of affection of the heart in connection 
with the form of renal disease, the facts are as follows : Recent 
pericarditis existed in 3 cases, namely, in 2 of 7 cases of con- 
tracted kidneys, and in the case in which the kidneys appeared 
to the naked eye healthy. Chronic pericarditis existed in one of 
the cases of contracted kidneys. Enlargement of the heart, with- 
out valvular lesions, existed in 4 of the 10 cases of fatty kidneys, 
and in 3 of the 7 cases of contracted kidneys.1 Enlargement 
without valvular lesion also existed in the case of cystic destruc- 
tion of both kidneys; in the case of cystic destruction of one, 
with fatty disease of the other kidney ; in the case of contrac- 
tion of one, with fatty disease of the other kidney, and in one 
of two cases in which the form of renal disease was not de- 
terminable. Enlargement without valvular lesions thus existed 
in 11 of 20 cases of the different renal diseases. Enlargement 
with valvular lesions existed in 6 of these 20 cases. The coex- 
istence of recent pericarditis and enlargement of the heart is 
noted in one case. Old pericardial adhesions existed in one 
of the cases of fatty kidneys. 
These facts illustrate the occasional development of peri- 
carditis, especially in connection with contracted kidneys. 
They illustrate, also, the frequency of simple enlargement of 
the heart, that is, enlargement without valvular lesions, as a 
concomitant of Bright's diseases. It is certainly a fair infer- 
ence, from the infrequency of simple enlargement of the heart 
except in this pathological connection, that the renal stands 
to the cardiac affection in a causative relation. On the other 
hand, the frequency of enlargement of the heart associated 
with valvular lesions, and the number of cases in which renal 
disease does not coexist, render it probable that the associa- 
tion of the former with the latter in a certain proportion of 
cases is due to coincidence. The coexistence of cardiac and 
other affections with Bright's diseases will constitute points of 
inquiry relating to symptoms and complications referable to 
11 include one case in which it was stated that the aortic valves were 
attenuated. bright's diseases. 
237 
the different anatomical systems of the body in the fatal cases 
in which post-mortem examinations were not made, in the cases 
ending in recovery, and in the cases the ending of which is not 
known. 
2.-Fatality, and Cases of Recovery. 
Of the one hundred and two cases under analysis, death 
was known to have occurred in fifty-six. In most of twenty- 
five cases the patients passed from under my observation, 
the renal disease existing, and the subsequent history was not 
ascertained; a few cases are known to be still in prog- 
ress. Eliminating these twenty-five cases, the fatality was 
fifty-six in seventy-seven cases. The fatal cases will be ana- 
lyzed, with respect to the immediate causes of death, in another 
section of this report. 
In twenty-two cases the patients were considered as hav- 
ing recovered, making the proportion, in the number of cases 
in which the result was known, twenty-two in seventy-six 
cases. Was the recovery complete in these twenty-two cases? 
This question is especially pertinent in view of the fact that in 
some chronic cases of Bright's diseases the morbid conditions 
of the urine temporarily disappear, and such a degree of im- 
provement takes place, as regards other symptoms, that, if the 
patients be lost sight of, recovery may be incorrectly assumed. It 
is undoubtedly proper to consider that there is room for the sup- 
position of this being true of some of these twenty-t'wo cases. 
I shall proceed to analyze this group of cases with reference to 
the question just raised, as well as other points of inquiry. As 
regards the completeness of the recovery, the cases are to be 
interrogated with respect to the urine, the dropsy, and the 
general health at the time when the patients were considered 
as having recovered. The health of the patients subsequently, 
when this was known, has an obvious bearing on the question. 
The renal disease wras a sequel of scarlatina in two cases, and 
In one case of scarlatina combined with diphtheria. These 
three cases were in private practice, and in each the patient 
was known to have been healthy for several years after the 
date of recovery. In one case the renal disease occurred in 
connection with pregnancy, and premature delivery of a dead 238 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
child took place. There was great anasarca, and hydrothorax, 
to such an extent that life appeared in imminent danger. 
This patient, five months after the date of recovery, was in 
perfect health. This case was in private practice. In another 
case in private practice, after a year from the date of the dis- 
appearance of albuminuria and general dropsy, the patient 
was free from any evidence of renal disease, but suffered 
from an enlarged prostate and cystitis. In another case the 
patient, a young physician, after dropsy and albuminuria had 
disappeared, was under my observation for fourteen months, 
and was in good health. lie then had double pneumonia, 
which was followed by a copious purulent expectoration, and 
he left the country for his health. The subsequent history was 
not ascertained. In another case, also in private practice, the 
patient was known to have been in good health for ten years 
after recovery from dropsy and albuminuria. The remaining 
fifteen cases were in hospital practice. In one of these cases 
the patient was known to be well eleven months after the date 
of discharge. In one case, the patient, a female, was em- 
ployed as a ward-helper for several weeks after recovery. In 
another case the patient was known to be at work as a car- 
penter and well three months after the date of discharge. 
In the twelve cases which remain, nothing was ascertained of 
the patients after they had left the hospital. 
It is thus seen that doubt as to whether recovery was 
real can be entertained only as regards the twelve hospital 
cases just referred to. The facts noted in these cases at the 
time of discharge are as follows: In all the cases the general 
health was such that the patients were considered as not re- 
quiring further treatment, and as well enough to return to their 
occupations. In three cases it is noted that, at the time of 
discharge, the urine was entirely free from albumen. In six 
cases it is simply noted that the patients were discharged well; 
the entire absence of abuminuria is not stated, but it may 
be fairly inferred. In three cases it is noted that there was a 
trace of albumen in the urine at the time of discharge from the 
hospital. In these last three cases it is to be admitted that the 
evidence of complete recovery is not conclusive. While it is 
probable that, in these cases, the albuminuria did afterward bright's diseases. 
239 
entirely disappear, it cannot be asserted that the kidneys were 
healthy when albumen, in never so small quantity, continued 
to be found in the urine. The probability of complete recov- 
ery is certainly greater in the nine cases in which albuminuria 
did not exist when the patients were discharged. It should, 
however, be conceded that, for conclusive evidence of com- 
pleteness of recovery in these cases, the continuance of health, 
for a considerable period after the disappearance of all the 
symptoms of renal disease, should be ascertained. 
Is there room for doubt concerning the diagnosis of renal 
disease in any of these twenty-two cases ? I can answer this 
question in the negative. In all the cases the urine contained 
albumen in more or less abundance. In all there was more 
or less general dropsy. In the greater number the dropsy was 
either great or considerable. Moreover, in no case was the 
dropsy, or the albuminuria attributable to disease of the heart. 
These facts are sufficient to establish the correctness of the 
diagnosis as regards the existence of renal disease. 
I come now to a question of much interest, namely, what 
form or forms of renal disease existed in the cases which are 
considered as having ended in recovery ? Undoubtedly, in 
certain of the cases the affection was that known as desquama- 
tive or tubal nephritis. It may be assumed that this affec- 
tion existed in the three cases in which the disease was a sequel 
of scarlatina. It was the disease, doubtless, in more or less 
of the other cases. It must have been the disease, of course, in 
all the cases ending in complete recovery, if it be true that 
this alone of Bright's diseases does not involve incurable 
lesions. But it is by no means certain that all the other dis- 
eases are incurable. The smooth white kidney, the fatty kid- 
ney, and perhaps, also, the waxy kidney, existing to a certain 
extent, may not necessarily be permanent. We are not -war- 
ranted in denying the possibility of complete recovery from 
these affections. Another important statement may be made 
in this connection, namely, more or less damage to the kid- 
neys may be produced by these affections, or they may remain 
permanently to a certain extent, and the functional capacity 
of the kidneys be amply sufficient for life and health. This 
statement is applicable to the contracted or cirrhotic kid- 240 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
ney, as well as to the other of Bright's diseases just named. 
The kidneys may be the seat of either of the several le- 
sions which are called degenerative; these lesions, having 
reached a certain point, may remain, the local disease may 
cease to be progressive, and there may be no evidence, either 
local or general, of the existence of any renal affection. This 
latency and innocuousness of lesions may have been exempli- 
fied in some of the cases which appeared to end in recovery. 
To determine whether this was so or not is obviously im- 
possible. 
There are certain circumstances and symptoms which, in 
some of the cases, establish the diagnosis of tubal nephritis. 
Such are, the disease occurring after scarlatina, or after expo- 
sure to cold and wet; the rapid development of a considerable 
degree of general dropsy, and hsematuria or a smoky appearance 
of the urine with epithelial and hyaline casts. But, in a cer- 
tain proportion of cases these diagnostic points either did not 
exist or were not available when the patients came under ob- 
servation. With reference to prognosis, it is an important 
fact that, especially in hospital practice, cases may have char- 
acters rendering probable the existence of lesions which, 
in general, involve progressive disease, ending fatally sooner 
or later, and either complete recovery may take place, or the 
renal affection may become latent, and, for a time, if not per- 
manently, innocuous. In illustration of this fact I shall sub- 
join a succinct account of several of the cases. 
Case I.-Albuminuria and general dropsy, with epileptiform 
convulsions, coma, and temporary amaurosis. Recovery 
after thirty four days in hospital. 
Christina Ella, aged fifteen years, admitted into hospital 
January 12, 1856. She had been subject to frequent recur- 
rence of attacks of intermittent fever during the preceding 
summer and autumn. She had never menstruated. At the 
time of her admission there was moderate anasarca, which 
had existed for six days. The urine contained albumen in 
abundance, with numerous granular casts. On the day after 
admission she was attacked with epileptiform convulsions, and 
in the course of twenty-four hours she had six attacks. In bright's diseases. 
241 
these attacks the face was distorted, the lips were covered with 
foamy saliva, and the tongue was wounded. She complained 
of cephalalgia prior to and between the attacks. After the at- 
tacks of convulsions she lay motionless, in a state of coma, for 
two days. On the day of the convulsions and the previous 
day, vision was lost. She emerged from the state of coma, the 
convulsions did not return, and vision was regained completely 
in six days ; albumen and casts ceased to be found in the urine, 
the dropsy disappeared, and the patient was discharged, ap- 
parently well, alter having been in hospital thirty-four days. 
She was purged freely with croton-oil, when the convulsions 
occurred. The nitrate of potassa was then given, with a 
sensible diuretic effect. Subsequently, quinia and iron were 
prescribed. 
Case II.-Albuminuria and general dropsy. The patient 
discharged, well, excepting a trace of albumen in the urine, 
after remaining in the hospital a month. 
T. George, aged thirty-six, farmer, admitted December 27, 
1856. He was accustomed to drink beer freely. He was able 
to W'ork up to ten days before his admission, when oedema of 
the face and limbs occurred, accompanied by headache, ano- 
rexia, and slight diarrhoea. The urine contained an abundance 
of albumen and epithelial casts. The anasarca was consid- 
erable, and there was dropsy of the pleura and peritonaeum. 
Cephalalgia was a prominent symptom ; but convulsions and 
coma did not occur. After remaining in hospital a month, he 
was discharged, the dropsy having entirely gone; the urine 
was free from casts, but it gave a trace of albumen; the ap- 
petite and digestion were good, and he felt able to return to his 
occupation. The treatment was a saline purgative, followed by 
the bitartrate of potassa, which acted efficiently as a diuretic. 
Subsequently gallic acid was prescribed. 
Case III.-Albuminuria and general dropsy; disease of 
heart. Recovery, and the patient well, eleven months after 
the date of discharge. 
Mary Tooky, aged eighteen, domestic, admitted January 
7, 1861. She had always had good health prior to her present 242 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
illness, and her habits were good. She had been ill for three 
weeks before her admission. When admitted, the urine was 
loaded with albumen; there was moderate anasarca, with 
notable pallor of the face. Cephalalgia was a prominent symp- 
tom, but convulsions or coma did not occur. A mitral systolic 
and an aortic direct cardiac murmur existed, but the heart was 
not enlarged. At the end of two months the patient -was dis- 
charged, the dropsy having disappeared, the urine being free 
from albumen and presenting no microscopical characters of 
disease. Eleven months afterward this patient was in excel- 
lent health. She was treated with the acetate of potassa, the 
tincture of aconite, and the tartrate of iron. 
Case IV.-Albuminuria and general dropsy ; coma ; tracheal 
rales. Discharged well, after thirty-two days in hospital. 
Mary Roberts, aged twenty-nine, domestic, admitted Feb- 
ruary 10,1863. She was accustomed to drink ale freely. Iler 
health was good prior to her present illness. She was very 
stout, weighing 185 lbs. Iler illness commenced six days be- 
fore her admission. (Edema took place, accompanied by vom- 
iting. On her admission there was considerable anasarca, and 
the urine was highly albuminous, the quantity passed in twenty- 
four hours being only two ounces. Cephalalgia was a promi- 
nent symptom; and on the second day after her admission 
she fell into complete coma. For a time she seemed to be 
moribund, the breathing being accompanied by tracheal rales 
She emerged from this state after the use of the hot-air bath 
and free purging from croton-oil. On the thirty-second day af- 
ter admission she was discharged, apparently well. The treat- 
ment embraced the frequent employment of the hot-air bath. 
Case V.-Albuminuria and general dropsy ; hydrothorax. 
Recovery after four and a half months in hospital. 
Mary Quinn, aged thirty-nine, cook, admitted July 8,1864. 
Iler illness began thirteen days before her admission. She did 
not come under my observation until August 1st, twenty-three 
days after admission. The anasarca, which had been consid- 
erable, was then slight, but there was large pleuritic effusion. 
On both sides, at the level of the liquid, bronchial respiration bright's diseases. 
243 
and bronchophony were marked. The patient suffered greatly 
from dyspnoea, and for two weeks she was obliged to keep 
constantly the sitting posture. The urine was albuminous. 
Moderate purging with elaterium was kept up for two weeks. 
The hydrothorax progressively diminished, and she improved 
in all respects. September 28th she was greatly improved, 
being up and about the ward; the oedema had disappeared; 
a little fluid only remained in the pleural cavities, and the 
urine was free from albumen. She was discharged well in the 
following November, having been in hospital four and a half 
months. Aside from the employment of elaterium, the treat- 
ment is not noted. 
Case VI.-Albuminuria and general dropsy. Patient dis- 
charged, apparently well, excepting a trace of albumen in 
the urine, after twenty-one days in hospital. 
Alfred Russell, aged seventeen, laborer, admitted April 12, 
1861. He was a moderate beer-drinker. (Edema of the lower 
limbs and of the face had existed for two months, but he had 
continued to work until a week before his admission. At the 
time of his admission the anasarca was considerable. The 
urine contained albumen in abundance and small epithelial 
casts. He progressively improved, and twenty-one days after 
his admission he was discharged, apparently perfectly well, 
excepting a trace of albumen in the urine. He was treated 
solely with the bitartrate of potassa, which acted efficiently 
as a diuretic, the patient at one time passing five pints of 
urine daily. 
Case VII.-Albuminuria and general dropsy; large pleu- 
ritic effusion ; recovery. 
Mrs. II., a young married woman, a patient of Prof. L. A. 
Sayre, was seen by me in consultation, in October, 1863. She 
was then greatly anasarcous, and the lower limbs were enor- 
mously swollen. The urine was highly albuminous. She was 
in the latter part of pregnancy. Premature labor shortly 
afterward took place. I saw her again on December 6 
and 10, 1863. The anasarca was much diminished ; but the 
chest, on both sides, was nearly filled with liquid. Bronchial 244 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
respiration and bronchophony existed on both sides at the level 
of the liquid. The suffering from the want of breath was ex- 
treme, and there seemed to be imminent danger of death from 
apnoea. Notable relief was obtained by the repeated employ- 
ment of elaterium. Five months afterward I was accosted by 
this lady in the street, and should never have recognized her. 
Iler appearance was typical of fine health, and she stated that 
she was perfectly well. 
3.-Antecedent Circumstances and the Previous History. 
In this section I shall give whatever facts may be obtained 
by analyzing the cases with respect to points of inquiry which 
have a bearing- on the causation of Bright's diseases, and the 
history as regards their development. The first questions 
which arise relate to sex, age, occupation, and habits of life. 
Sex.-Of 102 patients, 67 were males and 35 were females. 
Of 55 patients, in the cases known to have ended fatally, 34 
were males and 21 were females. Of 22 patients who recov- 
ered, 13 were males and 9 were females. Of 25 patients, in 
the cases in which the termination was not known, 20 were 
males and 5 females. 
Age.-In 6 cases the renal disease was a sequel of scarla- 
tina in children ; in 3 the age being 6 years, in 1 case 3 years, 
in 1 case 7 years, and in 1 case 4 years. Eliminating these 
six cases, the remaining cases, with respect to age, may be 
grouped into-1st, those which ended fatally ; 2d, those which 
ended in recovery; and 3d, those in which the termination 
was not known. 
In 50 fatal cases the minimum of age was 5 years. This 
was the age in one case ; there is ground for suspecting that 
scarlatina preceded the renal disease in this case. The next 
lowest age was 14 years. This, too, was the age in only a 
single case. The next lowest age was 17 years, and the next 
19 years. The maximum of age was 70 years; one patient 
only was of this age, and the next oldest was 56 years of age. 
The mean age in this group of cases is a fraction over thirty- 
six years. 
In 18 cases ending in recovery, the minimum of age was 
15 and the maximum 63 years. The mean age in this group 
is a fraction over thirty-two years. bright's diseases. 
245 
In 24 cases in which the termination was not known, the 
minimum of age was 24, and the maximum 65 years. The 
mean age in this group is a fraction under thirty-four years. 
The little variation of the mean age in these three groups 
of cases is worthy of note. The analysis shows that, exclusive 
of scarlatina, the causes of Bright's diseases are chiefly operative 
after adolescence and before advanced age. 
Occupation.-1The occupation is noted in 60 cases, the pa- 
tients being males in 52 cases. Of the male patients, 18 were 
laborers, and 7 were merchants. A considerable number of 
callings are represented in the remainder of the cases, viz.: 
seaman, 4 cases; shoemaker, 3 cases; carpenter, 2 cases; 
farmer, 2 cases, and a single case of each of the following: 
liquor-dealer, boatman, printer, currier, bricklayer, copper- 
smith, clerk, student, lawyer, physician, banker, gardener, 
plasterer, furrier, stone-cutter, and coachman. Of the female 
patients, 7 were domestics, and one was a cook. This analysis 
goes to show that the cases of Bright's diseases do not per- 
tain to any particular occupation or occupations. 
Habits.-Limiting the term habits to those concerning the 
use of alcoholic beverages, the histories of 38 cases contain 
information on this point. In the histories of nearly all the 
cases in which the patients were females, nothing is noted in 
relation to this point; hence, in most of the 38 cases, the pa- 
tients were males. Of these 38 cases, in 18 the habits, as re- 
gards the use of alcoholic beverages, were good; in 13 cases 
the patients were spirit-drinkers and intemperate; 3 patients 
were moderate drinkers ; 4 drank malt liquors freely, and in 
one case it is noted that the patient was a free liver. So far as 
these facts go they certainly do not show any special causative 
influence pertaining to the use of alcoholic beverages in the 
production of Bright's diseases. The cases in which renal dis- 
ease followed scarlatina are not included among those ana- 
lyzed with respect to habits. 
Exclusive of sex, age, occupation, and habits, various points 
of inquiry, relating to antecedent circumstances and the 
previous history, and bearing on the causation of Bright's dis- 
eases, suggest themselves. Are the affections of the'kidneys 
preceded by any other diseases sufficiently often to render 246 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
probable a causative relation ? Are the manifestations of renal 
disease, meaning, especially, oedema or anasarca and uraemic 
phenomena, preceded, as a rule, by more or less impairment 
of the general health ; or, on the other hand, do these mani- 
festations occur when apparently the body is in a healthy con- 
dition ? What symptoms precede the special manifestation s 
of these diseases, viz., dropsy and uraemia ? I propose to ana- 
lyze the cases with reference to facts relating to these and 
other kindred questions. The histories of 78 cases contain 
more or less information respecting the antecedent circum- 
stances and the previous history. 
Antecedent Diseases.-As already stated, the renal disease 
was a sequel of scarlatina in children in six cases. In one case 
it followed scarlatina and confinement; and in another case 
it accompanied scarlatina, the patient being an adult. Ex- 
clusive of scarlatina, the antecedent diseases which are noted 
are the following: intermittent fever, articular rheumatism, 
gout, pulmonary tuberculosis, diphtheria, valvular disease of 
heart, sporadic cholera, syphilis, and diabetes mellitus. 
Intermittent fever was an antecedent disease in ten cases. 
The histories do not enable me to determine in how many of 
the 78 cases the patients had been exposed to malaria, but all 
the cases were observed in situations in which intermittent 
fever is of frequent occurrence. The proportion of cases, there- 
fore, 10 to 78, is not large enough to show any special patho- 
logical connection. Moreover, there are probably no grounds 
for supposing that Bright's diseases are more rife in situations 
which are malarious than in those in which periodical fevers 
are never produced. The facts, in the ten cases, relating to 
the intervals between the last attack of intermittent fever and 
the first manifestations of renal disease, do not favor the suppo- 
sition of a causative relation. In only two of the ten cases did 
the manifestations of renal disease follow immediately an at- 
tack of intermittent fever; in four cases it is simply noted that 
the patients had been subject to attacks of intermittent fever; 
and ill four cases it is stated that an attack had not occurred 
for periods respectively as follows : three months, six months, 
one year, and two years. The most that can be inferred is, 
that in two cases an attack of intermittent fever may have bright's diseases. 
247 
acted as an exciting cause of the renal disease. The two cases, 
in which the manifestations of the renal affection followed im- 
mediately an attack of intermittent fever, ended, fatally; in 
one of the cases the affection being found to be the smooth 
white kidney on post-mortem examination, and no examina- 
tion after death having been made in the other case. 
Articular rheumatism was an antecedent disease in six cases. 
The facts in these cases do not go to show any pathological con- 
nection between the rheumatism and the renal affection. In one 
case, the patient, when admitted, had articular rheumatism. 
In the other cases an attack of rheumatism had not occurred 
for a considerable period prior to the manifestations of renal 
disease, namely, a year in one case, four months in one case, 
three or four months in one case, ten months in one case, and 
in one case five years. In all these cases the patients had re- 
covered from the rheumatism before the manifestations of re- 
nal disease occurred. 
* 
Gout had existed antecedently in three cases. In one of 
these cases the renal affection was preceded and accompanied by 
diabetes mellitus. This case is still in progress. In one of the 
cases the kidneys were found to be fatty after death, and uric 
acid crystals were observed in the pyramidal bodies. In one 
only, of the nine cases in which the kidneys were found to be 
contracted or cirrhotic after death, did gout either precede or 
accompany the renal disease. The cases under analysis thus 
furnish very little in support of the propriety of calling the 
contracted kidney " gouty kidney." 
Pulmonary tuberculosis existed antecedently in only two 
cases. This small proportion, when the frequency of tubercu- 
lous disease of the lungs is considered, shows conclusively that 
this disease does not involve any predisposition to the renal 
affections under consideration. 
Diphtheria was an antecedent disease in two cases. In one 
of these cases this disease had occurred sixteen months before 
the occurrence of the renal manifestations which existed at 
the time the case came under my observation; but the pa- 
tient had had transient dropsy five years before. In the 
other case, the diphtheria was associated with scarlatina, and 
the renal affection was a sequel of the combined diseases. 248 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Valvular lesions of the heart are noted in the previous his- 
tory of three cases. Two of these cases are among those in 
which rheumatism occurred. 
Sporadic cholera in one case occurred six months before 
the manifestations of renal disease, which in this case were 
uraemic coma and convulsions. It is noted in the previous his- 
tory of three cases that the patients had had syphilis; but in 
neither of the cases were there present any characteristic syphi- 
litic phenomena when the patients were under my observation. 
Diabetes mellitus preceded the renal disease in two cases. 
As illustrative of disease of the kidneys occurring secondarily 
to diabetes, these cases possess interest, and an abridgment of 
the histories is here introduced. In both these cases, at the 
ime of the writing of this report, the patients are living. 
Disease of the kidneys occurring as a complication of diabetes 
mellitus. 
Case I.-Mr. C., aged forty-five, came under my observation 
in consultation with Dr. R. Hubbard, of Bridgeport, Conn., in 
August, 1867. He was formerly a merchant in New York, 
but he had retired from business for the three or four preced- 
ing years on account of ill health. On retiring from business 
and becoming a resident of Bridgeport, he came under the 
care of Dr. Hubbard, who, finding that the quantity of urine 
was large, ascertained the existence of diabetes mellitus. The 
patient refused to adopt a diabetic diet, but continued to eat 
according to his desire and appetite, taking saccharine and 
farinaceous substances pretty freely. He did not pursue any 
course of meditation, but occupied himself in building, mak- 
ing alterations in his house, and cultivating his grounds. He 
was out of doors constantly, and he was accustomed to do 
much manual labor, becoming, to a considerable extent, an 
amateur carpenter. During his three years', or more, residence 
in Bridgeport, up to a few weeks before I saw him, he had 
enjoyed comfortable health. He gained in weight and strength 
after leaving New York; he was able to take much active ex- 
ercise, and considered himself pretty well, passing, however, 
constantly a considerable quantity of saccharine urine. A few 
weeks before I saw him, he began to have paroxysms of dysp- bright's diseases. 
249 
noea at night. Prior to this, for a long time, he was subject 
to attacks of severe cephalalgia. The paroxysms of dyspnoea 
were at first infrequent, but at length they recurred every 
night. In these paroxysms the respiration was labored, and 
there was the wheezing of asthma. They were relieved by 
ether and chloroform given by the mouth. In the intervals, 
respiration was not notably embarrassed. The attacks of ce- 
phalalgia were relieved by opium. 
About two weeks before I saw him, he was induced to un- 
dertake a journey to the White Mountains, by the hope that 
change of air would be beneficial. He journeyed about forty 
miles, and found himself so much worse, that he returned 
home. After commencing his journey, his lower limbs began 
to swell, and the oedema daily increased. He suffered from 
a sense of suffocation on lying down, and passed the nights in 
an easy-chair. The appetite failed, and he became quite fee- 
ble. On his return home the urine was examined, and it was 
found to contain albumen in considerable quantity. It did 
not now contain sugar, and the quantity was considerably less 
than usual. 
When I saw him, August 2, 1867, his aspect was not mor- 
bid ; he had good color; the lower limbs were much swollen 
below the knees, but elsewhere there was no oedema ; he had 
very little appetite ; the pulse was frequent and feeble; he felt 
unable to lie down, but he breathed without labor while sitting 
or when walking about the room. The urine passed in twenty- 
four hours was 76 oz., the sp. gr. was 1.010; it was consider- 
ably albuminous, and it did not contain sugar. On examina- 
tion of the chest, there was no evidence of hydrothorax, but 
subcrepitant rales existed at the base on both sides. The heart 
was enlarged, without cardiac murmur; and the sounds of the 
heart were feeble, the second sound being louder than the first 
over the apex. 
At this time albuminuria had succeeded diabetes. Wheth- 
er the renal affection was tubal nephritis or degenerative dis- 
ease, was considered as doubtful. The urine was not smoky 
in appearance, but pale. The microscopical appearances are 
not noted. Diuretics were given, and afterward tonics. The 250 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
dyspnoea was attributed in part to oedema of the lungs, and in 
part to an asthmatic element. 
About three weeks afterward I noted that I had received 
information of much improvement, the patient going out of 
doors, eating well, and being able to lie down during the en- 
tire night. 
Two months afterward, the patient paid me a visit. He 
then presented quite a healthy aspect. He was able to walk 
about freely. There was no oedema. The urine, for several 
weeks, had been free from albumen, and the quantity was not 
much above that of health. His appetite and digestion were 
fair. His diet had been restricted, in a great measure, to ani- 
mal food. 
This note was made eighteen months before the time of 
writing this report. For some time afterward I learned that 
he continued to have comfortable health ; but recently I have 
been informed that he has general dropsy, and that he is in a 
very feeble condition. 
Case II.-Mr. P., aged sixty-five, came under my observa- 
tion, February 18, 1869, in consultation with Dr. William II. 
Draper. For several years past there has been more or less diure- 
sis, and the urine has been saccharine. In August, 1868, he 
was suddenly seized with convulsions, which were followed by 
temporary hemiplegia and aphasia. Three subsequent attacks 
had occurred, temporary hemiplegia with aphasia following 
the convulsions in each attack. The last attack was on the 
day previous to my visit. Dr. Draper had examined the urine 
repeatedly, and found it to contain always both sugar and al- 
bumen. The patient was formerly subject to attacks of gout. 
He recovered from the last attack of convulsions rapidly, as 
after the previous attacks; and at the time of writing this re- 
port he is sufficiently well to be up and to ride out of doors. 
The urine in quantity is not much above the average of health; 
the sp. gr. varies from 1.020 to 1.023 ; sugar is always present, 
and also albumen in small quantity. In some specimens a few 
granular casts have been observed. The heart in this case is 
unaffected. 
These cases are especially interesting, as showing the toler- bright's diseases. 
251 
ance of renal disease, notwithstanding the previous existence of 
saccharine diabetes for a long time. In the first of the cases, the 
recovery of comfortable health, under the circumstances which 
existed when he came under my observation, is truly remark- 
able. The question arises, in connection with these cases, 
whether the diuretic effect of sugar in the blood may not af- 
ford more or less security against uraemia. 
In one of my cases the patient had ichthyosis extending 
over the upper and lower extremities and over the body. The 
urine in this case was abundant (80 oz. in twenty-four hours) 
and the sp. gr. 1.007. There was considerable dropsy, which 
nearly disappeared after keeping the bed in hospital for four 
days without any medicinal treatment. He left the hospital 
after remaining four days. 
THE CONDITION AS REGARDS GENERAL HEALTH PRIOR TO THE 
MANIFESTATIONS OF RENAL DISEASE. 
The facts belonging under this head have an obvious bear- 
ing on the etiology. Bright's diseases doubtless involve an 
internal or constitutional determining cause. Now, does the 
previous history afford proof of more or less impairment of 
the general health before the occurrence of events distinctly 
referable to renal disease ? Analyzing the cases with refer- 
ence to this inquiry, of course those are excluded in which 
there were antecedent diseases. Excluding these, the notes 
contain information relating to the inquiry in fifty-three cases. 
Of these fifty-three cases, in thirty the health was good prior 
to the manifestations of renal disease. In fourteen of the 
thirty cases, the event which denoted the existence of renal dis- 
ease was either oedema or anasarca. In six of the thirty cases, 
uraemic coma or convulsions occurred either when the patients 
were supposed to be in good health, or these events were pre- 
ceded by other ailments for a period not longer than three or 
four days. Evidence of impaired health prior to the mani- 
festations of renal disease is afforded by the previous history 
in twenty-three of the fifty-three cases. These facts go to 
show that, assuming the existence of general or constitutional 
causes of Bright's diseases, these causes do not, in the majority 
of cases, give rise to appreciable morbid effects anterior to the 252 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
existence of disease of the kidneys. It follows that in the ma- 
jority of cases the occurrence of Bright's diseases cannot be fore- 
seen, or even suspected, before the obvious manifestations of 
these diseases take place. These diseases are not peculiar in 
this respect; the same is true, for example, of pulmonary 
tuberculosis. 
THE SYMPTOMS PRECEDING THE SPECIAL MANIFESTATIONS OF 
bright's DISEASES, NAMELY, DROPSY AND ER/EMIA. 
In the twenty-three cases in which the manifestations of 
renal disease were preceded, for a greater or less period, by im- 
pairment of the general health, the facts noted are as follows : 
Case I.-General debility had existed for several years. A 
fatal case. No autopsy. 
Case II.-The patient had had a miscarriage, from which 
she had not recovered ; but the period after the miscarriage, 
before the manifestations of renal disease occurred, and the 
symptoms denoting impaired health, are not noted. A fatal 
case. No autopsy. 
Case III.-The patient had been progressively losing 
weight and strength for a year. A fatal case. No autopsy. 
Case IV.-The same was true in this case. A fatal case. 
No autopsy. 
Case V.-Indefinite ailments had existed for three weeks, 
and the patient was ptyalized by mercury. A fatal case. 
The form of renal disease not now determinable. 
Case VI.-The patient was well up to four weeks before 
the occurrence of dropsy, but the ailments in these four weeks 
are not noted. A fatal case, and the kidneys were contracted. 
Case VII.-Cephalalgia and frequent vomiting preceded, 
but it was not noted for how long a period. A fatal case, and 
the kidneys were contracted. 
Case VIII.-The menses had been suppressed for a year, 
no other evidence of ill health being noted. A fatal case, and 
the kidneys were contracted. 
Case IX.-Cephalalgia and diarrhoea had existed for five 
weeks. A fatal case, and the kidneys were contracted. 
Case X.-Cephalalgia had existed for six weeks. A fatal 
case, and the kidneys were not examined after death. bright's diseases. 
253 
Case XI.-Cephalalgia and occasional vomiting preceded ; 
it is not noted for how long a period. A fatal case, and the 
kidneys were contracted. 
Case XII.-Febrile phenomena preceded for several days. 
Recovery in this case. 
Case XIII.-General debility, with loss of appetite, and 
occasional nausea, had existed for two weeks. 
Case XIV.-General debility and loss of appetite had ex- 
isted for three weeks. Recovery in this case. 
Case XV.-The patient had not been well for some time, 
but the length of time and the ailments are not noted. Re- 
covery in this case. 
Case XVI.-The patient had never recovered from a con- 
finement with flooding which occurred a year before the mani- 
festations of renal disease. She also had had phlegmasia dolens. 
Ending in this case not known. 
Case XVII.-The health had been impaired for a month. 
The ailments are not noted. Ending in this case not known. 
Case XVIII.-The patient was weak, and had pains in 
different parts of the body for three months. Ending in this 
case not known. 
Case XIX.-The patient had had cephalalgia, wandering 
pains, epistaxis, and frequent vomiting for seven months. 
Ending in this case not known. 
Case XX.-Debility and pain in the loins had existed 
for three months. Ending in this case not known. 
Case XXI.-Diarrhoea had existed for three months. 
Ending in this case not known. 
Case XXII.-Cephalalgia had existed, the duration not 
noted. Ending in this case not known. 
Case XXIII.-Pain in the back had existed for two weeks. 
Ending in this case not known. 
In connection with the points of inquiry in this and the 
preceding section the following questions arise: Do the differ- 
ent Bright's diseases differ as regards the proportion of cases 
in which the renal manifestations occur without the evidence 
of previous impairment of the general health; and, of the 
symptoms which do precede these manifestations in a certain 
number of cases, are there any which belong particularly to 254 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
either of these diseases ? My stock of facts is not sufficient to 
supply data for answering these questions. I can only state 
that the cases in which the manifestations of renal disease were, 
and those which were not, preceded by symptoms denoting 
impaired health, are distributed among the three groups of 
cases in my collection, namely, those which proved fatal, those 
which ended in recovery, and those in which the termination 
is not noted. 
There is an antecedent symptom which I have reserved for 
a separate notice. I refer to dimness of vision. This symp- 
tom is noted as having preceded the manifestations of renal 
disease in live cases. In one of these cases the patient had 
consulted Prof. Beard, an eminent oculist, of New Orleans, 
for this difficulty, and the existence of albuminuria was ascer- 
tained by Dr. Beard, renal disease not having been previously 
suspected. In another case the patient, in like manner, con- 
sulted Prof. Henry D. Noyes, of New York, who was the first 
to ascertain, in the case, the existence of albuminuria. In 
each of the five cases the dimness of vision was associated 
with other ailments, namely, in two cases with progressive loss 
of weight and strength for a year; in three cases with cepha- 
lalgia ; in one case with diarrhoea, and in one case with 
diuresis. 
What pathological significance have the symptoms which, 
in certain cases, precede the occurrence of either dropsy or 
uraemic coma and convulsions ? Are they connected with the 
internal or constitutional causes of the renal disease; or, on the 
other hand, do they proceed from already existing disease of 
the kidneys? The latter is the more reasonable as regards 
antecedent symptoms corresponding with those observed after 
the occurrence of the special manifestations of renal disease. 
Reasoning in this way, certain of the previous ailments, 
namely, cephalalgia, vomiting, diarrhoea, and dimness of 
vision, are premonitions of the manifestations which are more 
obvious and distinctive; these ailments are symptomatic of 
an already existing disease of the kidneys. The practical im- 
portance of this point is obvious. Regarding these ailments 
as premonitions of dropsy and uraemic coma or convulsions, 
an examination of the urine may be expected to furnish evi- bright's diseases. 
255 
dence of renal disease in season for measures to be employed 
to prevent or postpone the occurrence of more serious effects. 
The latency of'Bright's diseases, in a large proportion of 
cases, as regards the general health, has been shown by the 
facts presented in the section preceding the last. It is further 
shown by cases in which laboring persons continued to work 
after oedema had occurred. It is noted in the previous history 
of some cases, that oedema of the limbs and face had been 
noticed for weeks and even months before the health was suf- 
ficiently impaired to oblige the patient to quit work. This 
remarkable latency is a fact which enforces the importance of 
examinations of the urine, not only when morbid symptoms 
are present, or the general health is in any degree impaired, 
but as a means of interrogating the kidneys even when persons 
may appear to be perfectly well. If, as is probable, it be true 
that, in most of Bright's diseases, more is to be effected in the 
way of preventing further progress of the renal affection than 
by efforts to save or prolong life after the affection has ad- 
vanced sufficiently to give rise to dropsy or uraemia, the im- 
portance of as early a diagnosis as possible is at once apparent. 
Doubtless, in many, if not most, of the cases in which the 
manifestations of renal disease occurred in persons apparently 
in good health, the urine would have been found for weeks or 
months, and possibly even for years, to furnish proof that the 
kidneys were not healthy. A collection of facts bearing on 
this point is a desideratum. 
Assuming that, in certain cases of Bright's diseases, tlie 
system tolerates lesions, greater or less in degree, of the kid- 
neys, for an indefinite period, an important inquiry relates to 
the causes which at length determine the occurrence of the 
renal manifestations. What are the circumstances which oc- 
casion, at a particular time, either dropsy or uraemic coma 
and convulsions ? My cases do not furnish data for a satisfac- 
tory answer to this question. In some of the cases the illness 
was attributed by the patients or their friends to exposure to 
cold ; but it is well known how common it is to refer illness 
of all kinds to this source on insufficient ground. On the 
other hand, the previous history in most of the cases gives no 
account of any exciting causes. Certain it is that, in many, if 256 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
not the great majority of cases, the time when the manifesta- 
tions of the renal disease appear is not determined by any ob- 
vious extrinsic exciting causes. In illustration of this fact, 
and also as examples of the latency of Bright's diseases, I shall 
subjoin the leading features in a few cases characterized by the 
sudden occurrence of uraemic coma and convulsions. 
Cases illustrative of uraemic coma and convulsions, without 
obvious exciting causes, and of the latency of Bright'1 s 
diseases. 
Case I.-Mrs. F., aged twenty-four, having been at a 
place of amusement the previous evening, and having slept 
well during the night, awoke apparently well, July 20, 1867. 
She made no complaint of illness, but at 9 o'clock, a. m., she 
suddenly became comatose. A quart of urine was soon after- 
ward withdrawn by means of the catheter, and it was found to 
be highly albuminous, the specific gravity being 1.010. Ela- 
terium was given repeatedly, but it was immediately rejected. 
She vomited at short intervals. The vapor-bath was also em- 
ployed. I saw her, in consultation with Drs. Hallett and 
Gilfillan, of Brooklyn, at 1 a. m., July 21st. She could be 
roused sufficiently to open the eyes, but she could not be made 
to speak, nor to protrude the tongue. The respirations were 
irregular, long intervals occurring, followed by rapid acts of 
breathing. The pupils were largely dilated. Death took 
place at half-past two o'clock the following morning. Three 
years previously, during pregnancy, uraemic coma had oc- 
curred, and premature labor was induced by Dr. C. L. Mitchell. 
At this time she was seen, in consultation, by my colleague, 
Prof. George T. Elliot. Again, eighteen months previously, 
in pregnancy, premonitions of uraemic coma had occurred, 
which disappeared after a spontaneous miscarriage. During 
the year preceding the fatal attack, examinations of the urine, 
made from time to time, showed sometimes the presence and 
sometimes the absence of albumen and casts, the specific 
gravity being always low. Iler general health had been ex- 
cellent.1 
1 This case is reported in Prof. Elliot's "Obstetric Clinic," p. 115. bright's diseases. 
257 
Case IT.-Mr. F., aged fifty-two, was seen by me in con- 
sultation with Prof. Fordyce Barker, October 4, 1864. lie 
had been ill for four days with symptoms such as accompany 
what is commonly called a bilious attack. On the day of my 
visit the gastric symptoms had mostly ceased, but there was 
suppression of urine. An hour before my visit, he had seemed 
more comfortable than at any time during his illness ; but, in 
the mean time, he had become comatose, and he had a slight 
convulsion during my visit. Elaterium was given without avail, 
and death took place at one o'clock on the following morning. 
Prior to this illness he was in fair health, and there were no 
symptoms pointing to the existence of renal disease.1 
Case III.-Harris, aged about fifty-five, was admitted 
into Bellevue'Hospital in the summer of 1866, with sporadic 
cholera. He recovered speedily from this disease, and was 
employed in the hospital as an orderly man. He appeared to 
be in perfect health until January 20, 1867, when he had a 
slight chill, followed by some febrile movement, headache, 
slight diarrhoea, and general malaise. His illness was not suf- 
ficient to keep him constantly in bed. The development of 
typhus fever was suspected. On the 28th he vomited and 
complained of vertigo. On the next day he showed some de- 
lirium. On the 31st he was seized with convulsions, which 
recurred at short intervals, and in the intervals he was coma- 
tose. Death took place on this date. On the morning of the 
day of his death, disease of the kidneys being now for the first 
time suspected, the urine was found to be highly albuminous, 
and to contain granular casts. 
Case IV.-The following account of this case is based on 
a record made by Dr. O. C. Sparrow, formerly clinical assist- 
ant at the Long Island College Hospital: 
Mr. G., aged forty-nine, coppersmith, had been subject for 
some years to gouty attacks, and for several weeks preceding 
his present illness he had complained of a constant sense of 
1 This case is given in my work on Practice, 3d edition, p. 768. For 
another case in which sudden coma, followed by convulsions, occurred, the 
patient being apparently in good health, and renal disease not having been 
previously suspected, see ibid., same page. This case is included among 
those under analysis. 258 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
fatigue. The skin was sallow. He had at times spoken of 
slight pain in the head, and of dull pain in the loins. There 
was no dropsy. The urine, examined repeatedly, was always 
found to be free from albumen. The quantity of urine was 
habitually large. The appetite and digestion were fair. 
This is the history prior to June 18, 1867. Up to this 
date he attended to his business ; but, in addition to the symp- 
toms noted above, he had occasionally vomited. On the date 
just named, vomiting became an urgent symptom. The 
stomach was intolerant of the blandest fluids; even a teaspoon- 
ful of rice-water was immediately rejected. He had no pain 
nor febrile movement. The vomiting persisted in spite of 
various remedies. A watery liquid, of almost inky blackness, 
was vomited, in considerable quantity, with very little nausea. 
The urine, again examined, was found not to contain albumen. 
The following day the vomiting ceased, apparently having 
been arrested by suppositories of morphia. The pulse be- 
came frequent and feeble; the pupils were moderately con- 
tracted ; there was a kind of mirthful delirium, with subsul- 
tus, and at length some general convulsive movements. Stu- 
por and coma supervened, and death took place on June 21st, 
the fourth day from the occurrence of vomiting and the sus- 
pension of his work. 
On examination, after death, the kidneys were found to be 
much contracted, the weight of both being five ounces. The 
heart was hypertrophied, the weight being nineteen ounces, 
and the valves were sound. The liver presented the appear- 
ance of incipient cirrhosis. All the arteries examined were 
atheromatous, especially those of the brain. There was no 
evidence of meningitis. The urine withdrawn from the blad- 
der, after death, contained a moderate amount of albumen 
and an abundance of tubular casts. 
The state of pregnancy appears, in certain cases, to exert 
an agency in the causation of Bright's diseases. The facts 
gathered from my notes in relation to this point are as follows: 
In two cases, dropsy commenced during pregnancy, and in 
both these cases miscarriage took place. An account of one 
of these cases has been given among the cases illustrative of 
recovery. In one case dropsy began two months after con- bright's diseases. 
259 
finement. The patient attributed it to taking a cold bath at 
night, and sleeping without a night-dress. (Edema of the face 
and lower limbs was first noticed the following morning. In 
one case, an account of which is given in illustration of the 
occurrence of sudden coma without premonitions or exciting 
causes, the first manifestation of renal disease had occurred two 
years before, while the patient was pregnant, and premature de- 
livery was induced. In one case, the manifestations of renal 
disease followed a miscarriage. In another case, scarlatina 
occurred shortly after confinement, and the renal disease was 
developed as a sequel of the scarlatina. Finally, in one case, 
the patient stated that she had not been well since her confine- 
ment, which was accompanied by flooding, but dropsy did 
not manifest itself until a year afterward. 
4.-Symptoms and Complications. 
As already stated, my records are not sufficiently compre- 
hensive and complete to furnish data for determining, with 
numerical exactitude, the proportion of cases in which different 
symptoms and complications were present or absent. The ob- 
jects of the analysis under this heading will be to examine the 
histories with reference to the facts which were noted, select- 
ing those which appear to be worthy of being presented, and 
offering remarks which the facts may suggest. I will interro- 
gate the cases with reference, first, to the urine, and second, to 
dropsy; afterward with reference to symptoms and complica- 
tions relating respectively to the digestive, the nervous, the 
respiratory, and the circulatory system. 
Urine.-Information concerning the urine is noted in 91 
cases. In all but 3 of these 91 cases the urine contained more or 
less albumen. The albumen is stated to have been large or abun- 
dant in 55 cases. It was either moderate or small in 8 cases. 
In 25 cases the presence of albumen is noted without any state- 
ments regarding quantity. The small number of exceptions 
to the rule that albuminuria exists in Bright's diseases is a 
noteworthy fact. It is not uncommon to hear the opinion ex- 
pressed that albumen is not very unfrequently absent. Espe- 
cially in cases of the lesion known as the contracted or cir- 260 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
rhotic kidney, albuminuria is supposed by some to be fre- 
quently wanting. Examining the cases in which this lesion 
was found after death, in 8 the histories contain information 
on this point. Of these cases, in 6 the urine was albuminous. 
The quantity of albumen was considerable in 4 of these 6 
cases; it was moderate in one case, and only the fact of albumi- 
nuria is stated in one case. In 2 cases the urine was not 
albuminous. In one of these 2 cases, however, although re- 
peatedly before death the urine had been examined for albu- 
men with a negative result, the urine withdrawn from the 
bladder after death was found to be albuminous, and to con- 
tain casts. In the other case a single examination only of the 
urine was made. In the third of the 3 cases in which there 
was no albuminuria, the kidneys were found to be waxy after 
death. The urine was repeatedly examined in this case. Al- 
buminuria thus existed in all the cases in which lesions other 
than the contracted and the waxy form of disease were found 
after death; in all the cases ending fatally in which post-mor- 
tem examinations were not made; in all the cases the termi- 
nation of which was not noted, and in all the cases which 
recovered. 
The presence or absence of tubular casts was noted in 29 
cases. Of these cases, casts were present in 25, and absent in 
4 cases. In the remainder of the cases, either the urine was 
not examined microscopically, or nothing was noted in relation 
to casts. As regards the different kinds of casts, in 7 cases, 
epithelial casts were observed ; in 9 cases, granular casts; in 
15 cases, hyaline or waxy casts ; in 5 cases, fatty casts, and in 
a single case the casts were bloody. Blood-corpuscles in the 
sediment of the urine were noted in 3 cases. The study of the 
urine, as regards casts, is of interest and importance in relation 
to several points of inquiry, among which are the following : 
their occurrence in the small number of cases of Bright's dis- 
eases in which albumen in the urine is not present; their sig- 
nificance as denoting different forms of renal disease, the ex- 
tent of lesions, and the condition of the tubules with respect to 
epithelium; their relations to different symptoms and events 
in cases of Bright's diseases, and their occurrence in the course 
of various diseases in which the kidneys may be only tran- bright's diseases. 
261 
siently affected. An analysis, with reference to these and other 
points of inquiry, of a large number of cases, in which micro- 
scopical examinations of the urine were made daily or frequent- 
ly, is a desideratum which must be left to the eyes and hands 
of others. 
The quantity of urine passed in twenty-four hours was 
noted in only a very few cases. In fact, the records contain 
information concerning quantity in only 20 cases. In 12 of 
these 20 cases the quantity is stated to have been more or less 
below the minimum of health. In 3 cases suppression oc- 
curred. In 4 cases the quantity was more or less above the 
maximum of health, exclusive of two cases in which diabetes 
mellitus existed. The quantity in twenty-four hours in one of 
these cases was 61 ounces; in another case 5 pints, and in an 
other case 69 ounces, the specific quantity in each of these 
cases being low. In one case of scanty urine the quantity in 
twenty-four hours at one time was only two ounces. Death 
occurred in each of the cases in which there was suppression, 
the suppression continuing until death. In two of these cases 
the patients died in uraemic coma; in the other case, it is noted 
that the death occurred suddenly, having been preceded by 
delirium and great jactitation. In the case in which the quan- 
tity of urine is noted to have diminished to two ounces in the 
twenty-four hours, profound coma occurred, but the case ended 
in recovery. The specific gravity of the urine whenever noted 
(10 cases) was, with a single exception, always below that of 
health, varying from 1.007 to 1.013. In the single excepted 
case it was 1.027. These cases are exclusive of those in which 
diabetes mellitus existed. 
In three cases the quantity of urine in twenty-four^ hours 
and the specific gravity were noted for a series of days, in 
order to observe the effect of diuretic remedies. The details 
in these three cases are as follows: 
Case I.-In this case, the termination was not known. 
The patient was discharged from hospital much improved, 
general dropsy having nearly disappeared ; but the urine was 
still albuminous. 
On the day after the date of his admission, the quantity of 
urine was 48 ounces, and the sp. gr. 1.010. Under the use of 262 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
squill and digitalis, with the infusion of juniper-berries, during 
the following eight days, the quantity varied from 52 oz. to 
79 oz., and the sp. gr. remained constantly at 1.010. Decem- 
ber 6th, half an ounce of the nitrate of potassa was substi- 
tuted for the squill, digitalis, and juniper. Under this remedy 
the quantity varied from 56 oz. to 97 oz., and the sp. gr. 
from 1.010 to 1.012. 
Case II.-This case ended fatally, and the anatomical 
characters were those of the smooth, white kidney. There 
was considerable anasarca, and the urine contained albumen 
in abundance. The mode of dying was by asthenia. 
The quantity of urine and sp. gr. for two successive days, 
shortly after admission into the hospital, the patient taking no 
remedies, but the hot-air bath being employed at night, -were, 
the first day, 22 oz., sp. gr. 1.015 ; the second day, 22 oz., 
sp. gr. 1.012. The next day but one vomiting and diarrhoea 
occurred. On this day the quantity was 18 oz., and the sp. 
gr. 1.008. Commencing four days afterward, the quantity and 
sp. gr. were ascertained for 11 successive days, no treatment 
being pursued. The quantity varied from 12 to 51 oz., and 
the sp. gr. from 1.008 to 1.014. Then for four days, the 
patient taking the iodide of potassium, the quantity varied 
from 14 to 23 oz., and the sp. gr. from 1.010 to 1.028. 
Case III.-This case ended fatally, and the anatomical 
characters were those of the smooth white kidney. The urine 
was albuminous, and there was considerable anasarca. The 
mode of dying was by asthenia. 
Shortly after admission the quantity of urine on one day 
wTas 20 oz., and the sp. gr. 1.015; and on the following day 
the quantity was 24 oz., the sp. gr. 1.015. 
Under treatment by the external application of squill, 
iodine, and digitalis, the urine, on five days, varied in quantity 
from 14 to 40 oz., and the sp. gr. from 1.015 to 1.030. Next, 
under the use of quinia and iron, the urine, on ten successive 
days, varied in quantity from 10 to 28 oz., and the sp. gr. from 
1.015 to 1.025. The nitrate of potassa was then given for three 
days, and the quantity varied from 14 to 16 oz., and the sp. 
gr. from 1.015 to 1.020. The treatment then being changed 
to the quinia and iron for three days, the quantity varied from bright's diseases. 
263 
1.014 to 1.016, and the sp. gr. remained 1.015. External diu- 
retics being again tried for four days, the quantity varied from 
9 to 14 oz., and the sp. gr. from 1.018 to 1.020. 
These observations are too few to warrant any deductions. 
So far as they go, they do not show much effect from diuretic 
remedies. I introduce them chiefly as suggestive of a direc- 
tion in which clinical researches may be prosecuted with ad- 
vantage. An extended series of recorded cases, embracing daily 
examinations of the urine with regard, not alone to quantity 
and the sp. gr., but the results of quantitative analyses, by fur- 
nishing data for showing the relations between different ab- 
normal conditions of the urine and the important events which 
enter into the clinical history of Bright's diseases, the effect of 
different diuretics, the circumstances which affect the opera- 
tion of these and other remedies, etc., would, doubtless, prove 
of no small practical value. 
Dropsy.-Of 89 cases in which either the existence or ab- 
sence of dropsy is noted, it existed in 74, and it was absent in 
15 cases. The dropsy was either slight or moderate in 21 cases. 
In a few of these cases it consisted only of oedema of the lower 
limbs, or of the face. The dropsy was considerable in 36 cases, 
there being in these cases more or less anasarca and effusion 
into serous cavities. The degree and extent of the dropsy are 
not noted in 17 cases. 
The relations of dropsy to other symptomatic events in 
Bright's diseases constitute an interesting field of inquiry. I 
shall consider here only the relations between dropsy and al- 
buminuria. 
Of the 15 cases in which there was no dropsy, in one case 
there was no albumen found in the urine during life, but the 
urine withdrawn from the bladder after death was found to be 
albuminous. In another case the urine was found, on a single 
examination, to be free from albumen. In another case there 
was suppression, and the urine had not previously been ex- 
amined. In all the other cases (12) the urine was more or less 
albuminous. In 3 cases simply the fact of albuminous urine 
is noted, the quantity of albumen not being stated. In one 
case the quantity was moderate, and in another case there was 
only a trace of albumen. In 7 cases the quantity of albumen in 264 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
the urine was either considerable or large. It follows, from 
these results of the analysis, that, in the cases in which Bright's 
diseases are unattended by dropsy, the urine, as a rule, is more 
or less albuminous; and that, in a proportion of at least one- 
half of such cases, albumen is abundantly present in the urine. 
Of the 21 cases in which the dropsy was slight or mod- 
erate, in one case there is no information concerning the urine. 
In all the remaining 20 cases the urine was more or less albu- 
minous. The fact only of albuminous urine is noted in 8 cases, 
the quantity not being stated. In 7 cases the quantity of al- 
bumen was considerable or large; in 3 cases it was moderate; 
in 2 cases it was small, in one of the latter a trace only being 
observed. These results go to show that in at least one-third 
of the cases in which the dropsy accompanying Bright's dis- 
eases is small or moderate, albumen exists in the urine in either 
considerable or large quantities. They go to show that, with 
a small or moderate amount of dropsy, the urine is always 
albuminous. 
Of the 36 cases in which the dropsy was considerable or 
great, in 5 it is simply noted that the urine was albuminous, 
and in 2 information concerning the urine is wanting. In the 
remaining 29 cases the quantity of albumen in the urine is 
noted as moderate in only one case, and in no case is it noted 
as slight. It is noted as either considerable or large in 28 cases. 
These results show a very striking correspondence of a consid- 
erable or a large amount of dropsy with a considerable or large 
amount of albumen in the urine. Either the former is de- 
pendent on the latter, or vice versa ; or, again, both the dropsy 
and albuminuria, in these cases, are dependent on a common 
cause. Bringing pathological reasoning to bear on this point, 
the first of these inferences is the most rational. 
Of the 17 cases in which the degree and extent of dropsy 
are not noted, in one case information concerning the urine is 
wanting. In all the other cases the urine was albuminous. 
In 10 cases the quantity of albumen was large, and in 6 cases 
the quantity was not noted. 
With reference to the relations between dropsy and albu- 
minuria, it is to be borne in mind that, in Bright's diseases, 
the urine is more or less albuminous save in a very small pro- bright's diseases. 
265 
portion of cases, the proportion, in this analysis, being 88 of 
91 cases. Of the 3 of 91 cases in which the urine did not con- 
tain albumen, dropsy was also wanting in 2 cases, and in the 
remaining case the history is deficient in information concern- 
ing dropsy. In as far, therefore, as the results of this analysis 
go, dropsy is wanting in the cases in which the urine is free 
from albumen. 
Interrogating, the cases in which, wx post-mortem examina- 
tion, tiie kidneys were found to be contracted or cirrhotic, in 8 
the histories contain information concerning dropsy. Dropsy 
existed in each of these 8 cases. The dropsy was slight, and 
consisted only of oedema of the face in 3 cases; it was consid- 
erable in 4 cases, and the fact only of anasarca is noted in 1 
case. In G 'cases in which fatty kidneys were found after 
death, dropsy was wanting in 1 case; it was considerable in 4 
cases, and in 1 case simply the existence of anasarca is noted. 
Hydroperitonaeum, in a degree notably disproportionate to 
the dropsical effusion in other situations, was noted in 7 
cases. In 2 of these cases tapping was resorted to, this 
operation in one of the cases being employed twice; all these 
cases but one ended fatally under my observation, the patient, 
in the excepted case, being discharged from hospital much 
improved, especially as regards the general dropsy, but the 
hydroperitonaeum continuing. In all the cases the patients had 
been spirit-drinkers. Five of the cases were in the group of 
cases in which post-mortem examinations are noted; and in 
all these cases the liver was found to be contracted. 
Symptoms and Complications referable to the Digestive 
System. 
Vomiting and diarrhoea, separately or together, are the 
most important of the symptoms in Bright's diseases, referable 
to the digestive system; I shall limit my analysis chiefly to 
these symptoms. The cases which were not under my obser- 
vation until their termination either in death or recovery, I do 
not embrace among those analyzed. The number of cases 
interrogated, therefore, is 76. Of these cases, in 34, 
the records do not contain definite information respecting 
either the presence or absence of vomiting or diarrhoea. The 266 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
probability is, that in these cases, neither vomiting nor diar- 
rhoea occurred; or, at all events, they were not prominent 
symptoms. In 40 cases, the notes enable me to determine 
either that one or both of these symptoms were present, or 
that they did not exist in any notable degree. Of these 40 
cases, vomiting alone was a symptom more or less prominent 
in 14; diarrhoea occurred alone in 4 ; and both vomiting and 
diarrhoea existed in 10 cases. Neither vomiting nor diarrhoea 
was present in 10 cases. Thus, in 28 of the 40 cases, vomiting 
or diarrhoea, or both, occurred, being more or less prominent 
and persisting. 
Of these 40 cases, 31 ended fatally, and 9 ended in recovery. 
Analyzing these two groups of cases separately, the results are 
as follows : of the 31 fatal cases, vomiting alone was more or 
less prominent in 12 ; diarrhoea alone was more or less promi- 
nent in 3; and both vomiting and diarrhoea were more or less 
prominent in 10 cases. In 6 cases neither of these symptoms 
existed in any notable degree. Of the 9 cases which ended 
in recovery, vomiting alone was more or less prominent in 2 
cases ; diarrhoea alone was more or less prominent in 1 case, 
and vomiting and diarrhoea together were not prominent in a 
single case. In 6 of the 9 cases neither existed in any notable 
degree. 
It is thus seen that there is a striking contrast between the 
cases ending fatally, and those ending in recovery, as regards 
the occurrence of these symptoms; and, so far as these cases 
go, they show that vomiting and diarrhoea, separately or to- 
gether, are symptoms which are more likely to occur in con- 
nection with cases which end fatally than with those which 
end in recovery. 
What relations have these symptoms with the occurrence 
of uraemic phenomena, meaning by this phrase now, as hith- 
erto, coma and convulsions ? The facts bearing on this ques- 
tion are as follows : Of the 12 fatal cases in which vomiting 
alone was prominent, either coma or convulsions, or both, 
occurred in 10, and were wanting in 2 cases. Of the 3 fatal 
cases in which diarrhoea alone was prominent, coma and con- 
vulsions did not occur in 2 cases, and in one case, death was 
preceded by semi-coma and delirium. Of the 10 fatal cases in bright's diseases. 
267 
which both vomiting and diarrhoea were prominent, coma or 
convulsions, or both, occurred in 3, and were wanting in 7 
cases. Of the 6 cases in which neither vomiting nor diarrhoea 
was prominent, coma or convulsions, or both, occurred in all, 
save one case. It would appear from these figures, that in fatal 
cases, coma and convulsions are more likely to take place when 
vomiting occurs alone than when it is associated with diarrhoea, 
or when the latter occurs alone ; and that coma and convulsions 
are as likely to take place in cases without either vomiting or 
diarrhoea as in cases in which vomiting alone is a prominent 
symptom. 
Of the 2 cases ending in recovery, in which vomiting was 
a prominent symptom, uraemic phenomena occurred in one and 
not in the other case. In the single case in which diarrhoea 
was prominent, there were no uraemic phenomena; and in the 
six cases in which neither vomiting nor diarrhoea was promi- 
nent, uraemic phenomena occurred in only a single case. Con- 
trasting the two groups of cases as regards the relations be- 
tween vomiting or diarrhoea, or both, and uraemic phenomena, 
the inference is, that the pathological conditions of the kidneys 
in cases which recover involve a lesser degree of liability, alike 
to these symptoms referable to the digestive system, and to 
coma and convulsions. Moreover, inasmuch as, in the group 
of fatal cases, both uraemic phenomena and the vomiting and 
diarrhoea are of much more frequent occurrence than in the 
cases which recover, it is, perhaps, fair to infer that the expla- 
nation of the latter symptoms which is generally held is cor- 
roborated, namely, that they are due to the elimination of 
urea through the alimentary canal, and are, therefore, among 
the effects of uraemia. The occurrence of coma and convul- 
sions less frequently in the cases in which diarrhoea is a promi- 
nent symptom, than in the cases in which vomiting is promi- 
nent, or the cases in which neither vomiting nor diarrhoea is 
prominent, favors the belief that the diarrhoea is to a certain ex- 
tent conservative. The bearing of this on practice is obvious. 
As regards complications affecting the digestive organs, 
cirrhosis of the liver was denoted, as already stated, under 
the heading Dropsy, by a disproportionate amount of effusion 
into the peritoneal cavity. In 5 of these cases the existence 268 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
of cirrhosis of the liver was ascertained by examinations after 
death. Haemorrhoids with considerable haemorrhage is noted 
in one case. Fissures of the anus with haemorrhage is noted 
in one case. 
Peritonitis was developed in one case, after the patient, a 
male, had been in hospital several months. Death took place 
on the day following. The fact that this was the only case in 
which this complication was determined by the diagnostic 
symptoms, coupled with the fact that in none of the cases, in 
which the notes embrace the appearances after death, was 
there evidence of peritoneal inflammation, goes to show that 
peritonitis occurs very unfrequently in the course of Bright's 
diseases. I may mention in this connection that I have seen 
in one case, in hospital practice, peritonitis developed after the 
operation of tapping. Of this case I made no notes. 
Symptoms and Complications referable to the Nervous 
System. 
The more important of the symptoms referable to the ner- 
vous system, which are observed in cases of Bright's diseases, 
are coma and convulsions, occurring separately or together, de- 
lirium, cephalalgia, and impairment or loss of vision. Consid- 
ering first coma and convulsions, and analyzing only the cases 
which ended either fatally or in recovery, the number, after 
rejecting six cases in which the histories do not -warrant any 
conclusion as to the presence or absence of these events, is 70. 
Of these 70 cases, coma without convulsions is noted in 13 
cases. Convulsions without coma is noted in 4 cases. Con- 
vulsions and coma are noted in 9 cases. The proportion of 
cases, thus, in which these uraemic events occurred, separately 
or together, is 26 in 70 cases. 
The relations of these uraemic events to the termination in 
either death or recovery is the first point of inquiry which sug- 
gests itself. Of the 13 cases in which coma occurred without 
convulsions, in 12 the cases ended fatally, one case only end- 
ing in recovery. Of the 4 cases in which convulsions with- 
out coma occurred, all ended fatally. Of the 9 cases in which 
coma and convulsions occurred, all ended fatally. Thus, of 
the 26 cases in which these uraemic events occurred, separately bright's diseases. 
269 
or together, 25 were fatal. These results show the significance 
of these events as regards prognosis. 
The relations of these events to dropsy is another point of 
inquiry. Of the 13 cases of coma without convulsions, in 2 
the notes are defective are regards dropsy. Anasarca existed 
in 8 of the remaining 11 cases. The anasarca was either con- 
siderable or great in 5, and slight or moderate in 3 of these 11 
cases. There was no dropsy in 3 of the 11 cases. Of the 4 
cases in which convulsions occurred without coma, dropsy ex- 
isted in all, being considerable or great in 2 cases, slight in one 
case, and in one case the amount is not stated. Of the 9 cases 
in which coma and convulsions occurred, anasarca existed, the 
amount not stated, in one case, and there was no dropsy in 8 
cases. Thus,' of the 26 cases in which these uraemic events 
occurred, separately or together, there was no dropsy in 11 
cases; considerable or great anasarca existed in 7 cases, and 
slight or moderate anasarca in 4 cases; the amount of the 
anasarca is not stated in 3 cases, and in 1 case it is not stated 
whether dropsy did or did not exist. 
Referring back to the section of this report in which dropsy 
is considered, it will be seen that in only 15 of 89 cases in 
which the notes contain information on this point was dropsy 
wanting. In 11 of these 15 cases, as just seen, either coma or 
convulsions, or both, occurred. Now, of the remaining 4 cases 
in which dropsy was wanting, 2 cases are among those, the 
ending of which is unknown, and these two cases are not in- 
cluded in the groups just analyzed. In each of these 2 cases 
coma and convulsions occurred; so that uraemic coma or con- 
vulsions, or both, occurred in 12 of the 15 cases in which 
dropsy was wanting. The conclusions are, that, of the cases 
of Bright's diseases in which the uraemic events now under 
consideration occur, dropsy is wanting in a proportion not 
much under one-half, and that these events occur in the vast 
majority of the cases of Bright's diseases in which dropsy is 
wanting. Again, absence of dropsy characterizes a much 
larger proportion of the cases in which coma and convulsions 
occur together, than of the cases in which either coma or con- 
vulsions occur separately. 
Delirium is noted in 7 of the 70 cases. In three cases only 270 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
is the kind or degree of the delirium noted. In one of these 3 
cases it is stated to have been passive, and in another case 
muttering. In one case it was very active, the patient shout- 
ing and requiring restraint. In this case convulsions occurred, 
and the active delirium followed the convulsions. Convul- 
sions occurred in another case. Coma without convulsions 
occurred in one case ; and in four cases neither coma nor con- 
vulsions occurred. It is thus seen that delirium, except, per- 
haps, in so slight a degree as not to be considered noteworthy, 
is not a frequent, and is very rarely a prominent symptom in 
Bright's diseases. 
Cephalalgia.-Pain in the head is noted in I of the cases 
ending either fatally or in recovery, and in 2 of the cases 
of which the termination is not known, making, in all, 9 cases. 
It is very probable that these were not the only cases in which 
this symptom existed, for, if not prominent and persistent, it 
would not be likely to be noted. In the 9 cases in which it is 
stated to have existed, it was a notable feature. Reference is 
now had to this symptom as existing while the cases were 
under observation, not as entering into the previous history. 
The chief point of interest relating to this symptom is its 
significance as shown by its association with other symptoms 
referable to the nervous system. The facts concerning this 
point are as follows: In 3 of the cases in which cephalalgia was 
a notable feature coma occurred. In 4 cases it was associated 
with impairment of vision, the impairment in two of these 
cases existing only when the pain in the head was intense. 
Tinnitus aurium was a prominent symptom associated in one 
case. In 3 cases there were no other symptoms of importance 
referable to the nervous system. Its presence, thus, in one- 
third of the cases in which coma occurred, and its association 
with impaired vision in nearly one-half of the cases in which 
it was noted, go to show the uraemic character of the symp- 
tom. As regards the bearing of the symptom on prog- 
nosis, it was present in precisely the same number of cases 
ending fatally and of those ending in recovery, namely, in 4 
cases of each group; as, however, the fatal cases analyzed are 
twice as many as the cases ending in recovery, the inference 
from the results of this analysis is, that it occurs oftener in bright's diseases. 
271 
cases in which recovery takes place than in those which end 
fatally. 
Impairment and Loss of Vision.-The vision was more or 
less affected in 9 cases of those ending either fatally or in re- 
covery, and in 4 cases of those the termination of which is not 
known, in all, 13 cases. The affection consisted in more or 
less mistiness of vision in 11 cases. In 2 cases there was 
complete loss of vision. Of the latter cases, in one the amau- 
rosis was of brief duration, the sight being completely restored 
in six days. During these six days the patient had convul- 
sions, and a portion of the time was in coma. In the other 
case the amaurosis had existed seven days before the admis- 
sion of the patient into hospital, and it continued when the 
patient was discharged, his stay in hospital having been four- 
teen days. Cephalalgia was a notable symptom in the latter 
case, but coma or convulsions did not occur. Of the 11 cases 
in which vision was not lost, but more or less impaired, the 
degree of impairment varied in the different cases between 
slight and considerable mistiness. In 4 of these cases coma 
occurred. Convulsions occurred in one case, coma not being 
noted in that case. Cephalalgia was a notable feature in two 
cases, in neither of which did coma or convulsions occur. 
Tinnitus aurium was associated in one case. In 2 cases the 
notes are not complete enough to say that no other symptoms 
referable to the nervous system occurred; but this fact is dis- 
tinctly noted in 2 cases. Muscae volitantes were associated 
in one case. 
As regards the persistence of the affection of vision, aside 
from the case in which restoration from complete blindness 
took place in six days, it is noted in 2 cases that the impair- 
ment was temporary, and in 2 cases vision was nearly, but 
not completely, restored. 
Of the cases in which neither loss nor impairment of vision 
is noted, 7 are among those which ended fatally, and 4 are 
among those ending in recovery. In the cases in which there 
was total blindness for six days, recovery took place. In 3 of 
the cases ending fatally, the autopsy showed contracted kidneys 
in one case, and fatty kidneys in 2 cases. 
The occurrence of either coma, convulsions, or cephalalgia, 272 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
in all the cases, save two, in which the histories contain infor- 
mation concerning other symptoms referable to the nervons 
system, is a fact which may be considered as showing the 
uraemic character of the affection of vision. As a symptom, 
however, its bearing on the prognosis is not unfavorable, since 
it occurred in the proportion of 7 in 49 of the fatal cases, and 
4 in 21 of the cases ending in recovery. 
Hemiplegia existed in 4 cases. In one of these cases it 
is simply stated that slight hemiplegia existed when the patient 
wTas admitted into hospital. Aortic lesions and enlargement 
of the heart existed in this case, and embolism may be sus- 
pected. In one case slight hemiplegia had existed for nine 
years, and it evidently had no connection with the renal dis- 
ease. . In one case, an account of ■which has been given in this 
report, transient hemiplegia of the right side and aphasia oc- 
curred repeatedly in connection with attacks of epileptiform 
convulsions, diabetes mellitus existing in this case. In the fourth 
case, the hemiplegia and the renal affection followed scar- 
latina combined with diphtheria. The patient recovered com- 
pletely from the hemiplegia as well as from the renal affection, 
and the paralysis was doubtless a sequel of the diphtheria. 
These facts, thus, do not go to show any special connection 
between the renal affection and the hemiplegia in the few 
cases in which the latter occurs. 
In view of the occurrence of cephalalgia, coma, and con- 
vulsions, in a certain proportion of cases, the inquiry arises, 
whether these symptoms may not denote the development of 
meningitis as a complication. In none of my cases is it noted 
that, preceding or accompanying any of these symptoms, 
there were others which pointed to inflammation within the 
cranium. Hence, it is fair to conclude that meningitis may 
be excluded, at least acute meningitis. Of the fatal cases in 
which autopsies were made, the head was examined in four 
only. In one of these cases the brain was congested, and the 
amount of subarachnoid effusion was rather large, but there 
was no exudation of lymph. In this case convulsions occurred, 
and in one of the convulsive attacks death took place. In an- 
other case the subarachnoid effusion was moderate, and it was 
slightly turbid. This patient was brought into hospital in a bright's diseases. 
273 
state of coma, and died soon after admission, the previous his- 
tory being unknown. In the third case, it is noted that there 
were no abnormal appearances within the skull. The vision 
was affected in this case, but coma or convulsions did not occur. 
In the fourth case the brain was congested, with no other mor- 
bid appearances. Coma and convulsions existed in this case. 
Symptoms and Complications referable to the Respiratory 
System. 
The analysis under this heading will relate chiefly to the 
occurrence of certain complications, namely, pleurisy, pneu- 
monia, pulmonary oedema, bronchitis, pulmonary tuberculosis, 
and oedema of the glottis. With reference to these compli- 
cations, I will arrange the cases into the following groups : 1. 
Fatal cases with autopsies; 2. Fatal cases in whichpost-mortem 
examinations were not made; 3. Cases, the ending of which 
is not known; and, 4. Cases ending in recovery. 
Of the fatal cases with autopsies (36), in 2 cases the 
lungs were not examined; in 16 cases the condition of 
the lungs is not noted, and in 8 cases it is stated that the 
lungs were healthy. In 2 cases pleurisy existed. The effu- 
sion of liquid in one of these cases was very large, and thora- 
centesis was resorted to. Recent lymph in this case existed 
on the other side without liquid effusion. Pericarditis also 
existed in this case. In the other case it is simply noted that 
recent pleurisy existed on the left side; and the lung on this 
side was tuberculous. Pneumonia is noted in but one of the 
cases in this group. The upper lobe of the right lung was in 
the first stage of pneumonia. Emphysema existed in this case. 
There was also much hydrothorax, and there were aortic 
lesions. Pulmonary oedema is noted in 3 cases, as found 
after death ; and in one case it was denoted by signs, but the 
lungs were not examined after death. The existence of bron- 
chitis is not noted in any of the cases in this group. Emphy- 
sema is noted in 3 cases. Pulmonary tuberculosis existed 
in 2 cases, in one case the lesions consisting of small tuber- 
culous cavities, and in the other case two collections of yellow 
and partially-softened tubercle were found in one lung. Cal- 274 
BELLEVUE AND CH ABIT Y HOSPITAL REPORTS. 
careous deposits were found in the lungs in one case. In 2 
cases oedema of the glottis occurred. In one of these cases 
laryngotomy was performed, after which there -was no obstruc- 
tion of breathing, but the patient became comatose, and died on 
the following day. In the other case the obstruction to breath- 
ing caused by the oedema was the immediate cause of death. 
The renal affection in one 6f these two cases was cystic de- 
struction of one kidney, the other being fatty; and in the 
other case, both kidneys were fatty. 
In 2 cases irregularity of respiration is noted; in one 
case the irregularity was characterized by considerable inter- 
vals between the respiratory acts ; in the other case the res- 
pirations at times becoming much accelerated, and this occur- 
ring especially just before the occurrence of convulsions. It 
is altogether probable that disturbance of the rhythm of respi- 
ration occurred in cases without having been noted. 
Of the fatal cases in which post-mortem examinations were 
not made (20), the lungs were free from disease, as deter- 
mined by symptoms and signs, in 17 cases. Bronchitis existed 
in one case. In one case tuberculous disease existed. In this 
case the patient had had cough and expectoration for several 
years, the tuberculous disease doubtless being antecedent to 
the renal affection. In one case the history is defective as 
regards the presence or absence of pulmonary disease. 
Of the cases the ending of which is unknown (25), in one 
case the history is defective with reference to pulmonary 
disease. In 15 cases there were not present symptoms or 
signs denoting any important pulmonary disease. In one case 
pneumonia occurred, the lower lobe of the right lung being 
affected, the patient recovering from this affection. In another 
case chronic pleurisy occurred, the left side of the chest be- 
coming filled with liquid effusion. The patient recovered 
from this affection. In 6 cases there existed cough and ex- 
pectoration with either moist or dry bronchial rales, without 
signs denoting any other affection than bronchitis. 
Of the cases ending in recovery (22), in 3 the amount 
of hydrothorax occasioned notable embarrassment in breath- 
ing, and inability to lie down. An account of two of these 
cases has been introduced, with those illustrative of recovery bright's diseases. 
275 
from the renal affection. In these 3 cases there were no 
symptoms nor signs denoting disease of the lungs. In 15 
of the remaining cases there were no symptoms nor signs of 
pulmonary disease. In 2 cases the histories are defective 
with respect to disease of the lungs. In one case the symp- 
toms denoted pulmonary oedema; and in one case there was 
bronchitis. 
Deducting, from the whole number of cases analyzed (102), 
those in which information concerning the existence or ab- 
sence of disease of the lungs is wanting, the number remain- 
ing is-80 cases. Of these 80 cases, in 58 there was no impor- 
tant disease of lungs. Pleurisy is noted in 32 cases ; pneumo- 
nia in 2 cases; pulmonary oedema in 5 cases; tuberculous 
disease in 4 cases; bronchitis in 8 cases; and oedema of the 
glottis in 2 cases. 
Of these several pulmonary affections, all, excepting the 
tuberculous cases and perhaps some cases of bronchitis, were 
secondary to the renal disease, and therefore they were, prop- 
erly speaking, complications. Considering the small number 
of cases of pulmonary tuberculosis (5), and the fact that in 
most, if not all, of these few cases the tuberculous was an 
tecedent to the renal disease, it is a warrantable conclusion 
that Bright's diseases involve no tendency whatever to a tuber- 
culous affection of the lungs, nor, on the other hand, are 
tuberculous patients prone to Bright's diseases. Moreover, 
making due allowance for the fact that patients affected with 
Bright's diseases are not exempt from the operation of causes 
other than those originating in the kidneys, which produce 
pleurisy, pneumonia, and bronchitis, the tendency to the latter 
affections, as complications, is by no means strong. 
Pulmonary oedema in no cases in this collection, save per- 
haps in two, existed sufficiently to involve great disturbance of 
respiration. I have, however, repeatedly observed its occur- 
rence, especially when mitral cardiac lesions coexisted, and 
sometimes in a degree to occasion immediate danger to life. 
(Edema of the glottis, although occurring in only two cases, is 
so rare in its occurrence in other pathological connections, that 
the renal diseases are to be considered as standing in a special 276 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
causative relation to it, especially when it occurs without be- 
ing preceded or accompanied by either laryngitis or pharyngitis. 
Symptoms and Complications referable to the Circulatory 
System. 
The important points of inquiry in this section of the report 
relate to affections of the heart. The cases ending fatally, in 
which examinations after death were made, have been already 
analyzed with reference to enlargement of the heart without 
valvular lesions, to valvular lesions, and to pericarditis. For 
the results of this analysis the reader is referred to the section 
treating of the lesions found after death in other organs than 
the kidneys. It remains to analyze, with reference to cardiac 
affections, as denoted by physical signs, the fatal cases without 
autopsies, the group of cases the ending of which was not as- 
certained, and the cases ending in recovery. 
Of the fatal cases without autopsies (20), it is noted in 9 
that there were no signs of disease of the heart. In 6 cases 
the notes are deficient in information, either positive or nega- 
tive, with reference to cardiac disease. In 5 cases cardiac 
affections existed. The affections in these 5 cases were as 
follows: In 2 cases there was enlargement of the heart, with- 
out any murmur denoting valvular lesions. In 2 cases there 
was enlargement with murmur denoting valvular lesions. In 
one of these cases the murmur was a mitral systolic murmur, 
w'ithout the evidence of insufficiency of the mitral valve (an 
intra-ventricular murmur). In the other case, examinations made 
prior to the occurrence of uraemic coma and convulsions were 
negative as regards cardiac murmur; but, during febrile move- 
ment which followed an attack of uraemic coma and convul- 
sions, a systolic murmur was heard at the base of the heart. In 
one case pericarditis occurred two days before death, as de- 
noted by pericardial pain and a friction murmur. 
In one case in which the absence of the signs of cardiac 
disease is noted, the action of the heart, shortly before the occur- 
rence of uraemic convulsions during which death took place, 
was notably slow and irregular, the pulse being only thirty- 
two per minute. This was not an idiosyncrasy, but it was 
incident to the renal disease bright's diseases. 
277 
Of the cases the ending of which is not known (25), in 
17 there were no signs of disease of the heart up to the 
time when the patients passed from under my observation; 
and in 5 cases the notes are defective. Cardiac affections 
existed in 3 cases. In one case enlargement of the heart 
existed without valvular murmur. In one case there were en- 
largement and a mitral regurgitant murmur. In one case a 
mitral systolic murmur existed without enlargement. In no 
case in this group was pericarditis noted. 
Of the cases ending in recovery (22), in 17 there were 
no signs of disease 9f the heart, and in 3 cases nothing is 
noted in relation to cardiac disease. In one case a mitral 
systolic and an aortic direct murmur existed without enlarge- 
ment of the heart; and in one case a mitral systolic murmur, 
without regurgitation (an intra-ventricular murmur), existed, 
also without enlargement of the heart. 
In one case in the last group the pulse was noted to be, for 
a time, sixty per minute and intermittent, no cardiac disease 
existing in this case. 
In one of the cases ending in recovery, pericarditis had 
occurred prior to the case coming under my observation, and 
when under my observation the evidences of pericardial adhe- 
sions were made out. The recovery from pericarditis, in this 
case, is a noteworthy fact. 
Striking out from these three groups the cases in which 
nothing is noted respecting the existence or absence of disease 
of the heart, the number of the cases remaining is 53. Of 
these 53 cases, in 10 cardiac affections existed. Of these 10 
cases, in 4 the heart was enlarged without valvular lesions; in 
2 enlargement was associated with valvular lesions; in 3 val- 
vular lesions existed without enlargement, and in one case peri- 
carditis occurred. 
Comparing these results with those obtained by an analysis 
of the fatal cases with autopsies (see section devoted to " Mor- 
bid Appearances after Death "), a striking disparity is observed 
as regards the proportion of cases in which the existence of 
cardiac affections is noted. This disparity is to be accounted 
for as follows: Of the cases the ending of which is not known, 
in a certain proportion, affections of the heart, which did not 278 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
exist when the patients were under observation, may have been 
subsequently developed. Of the fatal cases without autop- 
sies, in a certain proportion the patients passed from under 
my observation before death took place. Of cases ending in 
recovery, it is not to be expected that cardiac complications 
will be often found. Finally, I am quite willing to admit that, 
in some cases, a certain amount of enlargement, which would 
be apparent on examination after death, may have been over- 
looked in examinations during life. As regards the connection 
of cardiac affections with renal lesions in cases of Bright's dis- 
eases, I have nothing to add here to what has been said in a 
previous section. 
The occurrence of pericarditis in only one case in the group 
of cases in which recovery took place, and in no case in the 
group of cases the ending of which is not known, illustrates 
the fact that this complication of Bright's diseases is generally 
fatal. 
5.-The Progress in these Cases of Bright's Diseases, 
the Duration, and the Immediate Causes of Death. 
I shall consider the progress in these cases of Bright's dis- 
eases, the duration, and the immediate causes of death, under 
separate heads. 
The Progress in these Cases of Bright's Diseases. 
In a large majority of cases, Bright's diseases are steadily 
progressive, as' shown by their symptomatic phenomena. But, 
in a certain proportion of cases, their progress appears to be 
interrupted, and there are intermissions when recovery may 
seem to be near at hand, or even to have taken place. The 
remarkable latency of these diseases prior to the first mani- 
festations, when it is certain that the renal affection must have 
existed for a considerable period, has been already illustrated. 
I shall now cite some cases illustrating the occurrence of inter- 
vals in which this latency is shown after notable manifesta- 
tions of the renal affection have taken place. 
Case I.-Mr. D., aged about fifty-six, a stout, vigorous man, 
was seen by me, in consultation with Dr. C. D. Smith, in bright's diseases. 
279 
March, 1865. At that time lie was suffering much from 
cephalalgia. There was anorexia, and, of his own accord, he 
complained of a taste of hartshorn. The urine contained 
albumen in abundance, and waxy casts. He had, for a time, 
a little oedema of his lower limbs. The heart was enlarged, 
without any cardiac murmur. Under treatment with purga- 
tives and tonics he improved, and, after a few weeks, seemed 
nearly to have regained his usual health. The urine, however, 
continued to be albuminous. In the following May the 
cephalalgia returned; and, on getting up to go to the water- 
closet, after having retired at night, he fell upon the floor in 
coma. He had a slight convulsion. I saw him with Dr. 
Smith shortly after this occurrence, and remained with him 
most of the night. He emerged from the state of coma in a 
short time, and became actively delirious, struggling and shout- 
ing, so that he W'as brought under the influence of chloroform 
and kept under it for several hours. On the following day he 
became rational. After this he improved, and again seemed 
almost well ; the urine, however, continued to contain 
albumen in abundance. In June he went to his country-seat 
in Vermont. Here he had repeatedly attacks of convulsions, 
followed by active delirium, continuing for several days. In 
the intervals between these attacks he improved to such an 
extent that he seemed to be on the road to recovery. At 
length, vomiting became a prominent symptom; and death 
took place, apparently from inanition, early in October. There 
was no autopsy in this case. 
Case II.-Miss H., aged eighteen, was seen by me in con- 
sultation with Dr. Lutkins, together with the late Dr. Olcott, 
of Jersey City, April 22, 1866. A month previously she be- 
came anasarcous, having had apparently excellent health up to 
that time. Dr. Lutkins found the urine scanty (six or eight oz. 
in twenty-four hours) and loaded with albumen. She was treated 
with cathartics and small doses of mercury. Under this treat- 
ment the quantity of urine became greater, the anasarca nearly 
disappeared, the albumen in the urine was much diminished, 
and the patient seemed to be on the road to recovery, when 
epileptiform convulsions occurred, the urine at the same time 
becoming again scanty. She had numerous short convulsions. 280 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
After a few days these ceased, and she again appeared to be 
improving, when the convulsions returned, having been now 
preceded and being accompanied by vomiting. This recur- 
rence of the convulsions was on the day before my visit. I 
found her pallid, with some oedema of face and limbs, the mind 
intact, the heart's action very slow (thirty-two per minute) and 
irregular. The urine was scanty; it contained albumen in abun- 
dance, also large waxy casts, fatty casts, and crystals of uric 
acid. Croton-oil had been already given. Elaterium was sug- 
gested and employed. The convulsions, however, returned, 
and death took place on the day following that of my visit. 
Case III.-This case is very remarkable as an example of 
an interval of three months between attacks of ursemic intoxi- 
cation, the evidences of renal disease, inclusive of albumen and 
casts, having disappeared in this interval. 
Mr. D., aged about fifty-six, of a full habit and a free liver, 
consulted me in June, 1866, with reference to disturbed action 
of the heart. I found the evidence of some enlargement of 
the heart, with no cardiac murmur, the heart-sounds feeble, 
and the impulse not appreciable. The urine was not ex- 
amined. Under the use of tonic remedies, and improved die- 
tetic habits, his health.improved, and the sounds of the heart 
became stronger. Fatty degeneration of the heart was con- 
sidered as probable. 
On the 29th of the following September, apparently being 
well, while transacting business in a bank, he suddenly fell 
down in a state of coma. Epileptiform convulsions followed. 
Ue was first seen by Dr. Charles Y. Swan, and, in a short 
time, by his family physician, Dr. Louis A. Rodenstein. The 
convulsions recurred at short intervals, and were violent. I 
saw him several hours after the attack. Leeches had been ap- 
plied to the temples, and podophyllin had been given, which 
had operated moderately. He had now partially emerged from 
the coma. The urine had been examined, and was found to 
contain albumen in abundance. Elaterium was subsequently 
given, and warm applications made to the extremities. 
I visited him on the following day with Drs. Rodenstein 
and Swan, and Prof. Markoe. He had also been visited 
by Dr. W. II. Draper. The convulsions had not recurred, bright's diseases. 
281 
and lie had passed a comfortable night. The elaterium had 
operated freely, causing large watery evacuations. He had 
perspired freely. The mental faculties were partly restored, 
and in this respect there was progressive improvement during 
the day. A systolic murmur was heard in the second infra- 
costal space on the left of the sternum, the murmur not being 
propagated into the carotids. 
On the day following, in the afternoon, he had regained, 
fully, his mental faculties, and he was quite comfortable. 
Moderate purging with elaterium had been kept up, and the 
skin was still perspiring. The urine contained less albumen 
than on the preceding day. The sediment examined by Dr. 
Draper and Dr. Swan was found to contain tubular casts, 
varying in diameter from 3^ to j-oVo- an inch, some of 
them hyaline, and some granulo-fatty, together with renal epi- 
thelium, which was coarsely granular and fatty. 
On the next day the improvement was still more marked, 
and on the day following (October 3d) he was removed to his 
residence at Washington Heights. A specimen of urine, ob- 
tained on the day before his removal (October 2d), was exam- 
ined by Dr. A. Flint, Jr., and found to contain neither albu- 
men nor casts. Subsequently another specimen, which was 
sent to me, was examined with the same result. In a note 
dated October 17th, Dr. Rodenstein informed me that repeated 
examinations of the urine continued to show absence of albu- 
men and casts, and that the patient was apparently well. 
Mr. D. remained apparently in good health for about 
three months. At the end of this period, the urine, examined 
by Dr. J. B. Reynolds and Dr. J. S. Thebault, was found to 
contain albumen and casts. This was in the latter part of 
January, 1867. In February he made arrangements for going 
to Europe, and had some business annoyances. On the even- 
ing of February 18th, while engaged in a game of cards with his 
family, he was suddenly attacked with convulsions. The con- 
vulsions recurred at intervals up to 11 a. m., of the follow- 
ing day, and in the intervals he was nearly comatose. I saw 
him in the evening of February 19th, in consultation with Dr. 
Reynolds and Dr. Thebault. He was in a state of stupor, but he 
could be roused sufficiently to reply to a few questions. The 282 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
convulsions were not preceded by vomiting, nor by any pre- 
monitions. He had already been purged, but it was agreed 
to resort to elaterium. On the next day his condition was some- 
what improved. I did not see him afterward. Death took 
place February 22d. There was no autopsy. 
The foregoing illustrations of latency and intermittency, 
after notable manifestations of Bright's disease, and the occur- 
rence, unexpectedly, of uraemic coma and convulsions, have 
been taken from the groups of cases ending fatally. I shall 
now introduce a succinct account of two cases, in which the 
renal disease has apparently not progressed, in one of the cases 
for two and a half years, and in the other case for more than 
one year, the patients being at the present time living, and in 
a comfortable state of health. 
Case IV.-Mr. J., aged twenty, was seen by me in con- 
sultation with Dr. George A. Peters, November 10,1866. He 
had then pneumonia affecting the lower lobe of the right lung. 
The urine had a notably sooty appearance; it contained albu- 
men in abundance and hyaline casts. There was moderate 
oedema of the lower limbs, which had existed for some weeks 
prior to the pneumonia. He recovered from the pneumonia; 
he improved as regards appearance and strength; the urine 
lost the sooty appearance, but it continued to contain albumen. 
He was treated with occasional hydragogue cathartics, with di- 
uretics, and with tonic remedies. In January, 1867, his general 
health was fair, but albuminuria continued. In this month he 
sailed for the West Indies and Europe. This patient, since 
the date just named, has not been under my observation ; but 
I have been informed, while writing this report (March, 1869), 
that, although he still has albuminuria, he appears to be in fair 
health, and is about to be married. 
Case V.-Mr. S., merchant, aged thirty-one, was seen by 
me in consultation with Dr. S. B. Tuthill, May 19, 1868. 
The history of the case was as follows: A year previously, he 
had an attack of vomiting, and was thought to have gastritis. 
He was then in Nassau. A similar attack occurred in Octo- 
ber, 1867. In January, 1868, he had another similar attack, 
and with the vomiting he had two fits of epileptiform convul- 
sions. Ten days before my visit, another attack occurred, and bright's diseases. 
283 
with this attack he had two paroxysms of convulsions. Dr. 
Tuthill had charge of the case in January, and he then found 
the urine to contain albumen and granular casts. After the 
patient's recovery from the attack which then occurred, the 
albumen in the urine became less, and the casts were fewer, 
but neither completely disappeared. In the interval, how- 
ever, as in the previous intervals, his health was apparently 
good, and he was actively engaged in business. In the attack 
which occurred in May, the urine was loaded with albumen, 
and contained an abundance of granular casts, the quantity 
being about normal, and the sp. gr. 1.010. With the attack 
in January, his vision was impaired. The impairment nearly 
disappeared afterward, but considerable mistiness existed when 
I saw him in May. His aspect was healthy. There was no 
dropsy. There was no febrile movement, as determined by 
the pulse and thermometer. The vomiting was sudden and 
explosive. There was no diarrhoea. Prior to, and during this 
attack, cephalalgia was a prominent symptom. He had also, 
occasionally, vertigo, and his sleep had been dreamy and dis- 
turbed. The skin was not dry, and he perspired easily. As 
regards treatment, it was agreed that the urine should be 
watched with reference to the quantity of urea, and elimina- 
tion to be aided, if necessary, by the bowels and skin, the 
strength of the patient to be supported by a nutritious diet and 
tonic remedies. 
I did not see the patient afterward, but Dr. Tuthill has 
informed me (April, 1869) that he is apparently, at this time, 
in good health. 
An important point, which I desire to illustrate by these 
cases, as well as by others previously introduced, is, that 
Bright's diseases may remain latent for a considerable period 
prior to any special manifestations, and that, after such mani- 
festations occur, there are sometimes long periods during which 
the renal disease appears not to be progressive. In the group 
of cases, the ending of which is not known, the patients having 
passed from under my observation, are several cases, in which, 
notwithstanding the existence of renal disease, as shown by 
the urine, the improvement which had taken place and the 
condition of health rendered it probable that the affection of 284 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
the kidneys was stationary, if not retrogressive. Patients re- 
peatedly were discharged from hospital because they felt them- 
selves able to return to their occupations, although albuminuria 
persisted. The importance of this point relates especially to 
its practical bearing. If it be true, as clinical observations 
warrant us in believing, that a certain amount of renal disease 
may be so tolerated by the system as not to interfere with the 
possession of a fair amount of health for an indefinite period, 
it becomes a capital object of medical practice to promote this 
tolerance, and thus to prevent or postpone those complications 
and effects which impair health and destroy life. 
Duration.-In many of the cases, in which the ending 
either in death or recovery was known, it is impossible to de- 
termine the duration, owing to the date of the first symptoms 
not having been noted with definiteness in the histories. In 
the group of cases, the ending of which is not known, this 
group including a few cases in which the patients are known 
to be living, the duration is, of course, indeterminable. This 
last group of cases, however, furnishes some examples of a con- 
siderable duration, with, in some cases, such a degree of im- 
provement that there is room for the supposition that recovery 
may have taken place after the patients had passed from my 
observation. What shall be taken as criteria of the com- 
mencement of the renal disease ? In answer to this question, 
I would say that it seems to me proper to consider the renal 
disease as existing only when some of the special manifesta- 
tions are present, namely: dropsy, uraemic coma, or convul- 
sions, and albumen or tubular casts in the urine. The criteria 
pertaining to the urine are, in general, not ascertained until 
some of those previously named occur. It is probable that, 
in many cases, albumen or casts in the urine would have been 
found, for a greater or less period, prior to the other manifesta- 
tions, had urine been examined; but, as a rule, patients do 
not come under observation until after the development of 
either dropsy, uraemic phenomena, or some complication of the 
renal disease. That lesion of the kidneys, in chronic Bright's 
diseases, often exists for months, and even years, before the 
occurrence of any of the manifestations which I have called 
special, can hardly be doubted ; but, in endeavoring to deter- bright's diseases. 
285 
mine retrospectively the beginning of these diseases in a series 
of cases, the propriety of considering symptoms and ailments 
which may precede the renal manifestations, and which may 
reasonably be supposed to be dependent upon disease of the 
kidneys, is doubtful. In short, the criteria which have been 
named should be regarded as the only events in the previous 
history which are positively diagnostic. Adopting this course, 
I shall proceed to give the results of the analysis of the fatal 
cases, and of those ending in recovery, in which the commence- 
ment of the disease can be determined. Afterward I will cite 
the duration in some of the cases, the ending of which is not 
known, and the condition at the time when the patients passed 
from under observation. 
Of the fatal cases, the duration is determinable in 29. 
The case in which the duration was shortest ended fatally a few 
hours after the occurrence of uraemic coma and convulsions. 
Vomiting preceded these uraemic events for several days, 
and there was suppression of urine. This case has been given 
among the cases illustrative of the latency of renal disease. 
The next shortest duration was 2 days. This case has also 
been given in the same connection as the preceding. The 
duration in two cases was 4 days, and in one case 6 days. 
The longest duration was 2 years ; the next longest, 315 days; 
the next, 240 days ; and the next, 210 days. 
It will be of interest to study the duration in these 29 
cases, distributed into the following groups: 1st, cases in 
which death was attributable to the uraemic events, that is, to 
coma and convulsions; 2d, cases in which death was due to 
asthenia or exhaustion; and, 3d, cases in which some com- 
plication or coexisting affection produced death. 
The number of cases in the uraemic group is 14. In this 
group are contained the cases having the shortest and the 
longest duration, namely, two years and a few hours. The 
three periods of duration next to the maximum in this group 
are, 315, 180, and 150 days. The three periods next to the 
minimum are, 2, 4, and 6 days. The mean duration, exclu- 
sive of the case in which the duration was 2 years, and the 
case in which it was a few hours, is a fraction under 66 days. 
The number of cases in the asthenic group is 9. The 286 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
shortest duration in this group was 4 days; the longest was 
240 days. The mean duration, is a fraction over 134 days. 
In six of the fatal cases death was due to complications or 
coexisting affections. The facts in these cases, respectively, 
are as follow: Case I. Death was due to oedema of one lung 
and hydrothorax on the opposite side, old, universal, pleuritic 
adhesions existing on the side in which there was pulmonary 
oedema. The disease followed scarlatina, and the duration 
was 5 days. Case II. Death was due to pleuritis and peri- 
carditis. The renal disease was developed during pregnancy, 
and the duration was about 30 days. Case III. Death was 
due to pericarditis, and the duration was about 60 days. 
Case IV. Death was due to oedema of the glottis, and the 
duration was 180 days. Case V. Death was due to disease of 
heart, and the duration was 102 days. Case VI. Death was 
due to peritonitis and pericarditis, and the duration was 35 
days. 
Of the cases ending in recovery, the duration is determi- 
nable in 15. The minimum of duration in this group was 
7 days ; this was the duration in two cases. The next short- 
est duration was 16 days ; the next 20 days, and the next 22 
days. The maximum of duration was 245 days. The next 
longest duration was 122 days, the next 91 days, and the next 
82 days. The mean duration, in this group of cases, is a frac- 
tion over 52 days. 
From the group of cases of which the ending is not known, 
the following are selected, as showing the duration up to the 
time when the cases passed from my observation, together with 
the condition at that time: 
Case I.-After 90 days dropsy had disappeared, the albu- 
men in the urine was much diminished, and the patient was 
in all respects greatly improved. 
Case II.-In this case albuminuria had existed for 4 years. 
The patient did not consider himself a sick man ; but he com- 
plained of becoming easily fatigued and of want of breath on 
exercise. There was a mitral systolic cardiac murmur in this 
case. 
Case III.-The disease had existed 28 days before his 
admission into hospital. After remaining in hospital 45 days, bright's diseases. 
287 
dropsy had disappeared, and he reported that he felt well 
enough to go to work as a laborer. He left the hospital, 
but was readmitted in 20 days, with a return of dropsy. 
After some weeks the dropsy again disappeared, and the 
albumen in the urine was much diminished, but it did not 
disappear. He was employed in out-of-door work at the hos- 
pital. Six months afterward he looked well; he had gained 
in weight, and was able to do light work; the urine remaining 
moderately albuminous. 
Case IV.-In this case the disease had existed for 60 
days before his admission into hospital. After four months in 
hospital, he reported well enough to return to his occupa- 
tion, namely, a cook on board ship. The state of the urine at 
the time of bis discharge is not noted. 
Case V.-After seven months in hospital, the patient re- 
ported well enough to go to work as a plasterer; the state of 
the urine at the time of his discharge not being noted. 
Case VI.-After 84 days the patient was free from dropsy, 
and reported well enough to return to work as a laborer. 
Case VII.-More or less oedema of the limbs had existed 
in this case for 18 months; the patient, however, continu- 
ing to work as a furrier. After three days in hospital he 
was discharged at his request, in order that he might return to 
work, the oedema having diminished, but not disappeared. 
Case VIII.-It is stated that in this case the disease had 
existed but for a short time previous to admission into hos- 
pital. After 16 days in hospital the dropsy was much di- 
minished, and he left the hospital to return to work as a 
laborer. 
Case IX.-The disease had existed for 60 days before his 
admission into hospital. He remained in hospital 60 days, 
and left notably improved. 
The foregoing results of the analysis show a very wide 
range of variation as regards the duration of Bright's diseases. 
Taking, as the criterion of the commencement of the renal 
affection, uraemic coma in one case, and dropsy with albumi- 
nuria in another case, the opposite extremes, represented by 
two cases, are a few hours and four years ; and in the latter 
case the disease had not ended. It will be observed that the 288 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
average duration in fatal cases ending by asthenia is double 
that of cases ending with uraemic coma or convulsions. The 
maximum of the duration in cases ending in recovery is 
worthy of note, namely, 122 days; and the average duration 
in these cases does not much fall below that in the uraemic 
group of fatal cases. 
Causes of Death.-As regards the immediate causes of 
death, cases may be distributed here, as in the preceding sec- 
tion, into three groups. The first group will embrace cases in 
which death is due directly to uraemic coma or convulsions. 
In a certain proportion of cases patients die in a state of coma, 
which may or may not have been preceded by convulsions; 
and in some cases death occurs during a severe attack of con- 
vulsions. It does not, however, follow, in cases which prove 
fatal, after one or more attacks of coma or convulsions have 
occurred, that the fatal result will be due to the recurrence of 
these uraemic events; for sometimes, after these events have 
occurred repeatedly, the patient at length dies from exhaus- 
tion, dependent on innutrition, together with other causes. 
The second group will embrace the cases in which death is 
attributable to exhaustion, produced in part, indirectly per- 
haps, by the uraemic events just named, but in a certain pro- 
portion of cases taking place without these events having oc- 
curred during the whole course of the disease. Cases in wdiich 
the exhaustion is due to complicating or coexisting affections, 
are not included in this group. The fatal exhaustion is often 
very evidently the effect of innutrition, and in these cases 
vomiting and purging are apt to be prominent symptoms. 
The third group will embrace cases in which death is attribu- 
table, measurably or entirely, to complicating or coexisting dis- 
eases. Dividing the fatal cases into these three groups, I shall 
give a brief statement of the immediate cause or causes of 
death in each of the cases, the history of which contains infor- 
mation on this point, appending the kind of renal affection 
when this was ascertained post-mortem examination. 
Cases in which Death was attributable to Uraemic Coma or 
Convulsions. 
Case I.-After delirium and jactitation, death occurred bbight's diseases. 
289 
suddenly in coma. There was suppression of Urine for several 
days in this case. The kidneys were noted as granular. 
Case II.-Died in coma, which was preceded by delirium 
and sanguinolent dejections. The kidneys were fatty. 
Case III.-Died in an attack of convulsions. The kidneys 
were fatty. 
Case IV.-Died in deep coma. The kidneys were fatty. 
Case V.-Died in coma. The kidneys were contracted. 
Case VI.-Died in coma. The kidneys were contracted. 
Case VII.-Died in coma, preceded by convulsions. The 
kidneys were contracted. 
Case VIII.-Died in coma, preceded by convulsions. The 
kidneys were contracted. 
Case IX.-Died in coma. The kidneys were fatty. 
Case X.-Sudden death in coma. No autopsy. 
Case XI.-Died in coma, preceded by convulsions. No 
autopsy. 
Case XII.-Sudden death in coma with convulsions. No 
autopsy. 
Case XIII.-Died in coma, preceded by convulsions. No 
autopsy. 
Case XIV.-Died in coma. No autopsy. 
Case XV.-Died in coma. No autopsy. 
Case XVI.-Died in coma with convulsions. No autopsy 
Case XVII.-Died in convulsions. No autopsy. 
Case XVIII.-Died in coma, preceded by convulsions. 
No autopsy. 
Cases when Death was attributable to Exhaustion. 
Case I.-Vomiting, diarrhoea, and innutrition. Form of 
disease of the kidneys not determinable. 
Case II.-Vomiting, diarrhoea, and innutrition. Large 
white kidneys. 
Case III.-Vomiting, diarrhoea, and innutrition. Large 
white kidneys. 
Case IV.-Innutrition. Fatty kidneys. 
Case V.-Innutrition, preceded by vomiting and diarrhoea. 290 
BELLEVUE AND CHARITY HOSPITAL PORORTS. 
Repeated attacks of coma, convulsions, and delirium had oc- 
curred. No autopsy. 
Case VI.-Innutrition. The dropsy excessive. No autopsy. 
Complications or Coexisting Affections constituting measu- 
rably or entirely the Causes of Death. 
Case I.-Pulmonary oedema of one lung, which was uni- 
versally adherent by old pleuritic adhesions, and hydrothorax 
on the opposite side. Tubular nephritis. 
Case II.-Pleuritis and pericarditis. Probably tubular 
nephritis. 
Case III.-Pneumonia in first stage. Form of renal dis- 
ease not determinable. 
Case IV.-Pericarditis. Contracted kidneys. 
Case V.-Disease of heart. Typhoid delirium and ex- 
haustion. Contracted kidneys. 
Case VI.-Pulmonary congestion and oedema, with aortic 
lesions and enlargement of the heart. Also exhaustion from 
innutrition. Contracted kidneys. 
Case VII.-Chronic pericarditis, with large effusion. The 
death apparently hastened by the use of elaterium given with 
reference to the pericardial effusion. Contracted kidneys. 
Case VIII.-Recent pleurisy, tuberculous disease of the 
lungs existing. Fatty kidneys. 
Case IX.-Much hydroperitonseum and hobnailed liver ; 
but death took place in coma. Fatty kidneys. 
Case X.-Pericarditis. Contracted kidneys. 
Case XI.-Great contraction of the mitral orifice of the 
heart, giving rise to great dyspnoea. Contracted kidneys. 
Case XII.-(Edema of glottis, for which laryngotomy was 
performed, with relief. Death in coma the following day. 
The heart was much enlarged. One kidney destroyed by 
cysts, and the other kidney fatty. 
Case XIII.-Pulmonary oedema ; but death took place in 
coma. Fatty kidneys. 
Case XIV.-Much hydroperitonaeum. Tapping resorted 
to. Death from exhaustion. Waxy kidneys. 
Case XV.-Much hydroperitonseum, and contracted liver. 
Sudden death took place in coma. Fatty kidneys. bright's diseases. 
291 
Case XVI.-While apparently improving, the patient was 
suddenly seized with vomiting and purging, accompanied by 
great dyspnoea, with lividity, and he died in a few hours, with- 
out coma or convulsions. There was moderate oedema of the 
lungs. The pericardium contained three and a half ounces of 
liquid. The brain was normal. The heart weighed eleven 
ounces, and the valves were sound. Fatty kidneys. 
Case XVII.-Pulmonary oedema, with fatty degeneration 
of the heart, and aortic insufficiency. Kidneys not examined. 
Case XVIII.-(Edema of glottis, and death from suffoca- 
tion. Fatty kidneys. 
Case XIX.-Rupture of aneurism of abdominal aorta. 
One kidney contracted, and the other kidney fatty. 
Case XX.-Peritonitis and pericarditis. No autopsy. 
Case XXI.-Hydroperitonaeum, for which tapping was em- 
ployed. Gangrene of scrotum following punctures to relieve 
oedema. Death from exhaustion. 
A reviewal of the number of cases in these three groups 
shows that, of 45 fatal cases in which the causes of death ap- 
pear in the histories, in 18 the death was attributable to 
uraemic coma or convulsions; in 6 the death was due to ex- 
haustion, irrespective of complications or coexisting affections; 
and in 21 the causes of death related, measurably or entirely, 
to complications or coexisting affections. It will be observed 
that, in some of the cases in the last group, the patients 
died in coma, and in some the death was due to exhaustion. 
6.-Treatment. 
In none of these cases of Bright's diseases was any treat- 
ment pursued with a view to a direct curative effect upon the 
renal affection. The therapeutical measures employed, aside 
from those which were merely palliative and those which were 
addressed to concomitant affections, had reference to the fol- 
lowing objects: 1st, the elimination of excrementitious prin- 
ciples from the blood when uraemic coma or convulsions were 
present; 2d, the removal of dropsical effusion; 3d, the dimi- 
nution of albumen in the urine, and 4th, improvement of appe- 
tite, of digestion, and of the general condition of the patient. 292 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Premising that in a considerable number of cases the notes are 
defective as regards measures of treatment, I shall interrogate 
the histories containing information under this head, with 
respect to the different remedies which were employed for the 
objects just named. 
Diuretics.-Diuretic remedies entered prominently into the 
treatment of 19 of the cases in which the notes embrace an ac- 
count of therapeutical measures. These remedies were always 
given with reference to the dropsy, never for elimination when 
important uraemic events occurred. Different diuretic reme- 
dies were used, sometimes singly, and sometimes in combina- 
tion. The facts with respect to diuretics in these 19 cases will 
be most conveniently presented by distributing the cases 
according to the diuretics used. 
Cases in which the Bitartrate of Potassa was used. 
Case I.-Used with no benefit. A fatal case of the smooth 
■white kidney. 
Case II.-The patient was at once treated with this 
remedy, half an ounce being dissolved in a pint of water, and 
a wineglassful given every four hours. It acted as a diuretic, 
and in a week the dropsy, which was considerable, had en- 
tirely disappeared. Improvement took place in other re- 
spects ; the patient was up and able to do light work. Under 
the use of gallic acid for ten days the dropsy returned. The 
bitartrate of potassa was then resumed, and the dropsy speed- 
ily disappeared. The patient then left the hospital, thinking 
he was well enough to return to work as a laborer. Twenty 
days from the date of his discharge he was readmitted, the 
dropsy having returned. The remedy was again resumed, 
and in a short time the dropsy disappeared. The further 
progress of the case was not known. 
Case III.-After purging with the sulphate of magnesia, 
this case was treated with the bitartrate of potassa, and the 
patient was convalescent in seven days. The disease followed 
scarlatina. 
Case IV.-Under the use of the bitartrate of potassa the 
quantity of urine was doubled, and the dropsy disappeared. 
Recovery in this case. bright's diseases. 
293 
Case V.-In this case, after free purging, the bitartrate of 
potassa was used, and under its use the dropsy disappeared. 
Recovery in this case. 
Case VI.-There was much dropsy in this case. It disap- 
peared under the use of the bitartrate of potassa. 
Cases in which the Acetate of Potassa was used. 
Case I.-The acetate of potassa, 3 ss daily, was given with- 
out any diuretic effect, and with no benefit. A fatal case of 
contracted kidneys. 
Case II.-This remedy, given as in the preceding case, 
increased the quantity of urine, but with no benefit. A fatal 
case of fatty kidneys. 
Case III.-:This remedy, given as in the two preceding 
cases, acted efficiently as a diuretic, and under its use the 
dropsy was much diminished. The ending in this case not 
known. 
Case IV.-The acetate of potassa was given together with 
digitalis, the hot-air bath being also employed. The dropsy 
was much diminished, and there was notable general improve- 
ment. The ending in this case not known. 
Case V.-The dropsy, which was considerable, disappeared 
under the use of the acetate of potassa. Recovery in this 
case. 
Case in which the Nitrate of Potassa was used. 
In this case half an ounce of the nitrate of potassa was 
given daily. It acted as a diuretic, and under its use notable 
improvement took place. Recovery in this case. 
Cases in which several Diuretics were combined, and Cases in 
which the Diuretic Remedies are not specified. 
Case I.-Squill, digitalis, the infusion of juniper-berries, 
and the nitrate of potassa, were given in conjunction. The 
quantity of urine was notably increased; the dropsy disap- 
peared, and there was marked general improvement. The 
ending of this case was not known. 
Case II.-Squill and digitalis, with blue mass, together 
with the bitartrate of potassa, were given in conjunction. The 294 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
dropsy disappeared, and there was notable improvement. Re- 
covery in this case. 
Case III.-The notes simply state that the case was treated 
with diuretics. The disease followed scarlatina and diphtheria. 
Hemiplegia was a sequel as well as dropsy. Recovery in this 
case. 
Case IV.-In this case the dropsy, which was considerable, 
disappeared under the use of diuretics, the remedies not being 
named. Recovery in this case. 
The iodide of potassium was given in one fatal case with 
no benefit, the disease being the smooth white kidney. This 
remedy was also given, with no benefit, in a case the ending 
of which was not known. It was given, after purging with 
the sulphate of magnesia, in conjunction with an acidulated 
emulsion of pumpkin-seeds, in a case in which the disease fol- 
lowed scarlatina, the patient being convalescent in four days. 
The external use of diuretics was tried in one fatal case 
without any benefit. Squill and digitalis were applied exter- 
nally in another case, in which jalap and the bitartrate of 
potassa were also employed. It is not noted whether a diu- 
retic effect was produced ; but the dropsy disappeared, and the 
case ended in recovery. 
The foregoing facts go to show an increase of urine under 
the use of diuretics, and their efficacy as regards the removal 
of dropsy, in certain cases. They do not show any unfavor- 
able effect in any case. It has been a mooted question whether, 
in cases of tubal or desquamative nephritis, diuretics are not 
injurious. It may, perhaps, be assumed that this form of dis- 
ease existed in most of the cases ending in recovery. Now, in 
several of these cases diuretics acted efficiently, the dropsy dis- 
appeared, and improvement in general took place under their 
use. So far as the facts which have been presented bear upon 
this question, they are in favor of the employment of diuretics 
in the form of renal disease just named. Doubtless other 
diuretic remedies would have proved equally, if not more, 
efficacious. I have been led to observe in some cases not re- 
corded a notable diuretic effect from the infusion of parsley- 
root. bright's diseases. 
295 
Cathartics. 
Cathartic remedies were employed with reference to the 
elimination of excrementitious principles from the blood when 
ursemic coma or convulsions occurred, and also for the re- 
moval of dropsical effusion. For both these objects, cathartics 
having a hydragogue operation were used, namely, elaterium, 
croton-oil, the bitartrate of potassa and jalap, separately or 
combined, and the sulphate of magnesia. Cathartics entered, 
more or less prominently, into the treatment of 28 cases. In 
stating briefly the facts regarding the treatment in these 28 
cases, I shall adopt the arrangement just pursued with respect 
to diuretics. 
Cases in which Elaterium was used. 
Case I.-In this case one-fourth of a grain of elaterium was 
given daily for 54 consecutive days, with reference to dropsy. 
It produced several liquid dejections daily, the dropsy stead- 
ily diminished, and the patient constantly reported im- 
provement. After 54 days it was suspended on account 
of nausea, and gallic acid was given. The dropsy increased, 
and, after 10 days, the elaterium was resumed for a short time 
with the same effect as before; the strength of the patient de- 
clining, tonics were substituted and continued until the fatal 
termination. The kidneys were fatty. 
Case II.-Elaterium relieved in this case, notably for a 
time, uraemic stupor. This was a fatal case, and the kidneys 
were contracted. 
Case III.-In this case elaterium was given with reference 
to dropsy. The dropsy was somewhat diminished. Subse- 
quently, convulsions occurred, and the measures employed were 
cupping over the loins and the hot-air bath, without benefit. 
This was a fatal case, and the kidneys were fatty. 
Case IV.-In this case chronic pericarditis with large effu- 
sion existed. Elaterium was given to promote absorption of 
the pericardial effusion. The patient, already feeble, was much 
prostrated by the effect of the remedy, and the fatal ending 
was probably hastened by it. The kidneys were contracted. 
Case V.-In this case elaterium was given repeatedly, the 296 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
patient being in uraemic coma. The doses, however, were al- 
ways immediately rejected by vomiting. It was given also by 
enema, but with very little effect. This case was fatal. No 
autopsy. 
Case VI.-Elaterium, given hourly in doses of gr. j, in 
uraemic coma and convulsions, was of no avail. The case 
ended fatally. No autopsy. 
Case VII.-Uraemic convulsions existed in this case. Ela- 
terium was given freely without avail. This was a fatal case. 
No autopsy. 
Case VIII.-Uraemic coma and violent convulsions in this 
case occurred suddenly, when the patient apparently was well. 
Podophyllin was first given with a moderate purgative effect, 
and leeches applied to the temples. Free purging was induced 
by elaterium. The convulsions ceased, and the patient emerged 
from the coma after about twelve hours. He apparently 
recovered; but coma and convulsions recurred suddenly five 
and a half months afterward, and proved fatal. No autopsy. 
Case IX.-Coma and convulsions existed, and elaterium 
was given without avail. This was a fatal case. No autopsy. 
Case X.-Anasarca was much diminished, together with 
the albumen in the urine, and notable general improvement 
took place in this case, under treatment with elaterium from 
time to time, together with chalybeate tonics, the tepid bath, 
and exercise in the open air. The ending in this case was not 
known. 
Case XI.-In this case elaterium was repeatedly used with 
reference to dropsy, which was at once removed by it. In 
this case the disease still exists, as shown by albuminuria, but 
the patient is in fair general health. 
Case XII.-As regards dropsy, a little oedema below the 
eyes only existed in this case. There was complete amaurosis. 
The patient was in hospital 11 days, and during this time 
elaterium was given, together with the iodide of potassium, 
without any benefit. 
Case XIII.-The disease in this case was developed during 
pregnancy, and premature confinement took place. The 
anasarca was very great, the lower limbs being enormously 
swollen prior to the miscarriage. Afterward the anasarca was bright's diseases. 
297 
much diminished, but hydrothorax existed, both sides of the 
chest being two-thirds filled with liquid. The suffering from 
dyspnoea was extreme, and the danger of death seemed immi- 
nent. The patient was obliged to keep the sitting posture, and 
any movement of the body occasioned such an increase of the 
dyspnoea as to threaten life. Elaterium given under these 
circumstances produced large and frequent watery dejections 
with immediate and great relief. The hydrothorax was at 
once diminished, but it afterward increased so as to produce 
nearly the same amount of distress as before; and elaterium was 
again resorted tQ with the same prompt and effectual relief. 
Recovery took place in this case. 
Case XIV.-Dropsy was developed in this case, after ad- 
mission into hospital. It progressively increased, under the 
use of iron and quinia, for 10 days. Elaterium was then 
employed, and it was repeated twice, each time gr. 1-4 being 
given every two hours until the cathartic operation began. 
The effect upon the dropsy was marked. Recovery in this 
case. 
Case XV.-Hydrothorax existed in this case to such an 
extent that the patient was obliged to keep the sitting posture, 
and suffered much from dyspnoea. Purging was kept up by 
elaterium for two weeks, and under the use of this remedy the 
dropsy disappeared. Recovery in this case. 
Cases in which Jalap and the Bitartrate of Potassa were used. 
Case I.-In this case the anasarca was excessive; the eyes 
were partially closed by the oedema of the face, the limbs 
were enormously swollen, and vesication on the legs had taken 
place, occasioning much draining away of liquid. There ex- 
isted hydrothorax to such an extent that the patient kept the 
sitting posture. In seven days, under the use of the pulvis 
purgans, the hot-bath being employed four times, the ana- 
sarca was removed, and the patient was able for a time to 
be up and walking about the ward. Death subsequently took 
place by asthenia. No autopsy. 
Case II.-There was moderate dropsy in this case. The 
patient was in hospital about six months. During much of 
this time jalap was given so as to produce moderate purging, 298 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
and she had also gallic acid; no benefit was derived from this 
treatment, and she left the hospital unimproved. 
Case III.-There was considerable dropsy in this case, and 
the bitartrate of potassa was given in doses of half an ounce 
daily. It operated as a mild hydragogue. This was the only 
remedy given. In four weeks the patient was discharged free 
from dropsy, and feeling well enough to return to his work as 
a laborer. 
Case IV.-There was moderate anasarca in this case. 
Under the use of jalap and the bitartrate of potassa in purga- 
tive doses, the dropsy rapidly disappeared. Recovery in this 
case. 
Case V.-The anasarca was great in this case. Jalap and 
the bitartrate of potassa, given so as to produce fresh pur- 
ging, preceded the use of the bitartrate of potassa as a diuretic. 
The dropsy was removed, and the patient discharged well at 
the end of fifteen days. 
Case VI.-There was much anasarca in this case. It 
diminished greatly under the use of the pulvis purgans, and 
the hot-air bath. Tonics were then given until recovery took 
place. 
Cases in which Croton-Oil was used. 
Case I.-Croton-oil was given in this case during convul- 
sions which recurred at intervals during twenty-four hours. 
This remedy was followed by the nitrate of potassa as a diu- 
retic. After the convulsions ceased to recur, the patient re- 
mained for two days in a semi-comatose state. Recovery in 
this case. 
Case II.-In this case profound coma occurred on the 
second day after admission into hospital. It was accompanied 
by tracheal rales, and the patient appeared to be moribund. 
She was purged freely with croton-oil, and the hot-air bath was 
employed. Under these measures she emerged from the coma. 
Recovery in this case. 
Cases in which the Sulphate of Magnesia was used. 
Case I.-After treatment with diuretics, under which 
much improvement had taken place, the sulphate of magnesia 
was given. The dropsy disappeared under the use of the lat- 
er. Recovery in this case. bright's diseases. 
299 
Case II.-In this case purgation by means of the sulphate 
of magnesia preceded the use of the iodide of potassium, and 
an acidulated emulsion of pumpkin-seeds. The disease fol- 
lowed scarlatina; convalescence in four days. 
Case III.-Purgation by means of the sulphate of magne- 
sia, in this case, preceded the use of the bitartrate of potassa 
as a diuretic. The disease followed scarlatina, and the patient 
was convalescent in seven days. 
Case IV.-The sulphate of magnesia in this case was em- 
ployed prior to the bitartrate of potassa as a diuretic. Recov- 
ery in this case. 
In one case, the anasarca being great, it is simply stated 
that purgatives were first used, and afterward tonics. Re- 
covery took place in this case. 
Reviewing the facts relating to cathartics, of the 15 cases 
into the treatment of which elaterium entered, this remedy 
was given in 6 cases with reference to uraemic phenomena; 
in I cases with reference to dropsy; in one case of peri- 
carditis with large effusion, and in one case in which amauro- 
sis was associated with slight oedema of the face. In the case 
last named, the remedy was of no avail. In the case of peri- 
carditis, with effusion, its effect wras apparently injurious. In 
4 of the 6 uraemic cases, it was of no avail, but in one of these 
cases the remedy was not retained by the stomach. Its oper- 
ation was apparently notably useful in one of these cases, namely, 
Case VIII.; and it was measurably useful in another case, 
namely, Case II. In all the cases in which it was used with 
reference to dropsy, the effect was apparently useful. In 2 
of these cases there was reason to suppose that life was saved 
by this remedy, namely, Cases XIII. and XV. 
Of the 6 cases into the treatment of which jalap and the 
bitartrate of potassa, one or both, entered, in all, the object 
was the removal of dropsy. The treatment was effective in all 
save one case, no benefit being produced in that case, namely, 
Case II. Great dyspnoea from hydrothorax existed in one 
of these cases, namely, Case I. 
In the two cases in which croton-oil was used, there was 
coma, and in one of the cases convulsions. In both cases relief 300 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
followed the operation of this cathartic, and in both cases 
recovery took place. 
Of the 4 cases in which the sulphate of magnesia was 
given, in all, the object was the removal of the dropsy. In 
each of these cases diuretics entered into the treatment, either 
before or after the purgative; and in all the cases recovery 
took place. 
These facts certainly go to show the utility of hydrogogue 
cathartics given with reference both to uraemia and to dropsy. 
With reference to the latter, their utility is shown often er and 
is more marked. It is, however, to be borne in mind, that 
uraemic coma and convulsions are events denoting vastly more 
immediate danger than dropsy, and that, often, when these 
events occur, life is destroyed so quickly that there is not much 
time for the employment of means for elimination. This con- 
sideration, it is hardly necessary to add, leaves no room for 
choice between diuretics and cathartics. To trust to the for- 
mer, under such circumstances, is never warrantable, and, in 
fact, would be culpable. Nor is there much scope as regards 
the cathartics to be selected. Elaterium and croton-oil are 
preeminently the articles to be used. 
With regard to elaterium as a remedy for the removal of 
dropsy, I have frequently met with practitioners who entertain, 
as it seems to me, undue apprehensions of injury from it. 
It is a powerful remedy, and its use calls for care and j udgment; 
but, whenever the diminution or removal of dropsical effusion 
is urgently indicated, there are few, if any cases, in which this 
remedy may not be judiciously used. If the condition of the 
patient be such that there is room to fear harm from the 
depression which may be produced by its operation, it should 
be given in small doses, namely, one-eighth or one-fourth of a 
grain, repeated after intervals of one or two hours; and it 
should be discontinued when the purgative operation begins. 
This collection of cases furnishes some striking illustrations of 
the value of this remedy in cases of hydrothorax with large 
effusion. I could cite other examples of hydrothorax occur- 
ring in connection with disease of the heart, as well as in 
Bright's diseases, which would, in like manner, exemplify the 
value of this remedy. bright's diseases. 
301 
Cases in which the Hot-air and Vapor Bath were used. 
The hot-air bath entered into the treatment in 7 cases. 
It was used to eliminate excrementitious principles through 
the skin, and, also, with reference to dropsy. The operation 
consisted in heating air by means of a spirit-lamp in an appa- 
ratus for the purpose, a tube connected with the apparatus 
being inserted under the bedclothes. In one case, heated 
vapor or steam was introduced under the bedclothes. The 
facts in these 8 cases, in which treatment with the hot-air 
or vapor bath is noted in the histories, are as follows : 
Case I.-The hot-air bath in this case sometimes produced 
copious perspiration, and the patient felt weakened by it. At 
other times it occasioned an uncomfortable sensation of heat. 
Evidently in this case it was not beneficial. It was employed 
with reference to dropsy. The case ended fatally, and the 
disease was the large white kidney. 
Case II.-The hot-air bath and cupping over the loins 
were employed in this case during convulsions, without avail. 
The case ended fatally, and the kidneys were fatty. 
Case III.-In this case the hot-air bath was employed, in 
conjunction with the use of iron and quinia, with reference 
to dropsy. The dropsy nearly disappeared, and, after three 
months, the patient left the hospital much improved. She 
returned in a month quite feeble, and died shortly after being 
readmitted. The kidneys were fatty. 
Case IV.-The vapor-bath was resorted to in this case 
after elaterium had been given repeatedly and not retained by 
the stomach. The patient was in uraemic coma. No benefit 
was obtained. The case ended fatally. No autopsy. 
Case V.-In this case there was much anasarca and great 
dyspnoea from hydrothorax. The dropsy was removed in seven 
days under treatment by means of the hot-air bath in con- 
junction with the use of the pulvis purgans. The case sub- 
sequently ended fatally. No autopsy. 
Case VI.-In this case the dropsy was considerable. The 
patient had the hot-air bath daily. The acetate of potassa 
and digitalis were also used. The dropsy was removed, and 
the improvement in other respects was marked. The ending 302 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
in this case is not known. It is noted in the history of this 
case that " the hot-air baths seemed extremely useful. Under 
their use the dropsy disappeared, and he improved pari passu 
in other respects." 
Case VII.-In this case the patient fell into deep coma on 
the second day after admission into hospital, and seemed mori- 
bund. She emerged from coma after free purgation with cro- 
ton-oil. Afterward the dropsy disappeared, together with the 
albuminuria, under the use of the hot-air bath and the sulphate 
of magnesia. Recovery in this case. 
Case VIII.-It is only noted in this case, as regards treat- 
ment, that the hot-air bath was employed, and that, under its 
use, there was improvement. The subsequent treatment is not 
noted. Recovery in this case. 
The hot-air bath has been much employed in Bellevue Hos- 
pital in cases of Bright's diseases. These few cases represent 
the results of a larger experience, by affording illustrations of 
the usefulness of this measure in some cases, and its inutility 
in other cases. It is a measure which may be employed ten- 
tatively, and continued or not according to the effect. If it 
do not produce free perspiration, it not only does no good, but 
it is, to say the least, annoying to the patient. If, when free 
perspiration is produced, it be followed by a sense of fatigue 
or prostration, its employment is not advisable. If well borne, 
its use may be continued, but only as an adjunctive measure 
when uraemic coma, or excessive anasarca, or convulsions, afford 
indications for prompt and efficient treatment. Alone it is 
not adequate to effect the objects of treatment under these cir- 
cumstances. 
Cases in which Gallic Acid was used. 
Gallic acid entered into the treatment in 11 of the cases, 
the histories of which contain an account of the management. 
This remedy was given with a view to diminishing the amount 
of albumen in the urine, and thereby obviating a morbid con- 
dition supposed to be causative of dropsy. The facts in these 
11 cases are as follows: 
Case I.-Gallic acid, together with quinia and iron, and 
the external use of diuretics, constituted the treatment in this bright's diseases. 
303 
case. The treatment was without benefit. The case proved 
fatal, and the disease was the large white kidney. 
Case II.-After the use of elaterium for 54 consecu- 
tive days, with the effect of diminishing the dropsy, this reme- 
dy was discontinued, owing to its producing nausea, and gallic 
acid was given for 10 days. The dropsy increased during 
these 10 days, and the remedy was then discontinued. The 
case ended fatally, and the kidneys were fatty. 
Case III.-In this case gallic acid was used without effect. 
The dropsy was removed by diuretics. The ending in this 
case is not known. 
Case IV.-The dropsy in this case disappeared under the 
use of a diuretic remedy, namely, the bitartrate of potassa. 
The patient was then placed on the use of gallic acid in doses 
of grs. x, three times daily. The albumen in the urine be- 
came less under the use of this remedy, but the dropsy, to 
some extent, returned, and, after 10 days, the bitartrate of 
potassa was resumed with the same effect as before. This 
patient left the hospital much improved, and able to do light 
work. 
Case V.-Gallic acid, in doses of grs. v, three times daily, 
was given for some time in this case, without benefit. The 
dropsy was slight. The patient left the hospital afterward, 
feeling well enough to act as ship's cook. 
Case VI.-Dropsy was moderate in this case. Gallic acid 
grs. v, three times daily, with jalap as a cathartic every other 
day, constituted the treatment. The patient left the hospital 
unimproved. 
Case VII.-The dropsy in this case, which was consider- 
able, was much diminished under the use of a diuretic remedy, 
namely, the acetate of potassa. Gallic acid was then given in 
doses of grs. v, three times daily, and, under the use of this 
remedy, the dropsy continued to diminish. The ending in 
this case not known. 
Case VIII.-There was much anasarca in this case. The 
treatment consisted of gallic acid, and the tincture of the 
chloride of iron. The patient remained in hospital 11 
days, and left without any improvement. 
Case IX.-The dropsy in this case was considerable, and 304 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
it disappeared under the use of the bitartrate of potassa as a 
diuretic. After the disappearance of the dropsy, gallic acid 
was given in scruple-doses, and under the use of this remedy 
the albumen in the urine diminished. Recovery in this case. 
Case X.-Gallic acid in doses of grs. vj, three times daily, 
constituted the treatment in this case. The patient was 
12 days in hospital, and left with no dropsy, and only a 
trace of albumen in the urine. 
Case XI.-In this case, after the dropsy had diminished 
much under the use of elaterium, gallic acid in scruple doses 
was given. It soon, however, occasioned vomiting, and was 
discontinued. Recovery in this case. 
These cases furnish very little, if any, evidence in behalf of 
the utility of gallic acid. It is true that in one case, Case X., 
the dropsy disappeared, and the patient recovered under the 
use of this remedy alone ; but the question arises, in view of 
the absence of evidence in the other cases, whether in that case 
the hygienic conditions would not probably have been suffi- 
cient without the use of the gallic acid. 
Cases in which Tonic Remedies were used. 
Tonic remedies, as a rule, entered more or less into the 
treatment whenever cases were under observation for any con- 
siderable period. It is very difficult to estimate the amount 
of benefit which may have been derived from them. I shall 
content myself with giving briefly the facts as noted in 16 
cases, the histories of which contain information of the use of 
remedies of this class : 
Case I.-A fatal case, in which the disease was the large 
white kidney. Quinia and iron were used, with no apparent 
benefit. 
Case II.-In this case the treatment consisted of the use 
of quinia and iron in conjunction with the hot-air bath. 
Under this treatment the dropsy nearly disappeared, and the 
patient left the hospital at the end of three months, quite com- 
fortable. She returned in a month, very feeble, and died shortly 
after readmission. The kidneys were fatty. 
Case III.-After the dropsy had become much diminished, 
and notable general improvement had taken place under the bright's diseases. 
305 
use of elaterium, chalybeate tonics were given. The case 
passed from under my observation, and the progress afterward 
was not known. 
Case IV.-After the use of gallic acid without benefit, 
noticeable improvement in this case took place, under the use 
of quinia and iron. Patient left the hospital feeling able to 
work as ship's cook. 
Case V.-This case was treated solely by tonic remedies. 
The tonics given are not specified. After 16 days in hospital, 
the dropsy was greatly diminished, and the patient was dis- 
charged, feeling confident that he should soon be able to return 
to work as a laborer. 
Case VI.-In this case quinia and iron were given, and 
at the same time the acetate of potassa was used as a diuretic. 
Under this treatment the dropsy, which was considerable, di- 
minished, and the general improvement was marked. The 
ending not known in this case. 
Case VII.-The tincture of the chloride of iron and gallic 
acid were used successively in this case. The patient left the 
hospital after 11 days, not improved. 
Case VIII.-It is simply noted in this case that the tonics 
were given after the dropsy had disappeared, under the use of 
diuretics. Recovery in this case. 
Case IX.-In this case, after uraemic convulsions and 
coma had disappeared under the use of croton-oil, followed by 
the nitrate of potassa, quinia and iron were given. Recovery 
in this case. 
Case X.-The citrate of iron and quinia and the citrate of 
potassa constituted the treatment in this case. The patient 
recovered and left the hospital after 20 days. 
Case XI.-In this case dropsy progressively increased 
under the use of quinia and iron, during 10 days. Elaterium 
and gallic acid were afterward used. Recovery in this case. 
Case XII.-In this case, after dropsy had disappeared 
under the use of the acetate of potassa, the potassio-tartrate of 
iron was given until recovery. 
Case XIII.-The dropsy, in this case, having disappeared 
under the use of the pul vis purgans and the hot-air bath, qui- 
nia and iron were given until recovery. 306 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Case XIV.-Tonics, the remedies not specified, were given 
in this case after the disappearance of dropsy under the use of 
diuretics. Recovery in this case. 
Case XV.-This case came under observation three and a 
half months after the commencement of the disease, pericarditis 
having occurred, from which lie had recovered. The urine was 
albuminous, and there was some anasarca. Recovery took place 
under the use of the tincture of the chloride of iron. 
Case XVI.-Much dropsy existed in this case, which dis- 
appeared under the use of purgatives, the particular purgative 
remedies not being specified. Tonics, the remedies not speci- 
fied, were then used until recovery. 
In addition to the use of diuretics, cathartics, the hot-air 
or vapor bath, gallic acid, and tonics, the histories in this collec- 
tion of cases contain very little which is noteworthy. It is 
noted in one case that uraemic coma followed directly the 
arrest of vomiting by suppositories of morphia. This case 
proved fatal, and the kidneys were contracted. Per contra, in 
another case the patient had acquired the habit of taking 
opium largely to relieve vomiting and diarrhoea, and she was 
accustomed to take an ounce of McMunn's elixir of opium 
daily. There was much anasarca in this case, and the urine 
was loaded with albumen. Two months after this case came 
under my observation, her condition was not changed. Sub- 
sequently this case ended fatally. 
Chloroform and the warm bath were used in a case of 
uraemic convulsions, with no benefit, the case ending fatally, 
and the convulsions continuing until death. In another 
case the inhalation of chloroform was resorted to in order to 
arrest very active delirium which succeeded an attack of con- 
vulsions. The patient, a vigorous man, was kept under the 
influence of the chloroform for several hours. The effect in 
this case was good; the patient became rational when the use 
of the chloroform was discontinued, and for a time there was 
notable improvement. Death took place several months after- 
ward. 
Finally, it is noted in one of the cases that the patient en- 
tered the hospital with chronic pleurisy and general dropsy, and 
during five months in hospital he had no medicinal treatment bright's diseases. 
307 
excepting a palliative for cough and a liniment to the chest. 
At the end of five months, the pleuritic effusion and the gen- 
eral dropsy had disappeared, but the urine remained albumi- 
nous. At this time he was well enough to be employed at out- 
of-door work at the hospital. 
In judging of the efficacy of therapeutical measures in 
cases of Bright's diseases, an important consideration is not to 
be lost sight of, namely, an intrinsic tendency to death, or to re- 
covery, or to improvement, irrespective of any therapeutical 
agencies. How often would uraemic coma and convulsions 
cease spontaneously, and either recovery or more or less im- 
provement follow ? How often would dropsy either disappear 
or diminish to a greater or less extent, without any measures 
of treatment ?• What results would be furnished by an analy- 
sis of a series of cases in which hygienic measures were relied 
upon to the exclusion of therapeutical agencies ? These are 
questions which cannot now be answered ; and it is obvious 
that it must be a long time before the data on which the 
answers are to rest can be obtained. It is certain that physi- 
cians are not warranted in allowing cases to go without the- 
rapeutical interference in order to gather materials for the 
study of the natural history of these diseases. All that can be 
done is to report cases in which these diseases have received 
little or no medicinal treatment, owing to circumstances for 
which physicians are not responsible. An accumulation of 
such cases is much to be desired, in accordance with a funda- 
mental principle in medicine, namely, that knowledge of the 
natural history of diseases is the point of departure for the 
study of therapeutics. X.-AMPUTATIONS PERFORMED AT BELLEVUE 
HOSPITAL. 
Amputations performed at Bellevue Hospital. Compiled by 
F. J. Metcalfe, Acting Junior Assistant. March, 1869. 
Prof. F. II. Hamilton, M. D., 
Dear Sir : I beg to head this Report with an apology 
and explanation for not presenting more cases. The number 
of cases reported is very small for the number of years they 
include ; but, owing to the way in which the reports were 
formerly kept, I have only been able to find these few, which 
really represent but about one-sixth or one-eighth of the 
entire number. For a division of amputations, as regards the 
periods, I have taken a medium between your own classifica- 
tion and that adopted by the Surgeon-General of the United 
States Army; viz., immediate, or within twelve hours; primary, 
after twelve, and before the expiration of forty-eight hours ; 
intermediate, after two days, and before the expiration of three 
weeks ; secondary, after three weeks. 
Very respectfully, 
Your obedient servant, 
F. J. Metcalfe. 310 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
NAME. 
AGE 
SEX 
DISEASE. 
CONTINU- 
ANCE. 
PERIOD. 
DATE OF 
OPERATION. 
POINT OF 
OPERATION. 
OPERATOR. 
METHOD. 
ANAES- 
THETIC. 
RESULT. 
Thos. Cain 
45.. 
M.. 
Epithelioma of the 
hand. 
Began 2 
years ago 
as a wart 
on his 
hand. 
Secondary.. 
April 18, '68 
Lower third 
of forearm 
Dr. Hamilton... 
Circular.. 
Ether... 
Cured, July 4, 1868. 
Samuel Langdon 
25.. 
M.. 
Comp, fracture of 
forearm. 
Same day. 
Immediate 
or primary. 
April 10, '66 
Middle 3d 
of forearm 
Dr. Smith 
Flap 
Ether... 
Cured, May 30, 1866. 
Ellen Fitzgerald 
(Double amputation.) 
50.. 
F... 
Run over by street 
car, Sept. 23,'65, 
crushing left 
arm, right fore- 
arm, and break- 
ing thigh. 
6 hours af- 
ter acci- 
dent. 
Immediate. 
(Both oper- 
ations) . 
Sept. 25, '65 
(Both oper- 
ations). 
3 in. below 
head of hu- 
merus. 
4 in. above 
wrist. 
Dr. Hamilton... 
Double 
flap. 
Circular. 
Ether... 
Died on 6th day, Oct. 
1,1865. 
Chas. F. Davis 
47.. 
M.. 
Fracture of arm.. 
8 hours... 
Immediate.. 
April 20, '67. 
Just below 
elbow-joint 
Dr. Forman 
Flap 
Chlo'm. 
Cured, May 11, 1867. 
A Frenchman . 
21.. 
M.. 
Arm crashed in 
6th day... 
Inter- 
June, 1864.. 
Surgical. 
Dr. Hamilton... 
Flap 
Ether... 
Died on 3d day, hav- 
machinery June, 
1864. Gangrene 
supervened. 
mediate. 
Mrch. 30, '69 
Neck of hu- 
merus. 
ing never rallied 
from effects of ether 
and operation. 
Wm. Horseman. ... 
42.. 
M.. 
Compound com- 
plicated fracture 
of humerus. 
5 hours... 
Immediate. 
2 in. below 
neck of hu- 
merus. 
Dr. Cross 
Circular.. 
Ether... 
Died, March 31,1869. 
Ann Brakaback 
4.. 
F... 
Compound com- 
minuted fract. 
of humerus. 
6 hours... 
Immediate. 
Aug. 19, '67. 
2 in. below 
shoulder. 
Dr. Mott 
Flap 
Ether... 
Cured, Sept. 15, 1867. 
Robt. Widdis 
10.. 
M.. 
Compound com- 
minuted fract. 
of humerus. 
Same day. 
Immediate 
or primary. 
Aug. 29, '66. 
Junction of 
upper and 
middle 3ds 
Dr. Johnston... 
Flap 
Ether... 
Cured, Oct. 29, 1866. 
Peter M. Buchanan... 
27.. 
M.. 
Contusion and la- 
ceration of left 
forearm. Fract. 
of humerus. 
Same day. 
Immediate 
or primary. 
April 8, '68. 
Middle of 
humerus. 
Dr. Gouley 
Flap 
Ether... 
Cured. 
AMPUTATIONS IN CONTINUITY. 
FOREARM. 
ARM. AMPUTATIONS AT BELLEVUE HOSPITAL. 
311 
Catb. Moran 
27.. 
F... 
Stru mon a s vn o- 18 m on th s 
Secondary.. 
Immediate.. 
Sept. 29, '66 
Feb. 28, '67. 
March 3, '69 
June 22, '67. 
Middle of 
Dr. Hamilton... 
Dr. Sayre 
Circular. 
Cured, Dec. 10,1866. 
Died, March 3, 1867. 
Died of pyaemia. 
Cured, Sept. 14,1867. 
Died of osteo-myclitis 
and pyaemia. 
Died. 
Jacob Iloulet 
22.. 
M.. 
vitis of elbow- 
joint, with ca- 
ries. 
Laceration of right 
arm. 
Compound com- 
minuted fract. 
of forearm. 
Compound fract. 
flours... 
36 hours.. 
^fne day. 
2 hours... 
Several 
months. 
humerus. 
3 in. below 
sboulder- 
joint. 
Upper 3d of 
humerus. 
Upper 3d of 
humerus. 
Right arm, 
middle of 
humerus. 
Left arm. 
middle of 
humerus. 
Upper 3d of 
humerus. 
Flap...... 
Flap 
Flap 
Francis Devall 
33.. 
M. 
Primary.... 
Immediate 
Dr. Mott 
Ether... 
Jos. Wright 
8.. 
M.. 
Dr. Sayre 
Tobias Dillon 
24.. 
M. 
of humerus. 
Both arms crush- 
ed by machinery 
Hit on elbow by 
recoil of Parrott 
gun, causing ca- 
ries and necro- 
sis of joint. 
or primary. 
Immediate- 
Secondary. . 
Nov. 21, '65. 
Jan. 15, '66. 
Dr. Hamilton... 
Dr. Hamilton... 
Double 
flap. 
Circular. 
Double 
flap. 
(Double amputation.) 
W. D 
28.. 
M.. 
Ether... 
Chas. Ferris 
39.. 
M.. 
Fracture of both 
10 hours.. 
Immediate.. 
May 7, '68... 
Left leg at 
Dr. Smith and 
Flap 
Ether... 
Died, May 11, 1868. 
(Double amputation.) 
John Schmidt 
28.. 
M.. 
legs. 
Elephantiasis of 
leg. 
Compound com- 
15 days... 
24 hours.. 
Secondary... 
Primary.... 
July 31, '66. 
Aug. 21, '67. 
junction of 
middle and 
lower 3ds. 
Right leg at 
knee-joint. 
Just below 
Dr. Hudson .. 
Dr. Sayre 
Dr. Wood 
Flap 
Chlo'm. 
Died, Aug. 22, 1866. 
John Devalay 
26.. 
M.. 
patella. 
Junction of 
Flap 
Ether... 
Cured, Dec. 1,1867. 
James O'Hara 
30.. 
M. 
minuted fract. of 
tibia and fibula. 
Crashed by cars.. 
Run over by street 
16 hours.. 
5 hours... 
Primary.... 
Immediate.. 
Dec. 26, '63. 
Feb. 6, '64.. 
middle and 
upper 3ds. 
Middle of 
Dr. Hamilton... 
Flap 
Ether... 
Died on 26th day. 
Died on 14th day, of 
James Gillen 
12.. 
M.. 
leg. 
Below knee 
Dr. Lauderdale. 
Double 
Ether... 
Chas. Campbell 
6.. 
M.. 
car. 
Fracture of tibia 
10 hours.. 
Immediate.. 
Middle of 
Dr. Johnston... 
flap. 
Flap 
Ether... 
pyaemia. 
Cured. 
Thomas Moran 
24.. 
M.. 
and fibula. 
Contusion of leg.. 
20 hours.. 
Primary 
Sept. 12, '66 
leg. 
Middle of 
Dr. II. L. Smith 
Flap 
Ether... 
Died, Sept. 14,1866. 
leg. 
LEG. 312 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
NAME. 
AGE 
SEX 
DISEASE. 
CONTINU- 
ANCE. 
PERIOD. 
DATE OF 
OPERATION. 
POINT OF 
OPERATION. 
OPERATOR. 
METHOD. 
ANAES- 
THETIC. 
RESULT. 
John Morrissey 
19.. 
M.. 
Compound fract. 
of leg. 
~ uay s.... 
Primary..... 
Sept. 26, '68 
Middle of 
leg. 
Dr. Mott 
Flap , 
Chlo'm. 
Cured, Nov. 14,1868. 
Caroline Carroll 
35.. 
F... 
Spontaneous gan- 
grene of leg. 
9 days.... 
Inter- 
mediate. 
Jan. 23, '69. 
Lower 3d... 
Dr. Wood 
Flap 
Nitrous 
Oxide 
Died, Jan. 1,1869. 
Thomas Toley 
30.. 
M.. 
Run over by car.. 
3 hours... 
Immediate.. 
Sept. 4, '65. 
Just below 
knee. 
Dr. Hamilton... 
Circular.. 
Ether... 
Secondary hremorrh'e, 
Sept. 11. Tied femo- 
ral artery in Scar- 
pa's space. Died on 
12th day after ampu- 
tation. 
Lewis Morschhausser. 
14.. 
M.. 
Run over by car.. 
2 hours... 
Immediate.. 
Sept. 22, '64 
Middle of 
leg. 
Dr. Hamilton... 
Circular.. 
Ether... 
Complete and rapid 
recovery. 
German boy 
9.. 
M.. 
Run over by car.. 
Soon 
Immediate.. 
Sept., 1864.. 
Leg, below 
knee. 
Dr. Hamilton... 
Circular.. 
Ether... 
Dec. 7, 1864, had re- 
covered with a good 
stump. 
Recovered with a 
good stump. 
Thomas Flood 
23.. 
M.. 
Railroad accident 
-caries of tar- 
sal bones. 
4 months. 
Secondary.. 
March 18,'65 
4 in. above 
ankle. 
Dr. Hamilton... 
Circular.. 
Ether... 
John Ward 
29.. 
M.. 
Caries of tarsal 
bones. 
19 years.. 
Secondary.. 
March 18,'68 
4 in. above 
ankle. 
Dr. Hamilton... 
Circular.. 
Ether... 
United mostly by 1st 
intention a good 
Wm. Bruin 
11.. 
M.. 
Run over by car.. 
1 hour.... 
Immediate.. 
Aug. 29, '65. 
3 in. above 
ankle. 
Dr. Hamilton... 
Circular.. 
Ether... 
stump. 
United mostly by 1st 
intention; recovery 
complete. 
Ann H 
60.. 
F... 
Epithelioma of 
heel. 
Since 
childhood 
Secondary.. 
Jan. 13, '66. 
IX inches 
above ankle 
Dr. Hamilton... 
Circular.. 
Ether... 
Recovery slow, but 
complete.-See N. Y. 
Med. Rec., Feb., '66. 
Christiana Lissit 
53.. 
F... 
Compound frac- 
ture of leg. 
7 hours... 
Immediate.. 
June 4, '68.. 
Middle of 
leg. 
Dr. Sands 
Flap 
Ether... 
Died, June 19, 1868. 
James Watson 
(Double amputation.) 
9.. 
M.. 
Laceration of both 
feet. 
17 days... 
Secondary.. 
Jan. 12, '68. 
Junction of 
middle and 
lower 3ds 
in both legs 
Dr. Sands 
Flap 
Ether... 
Died, Feb. 21,1869. 
Mich! Nicholsberry.. 
56.. 
M.. 
Compound frac- 
ture of both legs. 
7 hours... 
Immediate.. 
Aug. 4, '68.. 
4 in. below 
kuce-joint 
Dr. Pratt 
Flap 
Ether... 
Cured, Sept. 10,1868. AMPUTATIONS AT BELLEVUE HOSPITAL. 
313 
Mil lick Tracy 
27.. 
M.. 
Fracture of tibia, 
Same day. 
Immediate 
Au". 6. '06.. Junction of 
Dr. 
Circular.. 
Chlo'm. 
Died, Aug. 14,1866. 
Died after the wound 
25.. 
F... 
fibula, and fe- 
mur. 
Large popliteal 
or primary. 
Secondary.. 
1862 
upper and 
middle 3ds 
of femur. 
Above mid- 
Dr. Hamilton... 
Circular.. 
Ether... 
James Harkins 
7.. 
M.. 
aneurism. 
Fracture of tibia 
Same day. 
Immediate 
Nov. 4, '66.. 
die of thigh 
Lower 3d of 
Dr. Ludlum 
Flap 
Ether... 
had partly closed. 
Cured. 
Chas. Crookander.... 
42.. 
M.. 
and fibula. 
Compound frac- 
31 hours.. 
or primary. 
Primary.... 
Oct. 29, '68.. 
femur. 
Upper 3d of 
Dr. Smith 
Flap 
Ether... 
Cured, Jan., 1869. 
Ernest Taruff 
2.. 
M.. 
ture of leg. 
Compound frac- 
5 hours... 
Immediate.. 
May 27, '67. 
femur. 
Middle of 
Dr. Sands 
Flap 
Ether... 
Cured, July 20,1867. 
Chas. Johnston 
30.. 
M.. 
ture of tibia and 
fibula. 
Compound com- 
3 days.... 
Inter- 
Nov. 2, '67.. 
femur. 
Middle of 
Dr. Smith 
Flap 
Ether... 
Died, Nov. 5, 1867. 
John Frost 
45.. 
M.. 
minuted fracture 
of femur. 
Compound com- 
minuted fracture 
of leg. 
20 hours.. 
mediate. 
Primary.... 
Jan. 23, '69. 
femur. 
Upper 3d of 
femur. 
Dr. Wood 
Flap 
Biehl. 
Died, Jan. 25,1869. 
Methy- 
lene. 
John Smith 
.... 27.. IM..I Gun-shot injury.. 110 months; Secondary.. ISept. 16, '671 Wrist-joint. |Dr. Hamilton... |Circular..|None...|Rapid and complete 
III II 1 1 1 III recovery. 
Ben. Pressly 
....133.. M..IFracture of fore-14 hours. 
.1 Immediate.. ISept. 7, '67.lElbow-jointDr. White... 
. JChlo'm.|Cured, Oct. 20,1868. 
I I | arm. 
Illi 
1 
1 1 
Michael McDonald... 
16.. 
M.. 
Fracture of 
and fibula. 
tibia 
IX hours. 
Immediate.. 
Aug. 13, '66. 
Knee-joint.. 
Dr. Sands 
Flap 
Ether... 
Died, Aug. 15,1866. 
Richard Adams 
38.. 
M.. 
Compound 
ture of leg. 
frac- 
20 days... 
Secondary.. 
Feb. 16, '69. 
Knee-joint.. 
Dr. Markoe 
Flap 
Ether... 
Cured. 
August Waterman.... 
15.. 
M.. 
Compound 
ture of leg. 
frac- 
6 hours... 
Immediate.. 
Aug. 19, '67. 
Knee-joint.. 
Dr. Mead 
Flap 
Chlo'm. 
Died, Sept. 25,1867. 
AMPUTATIONS IN CONTIGUITY. 
THIGH. 
WRIST. 
ELBOW. 
KNEE. 314 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
NAME. 
AGE 
SEX 
DISEASE. 
CONTINU- 
ANCE. 
PERIOD. 
DATE OF 
OPERATION. 
POINT OF 
OPERATION. 
OPERATOR. 
METHOD. 
ANES- 
THETIC. 
RESULT. 
Wm. Bees 
14.. 
M.. 
Compound dislo- 
cation of tibia. 
Same day. 
Immediate 
or primary. 
Sept. 5, '68. 
Knee-joint.. 
Dr. Mott 
Flap 
Chlo'm. 
Cured, Sept. 30,1868. 
Joseph Irabuck 
63.. 
M.. 
Elephantiasis of 
leg. 
Leg crushed by 
street car. 
15 years.. 
hours. 
Secondary.. 
Immediate.. 
Dec. 9, '68.. 
Knee-joint.. 
Dr. Sayre 
Flap 
Ether... 
Died, Jan. 15, 1869. 
10.. 
M.. 
Sept. 25, '64 
Knee-joint.. 
Dr. Hamilton... 
Circular.. 
Ether 
and 
brandy 
Ether... 
Cured. 
Wm. Brophy 
M.. 
Run over by car.. 
Compound frac- 
ture of leg. 
15 hours.. 
Primary.... 
Secondary.. 
March 5, '66 
Knee-joint.. 
Knee-joint 
removed, 
patella and 
IX inch of 
femur. 
Dr. Hamilton.. 
Died on 3d day. 
Died on 3d day from 
septicaemia.-See N. 
Y. Medical Gazette, 
Feb. 8, 1868. 
Fred. Sufford 
42" 
M.. 
7 days.... 
Jan. 6, '68... 
Dr. Hamilton... 
Oval 
Ether... 
Jolin Schmidt.... 
... '28.. IM.. IChronic ostitisl 10 years.. 1 Secondary.. 1 Sept.'22, '60 Hip-joint.. .|Dr. Hamilton... IFlap... 
. .'Ether... iDied of pyaemia. 
| | | and wt«o-myell.| 
1 i 
Jas. Clark 
!28.. IM..[Reamputation of 2 years. 
.[Secondary..[Dec. 9, 'CT..|6 in. below|Dr. Hamilton... 
Circular.. [Ether... [Cured, March 24,1868. 
, les for neuroma, 1 
original injury, 
1 gunshot. 
। knee. 
Wm. Cotter 
Jas. Flynn 
29.. 
32 
" 
M 
M 
Reamputation of 
lemur. 
Reamputation of 
femur. 
4 days.... 
Inter- 
mediate. 
Secondary.. 
May 30, '68.. 
Nov. 14, '68. 
Middle of 
femur. 
Upper 3d of 
femur. 
Dr. Hamilton... 
Dr. Wood 
Flap 
Flap 
Ether... 
Ether... 
Cured, Sept. 26,1868. 
Died, Dec. 14,1868. 
HEAMPUTA TIONS. 
HIP-JOINT. 
THIGH. 
LEG. AMPUTATIONS AT BELLEVUE HOSPITAL. 
315 
SUMMARY OF CASES. 
Total number of amputations and reamputations 55 
Amputations 52 
Reamputations 3 
- 55 
Amputations 
Died 26 
Cured 26 
- 52 
Of the fifty-two amputations, thirty-seven were either immediate or 
primary-that is, within forty-eight hours-of which number 
seventeen died, and twenty recovered. Three were intermedi- 
ate, and all died ; twelve were secondary, of which number seven 
died, and five recovered. 
Died 1 
Cured 2 
- 3 - 55 
Reamputations 
TOTAL NUMBER OF DEATHS AND CURES. 
Died 27 
Cured 28 
- 55 
Ether. 
Chloroform. 
Nitrous oxide, died ... 1 
Cured 
. 22 
Cured 
. 5 
Biehl, methylene, died.. 1 
Died 
. 21 
Died 
. 4 
No anaesthetic, cured.. 1 
43 
9 
3 - 55 
RESULTS IN WHICH ANESTHETICS WERE EMPLOYED. 
AMPUTATIONS IN CONTINUITY. 
Forearm. 
Arm. 
Zey. 
Thigh. 
Cured 3 
Cured 5 
Cured 10 
Cured 3 
Died 1 
Died 6 
Died 9 
Died 4 
-- 
- 
- 
-- 
4 
11 
19 
- 41 
AMPUTATIONS IN CONTIGUITY. 
Wrist. 
Elbow. 
Knee. 
Flip. 
Cured 
. 1 
Cured 
1 
Cured.... 
. 3 
Cured.... 
. 0 
Died 
. 0 
Died 
0 
Died 
. 5 
Died 
. 1 
1 
1 
8 
1 
- 11 
Cured... 
Leg. 
1 
Cured ... 
Thigh. 
.... 1 
1 
Died.... 
2 
- 3 - 55 
REAMPUTATIONS. XI.-REPORT OF CASES OF ANAESTHESIA. 
Report of ' Cases of Anesthesia at the Bellevue Hospital, 
with the Use of a New Inhaling Apparatus. By D. II. 
Goodwillie, M. D., D. D. S. 
The following record of cases of anaesthesia in the hos- 
pital, in which my inhaling apparatus has been employed, 
was prepared at the request of Professor Frank H. Hamilton 
and several members of the Medical Board of the Bellevue 
Hospital. The peculiar construction of the apparatus, which 
will be described further on, admits of its adaptation to the 
inhalation of different anaesthetic vapors, such as the vapor of 
ether, of chloroform, nitrous oxide gas, bichloride of methy 
lene, etc. Of the fifty instances recorded in the table, in 
which it was employed, anaesthesia was produced for slight as 
well as grave operations ; and in operations about the mouth 
and nose the inhaler was used during the operation. As will 
be seen by the recapitulation at the end of the table, the 
apparatus was used in both males and females, and at all 
ages, from fifteen months to fifty-eight years. 318 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
DATE. 
1867-'68. 
SEX 
AGE 
OPERATION. 
OPERATING 
SURGEON. 
TIME OF IN- 
HALATION. 
TIME TO 
PRODUCE 
ANESTHESIA. 
AMOUNT 
OF ETHER 
USED. 
REMARKS. 
Dec. 28... 
M.. 
88.. 
Amputation of thigh 
Dr. J. R. Wood 
35 minutes.. 
5 minutes.... 
4 ounces.... 
2% ounces.. 
No coughing, struggling, or sickness. 
No coughing, struggling, or sickness. 
Jan. 4.... 
M.. 
40.. 
Resetting fracture"of thigh.... 
Dr. L. A. Sayre. ... 
25 minutes.. 
4 minutes.... 
Jan. 4.... 
M.. 
4.. 
Operation lor hip-disease 
Dr. L. A. Sayre 
15 minutes.. 
5 minutes.... 
X ounce.... 
No coughing, struggling, or sickness. 
Jan. 6.... 
M.. 
38.. 
Extirpation of eye 
Dr. II. D. Noyes.... 
16 minutes.. 
6 minutes.... 
2X ounces.. 
Some coughing, struggling, and sickness. 
Jan. 8.... 
M.. 
35.. 
Lithotomy 
Dr. L. A. Sayre 
60 minutes.. 
5 minutes.... 
6 ounces.... 
A little struggling. 
Jan.11... 
F... 
36.. 
Resetting old fracture 
Dr. L. A. Sayre 
20 minutes.. 
6 minutes.... 
3X ounces.. 
No coughing, struggling, or sickness. 
Jan. 15... 
M.. 
17.. 
Anchylosis of knee 
Dr. L. A. Sayre 
23 minutes.. 
3 minutes.... 
2X ounces.. 
No coughing, struggling, or sickness. 
Jan. 15... 
M.. 
40.. 
Amputation of foot 
Dr. H. B. Sands.... 
30 minutes.. 
7 minutes.... 
3 ounces.... 
Some struggling. 
Jan. 15... 
F... 
43.. 
Cancer of breast 
Dr. H. B. Sands.... 
31 minutes.. 
5 minutes.... 
2X ounces.. 
No coughing, struggling, or sickness. 
Jan. 22... 
M.. 
40.. 
Amputation of foot 
Dr. H. B. Sauds.... 
35 minutes.. 
4 minutes.... 
4% ounces.. 
Difficult breathing*, from a cold. 
Jan. 25... 
M.. 
42.. 
Perineal section 
Dr. J. R. Wood 
25 minutes.. 
8 minutes.... 
4 ounces.... 
Strong man-tremor strong. 
Jan. 29... 
M.. 
9.. 
Amputation of both legs 
Dr. II. B. Sands.... 
22 minutes.. 
5 minutes.... 
% ounce.... 
No coughing, struggling, or sickness. 
Feb. 5.... 
M.. 
10.. 
Necrosis of tibia... 
Dr. T. M. Markoe.. 
15 minutes.. 
5 minutes.... 
2 ounces.... 
Sick, but did not stop the operation. 
Apnoea-some resistance in consequence. 
No coughing, struggling, or sickness. 
Feb. 8... . 
F... 
38.. 
Prolapsus ani 
Dr. A. B. Mott .... 
30 minutes.. 
4 minutes... 
3 ounces.... 
3X ounces.. 
Feb. 12... 
M.. 
51.. 
Hernia 
Dr. T. M. Markoe.. 
45 minutes.. 
8 minutes.... 
Feb. 15... 
M.. 
46.. 
Amputation of thigh 
Dr. J. R.Wood 
23 minutes.. 
5 minutes... 
3 ounces.... 
When etherized before* in the old way, was 
quite furious; came now quietly under the 
anaesthesia. 
Feb. 19... 
Feb. 19... 
M.. 
10.. 
Opening abscess 
Dr. L. A. Sayre 
8 minutes.. 
3 minutes.... 
X ounce.... 
No coughing, struggling, or sickness. 
M.. 
36.. 
Necrosis of calcaneum 
Dr. T. M. Markoe.. 
40 minutes.. 
5 minutes.... 
3ounces.... 
Strong Yuan-great tremor. 
Slight sickness ; did not interrupt operation. 
No coughing, struggling, or sickness. 
Feb. 22... 
M.. 
12.. 
Operation for hip-disease 
Dr. A. B. Mott 
28 minutes.. 
5 minutes.... 
1 ounce 
Feb. 27... 
M.. 
-. . 
Removal ot tumor 
Dr. L. A. Sayre 
10 minutes.. 
3minutes.... 
X ounce.... 
Feb. 26... 
M.. 
47.. 
Cancer of lip 
Dr. T. M. Markoe... 
11 minutes.. 
7 minutes.... 
3X ounces.. 
Strong man-tremor great. 
Marell 1.. 
M.. 
23.. 
Necrosis of humerus 
Dr. J. R.Wood 
16 minutes.. 
4 minutes.... 
2X ounces.. 
No coughing, struggling, or sickness. 
April 4... 
April 4... 
M.. 
46.. 
Amputation of thigh 
Necrosis of inferior maxillary 
35 minutes.. 
5 minutes 
4 ounces.... 
IX ounces.. 
No coughing, struggling, or sickness. 
No coughing, struggling, or sickness. 
F... 
6.. 
Dr. J. R. Wood 
15 minutes.. 
3 minutes.... 
April 4... 
M.. 
12.. 
Necrosis of arm 
Dr. J. R.Wood 
12 minutes.. 
5 minutes.... 
2 ounces.... 
No coughing, struggling, or sickness. 
April 4... 
M.. 
26.. 
Anchylosis of wrist 
Dr. J. R. Wood 
15 minutes.. 
6 minutes.... 
3 ounces.... 
Some st niggling. 
April 18. 
M.. 
40.. 
Amputation of hand 
Dr. F. II. Hamilton. 
10 minutes.. 
3 minutes.... 
1% ounces.. 
No coughing, struggling, or sickness. 
May 1.... 
F... 
36.. 
38.. 
Plastic operation on cheek.... 
Dr. J. W. S. Gouley. 
45 minutes.. 
8 minutes.... 
(>X ounces.. 
Very strong, intemperate woman. 
Slight resistance. 
May 2.... 
M.. 
Necrosis of skull 
Dr. F. H. Hamilton. 
23 minutes.. 
7 minutes.... 
4ounces.... 
May 9.... 
F... 
40.. 
Tenotomy 
Dr. F. H. Hamilton. 
10 minutes.. 
7 minutes.... 
1 ounce 
Phthisis of right lung. 
May 9.... 
M.. 
10.. 
Amputation of foot 
Dr. J. W. S. Gouley. 
60 minutes.. 
6 minutes.... 
4 ounces.... 
No coughing, struggling, or sickness. 
May 9.... 
M.. 
40. 
Amputation of loot 
Dr. J. W. S. Gouley. 
35 minutes.. 
- minutes.... 
4 ounces.... 
Patient had deliripm tremens. Died sixth day 
after operation ; autopsy revealed an abscess 
of brain ; old pericarditis ; heart somewhat 
fatty ; no delirium after the operation. 
May 10... 
M.. 
15.. 
Necrosis of tibia 
Dr. J. W. S. Gouley. 
70 minutes.. 
5 minutes.... 
4 ounces.... 
No coughing, struggling, or sickness. 
May 20... 
M.. 
13.. 
Necrosis of tibia 
Dr. J. W. S. Gouley. 
26 minutes.. 
5 minutes.... 
2X ounces.. 
Sickness. REPORT OF CASES OF ANAESTHESIA. 
319 
Mav 20... 
M.. 
21.. 
Tenotomy 
Dr. S. Smith 
12 minutes.. 
4 minutes.... 
1 ounce 
No coughing, struggling, or sickness. 
May 23... 
M.. 
36.. 
Necrosis of superior maxillary 
Dr. F. H. Hamilton. 
10 minutes.. 
5 minutes.... 
2X ounces.. 
No coughing, struggling, or sickness. 
May 23... 
F... 
1% 
Contracted fingers 
Dr. F. H. Hamilton. 
21 minutes.. 
1% minutes. 
X ounce.... 
No coughing, struggling, or sickness. 
May 23... 
M.. 
39.. 
Dislocation of thigh 
Dr. F. H. Hamilton. 
35 minutes.. 
8minutes.... 
3X ounces.. 
No coughing, struggling, or sickness. 
Some struggling. 
May 30... 
M.. 
34.. 
Reamputation of thigh 
Dr. F. H. Hamilton. 
36 minutes.. 
5 minutes.... 
4ounces.... 
June 3... 
F... 
19.. 
Amputation of foot 
Dr. F. II. Hamilton. 
16 minutes.. 
6minutes.... 
IX ounces.. 
Patient subject to epileptic fits. 
June 27.. 
M.. 
19.. 
Amputation of hand 
Dr. L. A. Sayre 
36 minutes.. 
4% minutes.. 
- ounces... 
Bichloride of methylene was used; very good 
anaesthesia. 
Oct. 10... 
M.. 
58.. 
Dislocation of shoulder 
Dr. F. II. Hamilton. 
10 minutes.. 
5 minutes.... 
- ounces... 
Bichloride of methylene; very favorable. 
Oct. 17... 
F... 
19.. 
Necrosis of tibia 
Dr. J. W. S. Gouley. 
55 minutes.. 
6 minutes.... 
4 ounces.... 
No coughing, struggling, or sickness. 
Oct. 17... 
M.. 
18.. 
Operation on hip-joint 
Rhinoplasty 
Dr. F. H. Hamilton. 
15 minutes.. 
5 minutes.... 
2 ounces.... 
No coughing, struggling, or sickness. 
Oct. 24... 
F... 
20.. 
Dr. F. II. Hamilton. 
55 minutes.. 
- minutes.... 
3 ounces.... 
Sick; stomach full of food. 
Oct. 31... 
M.. 
38.. 
Necrosis of tibia 
Dr. A. B. Mott 
35 minutes.. 
6 minutes.... 
3X ounces.. 
No coughing, struggling, or sickness. 
Oct. 31... 
M.. 
26.. 
Exsection of elbow-joint 
Dr. A. B. Mott 
60 minutes.. 
8 minutes.... 
4 ounces,... 
No coughing, struggling, or sickness. 
Oct. 31... 
F... 
IM 
Contracted muscle of neck.... 
Dr. F. H. Hamilton. 
10 minutes.. 
2 minutes.... 
X ounce.... 
No coughing, struggling, or sickness. 
July -... 
F... 
40.. 
Removal of tumor 
Dr. F. H. Hamilton. 
15 minutes.. 
6 minutes... 
2X ounces.. 
No coughing, struggling, or sickness. 
Aug. -... 
F... 
45.. 
Extirpation of eye 
Dr. F. H. Hamilton. 
40 minutes.. 
12 minutes.... 
3X ounces.. 
No coughing, struggling, or sickness. 
Thirty-seven males, thirteen females-whole number, fifty. 
Maximum age of patient, fifty-eight years ; minimum age of patient, fifteen months. 
Maximum time of ether-inhalation, seventy minutes ; minimum time of ether-inhalation, eight minutes. 
Maximum time to produce anaesthesia, twelve minutes ; minimum time to produce anaesthesia, one and a half minutes. 
Whole amount of ether used, two hundred and fifty-six ounces-minimum amount, one-third of an ounce ; maximum amount, six and a half ounces. 
Average amount of ether used in the above fifty cases is two ounces and five drachms. 
Average time to produce anaesthesia, five minutes and seven seconds. 
Average time anaesthesia was kept up for each operation, twenty-seven minutes and twenty-four seconds. 
Average age of patients, twenty-eight years and six months. 
As an average of the above cases, it appears that two ounces and five drachms of ether would produce anaesthesia in five minutes and one second, 
and keep it up for twenty-seven minutes and four seconds, in a patient aged twenty-eight years and six months. 
RECAPITULATION. 320 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
a. Bottle loosely filled with a sponge. 
b. Tube passing through the cork to the centre of the sponge. 
c. Tube to the inhaler. 
A. Facet containing the inhalation and exhalation valves and air- 
passage. 
C. Face-piece fitting over the mouth and nose (two sizes with a flex- 
ible border for children, or for inhalation by either the nose or mouth). 
DESCRIPTION OF THE INHALING APPARATUS. 
Fig. 2. 
EXPLANATION OF THE FACET CONTAINING THE VALVES. 
h. Inhalation-valve for the passage of the vapor. 
f. Exhalation-valve for the breath to pass out. 
j. Passage for the vapor inhaled, and the breath exhaled. 
g. Fresh air-passage, with an index to show the quantities of air or 
vapor inhaled at any given time. 
The relative proportions of vapor and air are changed by 
the revolution of the facet over the inhalation-valve (h, Fig. 2), 
and the air-passage (g, Fig. 2). These proportions are shown 
by the index. Thus, revolving from one to four increases the 
vapor, and, in the same proportion, decreases the air. The 
reverse obtains in revolving from four to one. One is the 
minimum amount of vapor and the maximum amount of air. 
Four is the maximum of vapor and minimum of air. 
When the patient inhales, the air passes into the bottle at 
b, causing the liquid to vaporize on the upper half of the 
sponge (the bottle ought never to be filled more than half full 
with the anaesthetic fluid) to pass out at c into the inhaler, to 
be taken into the lungs, the amount of vapor or air being EEPORT OF CASES OF ANAESTHESIA. 
321 
regulated by the revolution of the facet over the inhalation- 
valve (h) and the air-passage (g), which amount is shown by 
the index. 
The value of the inhalating apparatus, as seen by the 
record above, is its comparative safety, as air can at all times 
be inhaled, thus producing anaesthesia without partial as- 
phyxia. As it is under the complete control of the adminis- 
trator, any degree of anaesthesia can be produced. 
The gradual inhalation of the vapor produces less spasm 
of the glottis, and less coughing, struggling, and sickness. 
Anaesthesia is thus quietly produced and maintained, and 
there is a more rapid recovery from the anaesthetic. 
There is a great saving of the anaesthetic, as there can be 
no waste, the vapor passing directly from the bottle to the 
lungs, and there is little or no smell of the anaesthetic in the 
room. 
It will be observed, from the above report, that very few 
cases of sickness from the anaesthetic occurred. Had all the 
patients received attention before the operation, there un- 
doubtedly would have been less sickness. In the operations 
both on the mouth and nose, the inhaler was used during the 
operation. In two cases of amputation of the thigh, in which 
there was very great prostration, nitrous oxide was adminis- 
tered with good success, and neither of the patients suffered 
any depression from the anaesthetic. 
Chloroform, bichloride of methylene, and tetrachloride of 
carbon, have also been administered with this inhaling appa- 
ratus with success. XII.-PATHOLOGICAL REPORT. 
Report of the Pathological Department of Bellevue Hospi- 
tal. By J. W. Southack, Jr., M. D., Curator; E. G. 
Janeway, M. D., and Feancis Delafield, M. D., Assist- 
ant Curators. 
In June, 1866, the pathological department of Bellevue 
Hospital was reorganized and placed under the supervision of 
the present staff. Previous to that time there had been but 
eleven autopsies recorded. In the fifteen months that followed 
there were recorded two hundred and seventy-seven autopsies. 
These furnish the data for this, the first report of the patho- 
logical department. The cases extend from June 16,1866 (the 
date of the opening of the new post-mortem room), to October 
8, 1867. Especial attention is called to these dates, for, in 
classifying the various lesions in reference to the months in 
which they may have occurred, it must be borne in mind that 
the months from June to October have passed twice. 
The following is the classification that has been adopted : 
ORDER OF ARRANGEMENT. 
I. Brain and spinal cord, with membranes. 
II. Heart and vessels. 
III. Larynx, trachea, lungs, and appendages. 
IV. .zEsophagus and alimentary tract. 
V. Liver and spleen. 
VI. Kidneys. 
VII. Genito-urinary organs. 
VIII. Bones. 
IX. Cholera. 324 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
APOPLEXY OF THE BRAIN. 
Seven cases of recent extravasation of blood in or on the 
brain were observed. The post-mortem examinations in these 
cases occurred, one each in June and December, 1866, and in 
February, April, July, August, and September, 1867. Four 
of the patients were males, and three females. The ages of 
the males were as follows: 40, 45, 50, and 60 years; of the 
females, 22, 29, and 69 years. The average age of the males 
was 48f years ; of the females, 36f years. 
In three cases the extravasated blood was only found on 
the surface of the brain. In one case there was conjoined 
with a superficial extravasation, a clot in the brain, and in 
another case, softening of the brain. 
In one case the extravasation was limited to the brain, and 
in one case it was ventricular. 
Of the first class, in which the extravasation was only on 
the surface, all were males, in none of whom was there a 
fracture of the skull. 
Case I.-Age, forty years. There were about four fluid- 
ounces of blood in the cavity of the arachnoid. The anterior 
lobes were much depressed on their superior part. The 
patient had almost general paralysis of the muscles of the 
extremities, and is said to have been conscious till death. 
He had been very intemperate. The only lesion, besides the 
apoplexy, was hypostatic congestion of both lungs. 
Case II.-Age, sixty years. There was a large clot over 
nearly the whole upper surface of the left half of the cerebrum 
-a recent fracture of the right cervix femoris and an old one 
of the left were found associated with the apoplexy. The 
symptoms of apoplexy came on two days before death, and 
consisted at first in inability to protrude the tongue, and 
finally coma. Death occurred three days after the last frac- 
ture. 
Case III.-Age, forty years. There was a large clot over 
nearly the whole superior surface of the brain, and a thin clot 
over the medulla oblongata. This patient had typhoid symp- 
toms, with severe delirium, for eight days. He had ecchymoses PATHOLOGICAL EEPOET. 
325 
on the extremities, as if from injury. The only lesion besides 
the apoplexy was fatty kidney. 
Case IV.-Of the second class, the first was a female, 
twenty-two years of age. There was considerable clotted 
blood situated beneath the arachnoid, covering the superior 
portion of the right hemisphere, and also a large effusion at 
the base of the brain, compressing the pons and medulla. 
Two clots were also found in the brain. One was situated in 
the middle lobe of the left hemisphere, and was the size of a 
turkey's egg; the other, the size of a pigeon's egg, occupied 
the posterior lobe of the right hemisphere. Around the former, 
the brain was much softened. Associated with these lesions, 
were cardiac hypertrophy, the aortic and mitral valves being 
thickened and covered with vegetations, and waxy spleen and 
kidneys, there being also infarctions of these organs. The 
patient had had acute rheumatism. She died suddenly. 
Case V.-This was a male, forty-five years of age. A clot 
existed in the cavity of the arachnoid, at the base of either 
anterior cerebral lobe. These clots were small and partly de- 
colorized. The corpus striatum of left side had almost dis- 
appeared, there being a cavity in its interior. The ependyma 
of the lateral ventricle formed the roof of the cavity, and was 
perforated by a small opening. This cavity and the left lateral 
ventricle contained a small amount of opalescent fluid. The 
brain-substance around the cavity was softened and of a yel- 
lowish color. There were associated in this case, pulmonary 
apoplexy and emphysema, mitral stenosis and thickened aor- 
tic valves, with hypertrophy and dilatation of the heart, and 
fibrous kidneys. 
This patient had complete right hemiplegia, of sudden 
origin, involving motion and sensation, with impairment of in- 
tellect, nine months previous to death. The paralysis had im- 
proved, but the impairment of intellect remained. The death 
was preceded by urgent dyspnoea. 
Case VI.-In the case where the extravasation was limited 
to the brain, the subject was a female, sixty-nine years of age. 
A clot, the size of a pigeon's egg, was found in the right ante- 
rior lobe of the cerebrum, close to the lateral ventricle, and a 
smaller one in the left optic thalamus. The brain around 326 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
each was softened. The arachnoid covering the convex sur- 
face of the brain was opaque, and beneath it there was con- 
siderable serous effusion. Both lateral ventricles were filled 
with serum. There was also atheromatous degeneration of the 
arteries and of the valves of the heart, and Bright's disease of 
the kidney. 
The patient was unconscious for nine days preceding death, 
and it is stated that she retained power over her limbs for the 
greater part of this time. 
Case VII.-The case of ventricular apoplexy occurred in a 
female, twenty-nine years of age. The lateral ventricles were 
filled with a bloody serum, the third ventricle had a small clot, 
and the fourth was filled with clotted blood. The arteries were 
atheromatous. There were also tubercles of the lung and the 
spleen, and a fatty liver. The kidneys were normal. The 
patient had puerperal convulsions one day after labor, and 
died comatose four and a half hours after their first occur- 
rence. 
CYST OF THE BRAIN, RESULTING FROM APOPLEXY. 
Case I.-Of the three cases in which a cyst was found in 
the brain, one was a female, twenty-one years of age. A small 
cyst, the size of a pea, was situated in the left optic thalamus. 
The ganglion was smaller than its fellow, and square in shape. 
Its posterior border was softened, and colored yellowish red. 
The spleen and all the lymphatic glands were enlarged. The 
kidneys were fatty. She had right hemiplegia of sudden 
origin for three years previous to death. Both motion and 
sensation were affected. She recovered motor power slightly, 
but sensation was almost completely abolished. Convulsions, 
epileptiform in character, occurred from time to time. She 
died comatose. 
Case II.-The second was a male, twenty-six years of age. 
In this case there was a cyst to the outside of, and slightly in- 
volving the corpus striatum, situated in the middle lobe of the 
right hemisphere. Its size was that of a black walnut. It 
was lined by a delicate membrane, and crossed by an obliter- 
ated vessel. It contained a clear, serous fluid. The tissues 
around were of a yellowish color, but of normal consistence. PATHOLOGICAL REPORT. 
327 
The arteries were atheromatous. There was, in this case, 
cardiac hypertrophy with mitral regurgitation. The kidneys 
were fibrous and cystic. Hemiplegia of the left side, affecting 
motion and sensation, had come on one year previously. The 
patient died during a convulsion. 
Case III.-The third was a male, aged thirty-five years. 
At the base of the brain, in the middle lobe of the left side, 
was a cyst, one and three-fourths inches in diameter. The brain 
around it was firm and of a brown color. There were adhe- 
sions of the arachnoid surfaces to one another at this part, 
and also considerable subarachnoid serum on the convexity 
and in the ventricles. The patient died of cholera. 
SOFTENING of the brain. 
Only two cases of this lesion, independent of apoplexy, 
were observed. 
Case I.-This was in a female, aged sixty-two years. At the 
superior surface of the left anterior lobe of the cerebrum, was a 
small cavity, about one inch in diameter, covered by the arach- 
noid, and having a fold of pia mater dipping into it. It con- 
tained serum and softened brain-substance, and was bounded 
by brain-tissue. Coexisting with this lesion, were the follow- 
ing : hydrothorax, emphysema of the lungs, cardiac hyper- 
trophy, with thickening of, and vegetations on the aortic and 
mitral valves, fatty liver, and fibrous and cystic kidneys. De- 
lirium preceded death by coma. 
Case II.-The other case was a male, age unknown. The 
examination was made in October, 1866. There was red soft- 
ening of the left corpus striatum. The heart was hypertrophied, 
the aortic valves thickened, and the aorta atheromatous. The 
kidneys were fibrous. There was also some serum in the 
pleural cavities. The only thing known of the patient is that 
he had convulsions a short time before his death. He died 
comatose. f z, 
There were but two cases of acute meningitis. 
Case I.-The first was observed in a female, whose his- 
tory and age were unknown. The examination occurred in 
February, 1867. There was, in this case, in addition to the 
MENINGITIS. 328 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
meningitis, pneumonia with abscesses in the upper lobe of the 
right lung. Vegetations were found on the aortic valves, and 
the kidneys were fibrous. 
Case II.-The second case occurred in a male, aged forty- 
nine years. With the meningitis were associated double 
pneumonia, slight thickening of the aortic valves, and small 
bony plates in the capsule of the spleen. 
Meningitis of the subacute variety was observed in seven 
post-mortem examinations. The subjects of these examinations 
were all males, the youngest was twenty-three, and the oldest 
sixty years of age. The number dying between 20 and 30 
years, one ; 30 and 40 years, two ; 50 and 60 years, three. 
The average age was 41£ years. Of the examinations, two 
occurred in July, and one each, in September, October, and 
November, 1866, and two in May, 1867. The appearances 
which have been considered as distinctive of this variety are, 
slight opacity of the arachnoid, the occurrence of a small 
amount of fibrinous exudation on the under surface of the 
arachnoid, with a large amount of serous fluid, both suba- 
rachnoid and ventricular. 
In these cases the following complications were noted : 
In Case I.-Tuberculosis puhnonalis only. 
In Case II.-Tuberculosis puhnonalis, slight ulceration 
of the epiglottis, and atheromatous degeneration, with dila- 
tation of the aorta. 
In Case III.-Cirrhosis, and fatty liver, fatty kidneys, old 
pericardial adhesions, and calcified aortic valves. 
In Case IV.-A small abscess in the anterior mediastinum, 
fatty kidneys, and necrosis of the iliac bone, with abscess. 
In Case V.-Fibrous kidneys. 
In Case VI.-Here the lesions were numerous, viz.: small 
bony plates in the arachnoid covering the convexity of the 
brain, cardiac hypertrophy, with thickening of the aortic and 
mitral valves, slight cirrhosis of the liver, fatty kidneys, old 
peritoneal adhesions, calcareous plates in the portal and splenic 
veins, enlargement of the spleen, and ulceration of the carti- 
lages of the knee-joints, with a purulent fluid in the right 
knee. 
Case VII. was uncomplicated. PATHOLOGICAL REPORT. 
329 
Two cases of this disease were made the subject of exami- 
nations. 
Case I.-This was a male, aged twelve years. Besides the 
characteristic lesion, there was tuberculosis pulmonalis, with a 
cavity in one lung. The bronchial glands were enlarged, and 
in some the contents were cheesy, and the intestines presented 
numerous tubercular ulcers. There were also a few transpar- 
ent tubercles in the peritonaeum over the liver. 
Case II.-This was an infant, under six years of age. In 
this case there were tubercles in the lungs, liver, and spleen, 
all of semitransparent, gray, miliary variety. 
ACUTE HYDROCEPHALUS. 
Tubercles occurring in the brain or its membranes in 
adult life were observed once, in a female, aged twenty-three 
years. The examination was made in January, 1867. On 
the convex surface of the cerebrum on either side of the 
longitudinal fissure, and over the superior surface of the cere- 
bellum, were a considerable number of soft, yellow masses, 
varying in size from that of a pin's head to irregular, narrow 
tumors one-quarter of an inch in their long diameter. They 
were developed in the pia mater, but extended a short dis- 
tance into brain. In the right posterior lobe of the cerebrum 
was a similar mass, near the surface, of the size of a pea. The 
brain around it was softened. In the right corpus striatum 
were two similar masses, of the size of a split pea, around which 
were a few points of apoplectic extravasation. There was con- 
siderable serum under the arachnoid. Tubercles were found 
in the lungs, pleura, liver, kidneys, and spleen. Ulceration of 
the intestine was also noticed, with enlarged and softened 
glands in the omentum. 
TUBERCLES OF THE BRAIN. 
TUMORS IN THE BRAIN. 
Tumors of the brain were found in two instances. 
Case I.-Gummy Tumor.-A male, aged thirty-nine, died 
December, 1866. Eighteen months before, the right side be- 
came suddenly paralyzed, and he was confined to the bed for 330 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
some months. He lost the sight of one eye, and had amblyopia 
of the other eye on December 5th. Then the pupils were 
dilated, but acted to light. There was headache, and the pulse 
was 45, and full, delirium at times, then coma and death super- 
vened, December 18th. The man is said to have given a syphi- 
litic history. 
All the organs, except the brain, were normal. 
The tumor is situated in the left posterior lobe of the cere- 
brum. It is of irregular, spherical shape, and measures one and 
a quarter inches in its greatest diameter. Its upper surface 
is in contact with the arachnoid, which is thickened. The in- 
ferior surface, which is rounded, is situated in the brain-sub- 
stance, covered by a plexus of vessels, which extend a short 
distance into its substance. The brain-tissue in contact with 
it is softened and broken down. The tumor is of firm con- 
sistence, and of a white color. This white color is in some 
places opaque, at others semitransparent. The entire tumor is 
composed of a mass of granules with a few small, round cells, 
broken, and fibres here and there. In sections made after 
hardening, and treated with acetic acid, there is an appear- 
ance as if spindle-cells, far advanced in fatty degeneration, 
were arranged in parallel lines, in a granular basement-mem- 
brane. At the upper part of tumor is a portion one-eighth of 
an inch thick, consisting of bands of fibrous tissue. 
Case II.-Gllo-sarcoma.-This case occurred in a male, 
aged thirty-five years. He had chancre fifteen years ago, but 
no secondary symptoms. Two years ago he was troubled with 
occasional dizziness, lasting for a minute or so. This would 
be accompanied by slight twitchings of the limbs. A little 
later, the left side of face became paralyzed, and remained 
thus till October, 1866, when he had slight hemiplegia. This 
soon disappeared. Facial paralysis remained until death. 
In January he became suddenly blind. Attacks of vertigo 
increased constantly after admission into the hospital. For 
three days preceding death he was semi-comatose. He was 
comatose for ten hours, and died, February 14th. 
The brain was the only part allowed to be examined. 
There is a tumor embracing the whole thickness of the 
posterior lobe of the right hemisphere of the cerebrum, of an PATHOLOGICAL EEPOET. 
331 
irregular ovoid shape, two and a half inches in its greatest 
diameter. The pia mater and arachnoid covering it are thick- 
ened and adherent, and over the superior surface, the dura 
mater is also adherent. 
The tumor is tolerably well defined from the surrounding 
brain-substance, the latter being broken down into a softened 
and diffluent mass. This softening embraces, though to a 
less degree, the whole posterior half of the cerebrum. The 
tumor is of a yellowish, opaque, white, color, mottled with por- 
tions of a grayish color. The white parts are quite firm and 
resistant, while the grayish portions resemble in consistence, as 
in color, the gray matter of brain. The grayish portions 
consist: 
1. Of a large number of blood-vessels, for the most part 
filled with blood. 
2. A great number of small cells resembling those found in 
the neuroglia. They are mostly round or oval, slightly granu- 
lar, -g-gVo °f an inch in diameter, rather like nuclei than cells. 
About some of these nuclear cells are small, pale cell-bodies. 
There are also some cells similar in appearance to these, but 
larger, the cell-body better defined, measuring -^0 0 of an inch 
in diameter and containing a single nucleus, of an inch 
in diameter. 
3. In hardened sections, that have been brushed out, there 
is seen a delicate fibrous net-work, in the meshes of which the 
cells are held. As we pass from the gray to the yellow por- 
tions of the tumor, the vessels diminish in number and finally 
disappear. The cells become fatty, and, in the parts which 
are quite opaque and yellow, nothing can be seen but a mass 
of fine granules. 
On the inferior surface of the right posterior lobe of the 
cerebrum, are a number of haemorrhagic spots. 
SOFTENING OF THE SPINAL COBD. 
This lesion was observed in two cases. 
Case I.-This was a male, twenty-eight years of age. The 
cord, from the sixth dorsal vertebra to near its termination, 
was diffluent and creamy. The arachnoid was adherent to the 332 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
dura mater, and this, thickened and vascular, was fused with 
the posterior common ligament. 
There was extensive caries of the bodies and transverse 
processes of the sixth, seventh, eighth, and ninth dorsal ver- 
tebrae, and also of the adjoining ends of the ribs. The body 
of the seventh vertebra was broken in half, and the fragments 
projected into the canal, occupying about one-fourth of its 
calibre. There was, on either side of the vertebral column, 
corresponding to the sixth, seventh, and eighth vertebrae, an 
abscess situated beneath the pleura. The lungs were firmly 
adherent at these points, and only moderately so over the rest 
of their surface. There were also effete tubercles in the lung, 
cretaceous and cheesy. 
The kidneys and the spleen were waxy. 
The legs were flexed on the thighs, and the latter on the 
abdomen. One thigh was firmly adducted over the abdomen, 
and the other rested on it. The muscles were contracted, 
and it was only by their section and by extreme force that the 
legs could be straightened after death. 
In the history of the case, it is stated that the patient had 
injured himself in lifting. This act was followed by pain in 
the dorsal region of the spine. Two weeks later, he noticed 
slight paraplegia affecting motion and sensation. In three 
months this had become complete. During this time he had 
reflex movements. Afterward, there were spasmodic move- 
ments, flexing the legs on the thighs and the thighs on the 
abdomen. Gradually the legs became fixed in their position. 
Case II.-This was in a female, thirty-four years of age. 
The examination was made in October, 1867. 
In this case there was white softening of the spinal cord, 
more marked in the anterior than in the posterior columns. 
The centre of the softening was opposite the ninth dorsal ver- 
tebra; and opposite this point the cord was diffluent. The 
length of the softened portion was two and a half inches. The 
only other lesions were crude tubercle of the lungs and cys- 
titis. In this case there was gradually progressing paraplegia 
of motion and sensation. The legs became contracted and 
anaesthetic. The duration of the disease was four months. A PATHOLOGICAL REPORT. 
333 
short time previous to death, she had an attack of dysentery, 
from which she recovered, but died of debility induced by it. 
PEKICAKDITIS. 
This lesion was found in ten post-mortem examinations. 
They were distributed over the different months, in the follow- 
ing order: one in July, and one in November, 1866 ; one in 
January, three in February, one in April, two in May, and 
one in June, 1867. 
Six times it was found in males and four times in females. 
The youngest was twenty-six, and the oldest, sixty-two years 
of age. 
Death occurred between 25 and 35 years in 3. 
" " " 25 " 45 " 3. 
" " " 45 " 55 " 3. 
" 11 " 55 " 65 " 1. 
The average age was 42 J years. 
The product of the inflammation was, in eight cases, sero- 
lymph, and in only one case was it of sufficient amount to 
distend the sac. Once the effusion was bloody, and in another 
case, purulent. 
In two cases there were evidences of a previous inflamma- 
tion. In five cases the aortic and mitral valves were slightly 
thickened, and once there was associated, thickening of the 
tricuspid valves. In three instances this was evidently due to 
a recent inflammation, while in the other two it had been of 
some duration. 
There were associated with the pericarditis, in several cases, 
more than one of the attributed causes of the disease. Hence 
it has appeared better to give the complications in the different 
cases as follows: 
In the first case.-Double pneumonia and pleurisy, fatty 
kidneys, hepatitis gummosa, and erysipelas of face. 
In the second.-Single pneumonia, double pleurisy, and 
fibrous kidneys. 
In the third.-Purulent peritonitis, cirrhosis of liver, fatty 
kidneys, and pus in one of the knee-joints, with increase of the 
synovial fluid in the other. This case is the one mentioned as 
having purulent fluid in the pericardium. 334 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
In the fourth.-Empyema (left pleural sac), fibrous kidneys, 
and cirrhosis of liver. 
In the fifth.-Pneumo-hydrothorax on the right side, pleu- 
risy on the left side, with slight serous effusion, and tubercu- 
losis involving the lung, pleura, peritonaeum, and kidney. 
In the sixth.-Carcinoma of the right kidney, and fibrous 
degeneration of the left. 
In the seventh.-Emphysema of the lungs, and fatty kid- 
neys. 
In the eighth.-Emphysema of the lungs, fibrous kidneys, 
circumscribed softening of the brain, and vegetations on the 
valves of the left heart. 
In the ninth.-Phthisis, pleurisy on the left side, and ery- 
sipelas of the face. 
In the tenth.-Pneumonia, and fibrous kidneys. 
RECENT ENDOCARDITIS. 
This affection was only noticed in four cases. 
Case I.-A female, age doubtful. The endocarditis af- 
fected the mitral and tricuspid valves. The heart was other- 
wise normal. The liver and kidneys were fatty. 
Case II.-A female, aged forty. The mitral, tricuspid, 
and pulmonary valves were affected, the aortic valves being 
calcified. The heart weighed eighteen oz. and there was re- 
cent pericarditis. Hydrothorax, ascites, anasarca, and oedema 
of the lungs, with a slight pneumonia, and fibrous and cystic 
kidneys, were the complications. 
Case III.-A female, aged forty-eight. The disease af- 
fected only the aortic valves. There coexisted, pericarditis, 
pleurisy, phthisis, and facial erysipelas. 
Case IV.-A female, aged forty. The disease affected the 
aortic, mitral, and tricuspid valves. The heart weighed twenty 
oz. The complications in this case were pericarditis, pneu- 
monia, and fibrous and cystic kidneys, with ascites and oedema 
of the legs. 
VALVULAR LESIONS. 
Malfor mations.-Two cases of malformation "were ob- 
served. The first was one in which there were four pul- PATHOLOGICAL REPORT. 
335 
monic valves. The patient was a male, forty-five years of 
age, who died of general tuberculosis. In the second, there 
were two aortic valves. One leaf was as large as two ordi- 
nary valves, and at its base a thick band, extending from 
the valve to the arterial wall, and reaching one-third the 
height of the valve, divided it into two equal segments. The 
valves were slightly thickened. The heart was otherwise nor- 
mal, and weighed eight ounces. The patient was a male, 
twenty-seven years of age, and died of Bright's disease. 
Aortic Valves.-1The aortic valves were only once diseased 
alone to a marked extent. This case will be referred to again, 
under the head of vegetations. It is the one in which there 
was a rupture of the valve. 
Mitral Valves.-These valves were alone affected in nine 
cases, six times in females and three times in males. The ex- 
aminations occurred in the following months, two in July and 
in November, 1866, and one each in March, April, May, and 
June, 1867. The age of two of the patients could not be 
ascertained. Of the remaining seven, the youngest was a 
male of seventeen; the eldest a female of fifty years. The ages 
of the other females were respectively, twenty-two, twenty- 
three, of two, thirty-eight years, and of the remaining male, 
forty-nine years. The average age of these seven cases is 
33f years. There was marked stenosis of the orifice, due to 
thickening of the valves and adhesion of their edges, in three 
cases. In two of these cases the valves were also insufficient. 
In all of the remaining cases the valves were more or less thick- 
ened and insufficient. In but one case was there any calcific 
change in the valves; and this occurred in the youngest sub- 
ject, together with marked stenosis of the orifice. 
The weight of the heart, in seven of the cases, ranged be- 
tween 14 and 21^ oz., the average being 17| oz. Dilatation 
coexisting with hypertrophy occurred in two cases, affect- 
ing the auricles and the right ventricle. In two of the cases 
there was evidence of an old pericarditis. In one case the 
pulmonary artery was somewhat dilated, and in this case the 
valves were much thickened and insufficient. 
In three of the cases it was ascertained that there had been 
previous attacks of acute articular rheumatism. 336 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Complications.-In seven of the nine cases there was 
serous effusion in some part of the body. In three there were 
hydrothorax, ascites, anarsarca, and oedema of the lungs. In 
one, hydro-pericardium coexisted with these. In another there 
were oedema of the lungs, anasarca, and ascites; while in the 
remaining two there was merely oedema of the lungs. 
The kidneys were fibrous and cystic twice, while in the 
third case there was no marked change. In the next case they 
were fatty, and in the remaining cases they were fibrous once, 
fibrous and fatty once, and waxy once. 
Of the cases where there was no dropsical effusion, the kid- 
neys were once the seat of numerous abscesses, and in the 
other were fibrous. 
The lungs were twice affected, in one case, with multiple 
abscess, and in a second, with pneumonia. The liver was twice 
much congested, twice fatty, once waxy and fatty, and in one 
case each, the seat of gummata, cirrhosed, and granular. 
Infarction of the spleen and kidneys occurred in one case, 
as did also apoplexy, and an old apoplectic cyst of the brain. 
The two former lesions were associated with vegetations. 
Lesions of the Aortic and Mitral Valves.-These valves 
were found affected in the same subject in eight examinations. 
These examinations were distributed in the different months, 
in the following order: One each in June, July, December, 
1866, and in February, April, and July, 1867, and two in 
January, 1867. Six of the patients were males and two fe- 
males. The youngest was twenty-five, and the oldest sixty- 
two years of age. The average age was 45£ years; and exclud- 
ing the females, aged respectively fifty and sixty-two years, it 
was 41f. 
In two of the cases both valves were thickened, and in one 
of these there was mitral insufficiency. Twice the mitral 
valves were thickened, the aortic being calcareous and thick- 
ened. Once the mitral valves were calcified, with marked 
stenosis of the orifice, the aortic being thickened. In the re- 
maining four cases both valves were calcified. In two of these 
cases there was stenosis of, and insufficiency at the mitral ori- 
fice. In two cases there were several small, round perfora- 
tions of the aortic valves near their free extremity. The calci- PATHOLOGICAL REPORT. 
337 
fication was less marked in the females than in the males, and 
the average age of those in whom it was most marked was 
much less than that of those in whom it was but slight or did 
not exist. 
The heart was hypertrophied in all of these cases. The 
heaviest weighed thirty-one and the lightest sixteen oz. The 
average weight was 21f oz. for all; 22f oz. for males, and 17 
oz. for females. In two of the cases all of the cavities were 
dilated. There was recent pericarditis in one case, and in 
another there were bony plates in the pericardium and adhe- 
sion of the pericardial surfaces. In only one of these eight 
cases is rheumatism mentioned as having occurred previously. 
Complications.-In five of the eight cases there was drop- 
sical effusion in some part of the body. Twice it constituted 
a marked effusion under the arachnoid of the brain, and in one 
of these, also in the ventricles. Hydrothorax occurred four 
times, ascites four times, oedema of the lungs twice, anasarca 
four times. There was an apoplectic effusion in the brain in 
one case, and a spot of circumscribed softening in another. 
Pulmonary apoplexy occurred twice, pneumonia once, and 
emphysema of the lungs twice. 
The liver was fatty in two cases. The kidneys w'ere in 
three cases fatty, and in five, either fibrous or fibrous and cystic. 
One of the patients died of cholera. 
Lesions of the Aortic, LLitral, and Tricuspid Valves.- 
These valves were simultaneously affected in four cases. 
The examinations were distributed over the following months : 
one in December, 1866, and in January, August, and Octo- 
ber, 1867. Three were males and one was a female. The 
latter was the youngest, being twenty-three years of age. The 
age of one of the males was unknown: and that of the two 
others was, respectively, fifty and sixty-seven years. There was 
thickening of the valves in all of these cases, twice associated 
with tricuspid and mitral insufficiency. In these two cases all 
the cavities were dilated, and the heart itself was hypertrophied. 
One weighed twenty-seven and the other twenty-one oz. In the 
first case there had been previous rheumatism, the pericardium 
was adherent over the whole heart, and pneumonia and fatty 
liver and kidneys coexisted. The dropsical effusion was 338 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
limited to anasarca and ascites. In the second there was em- 
physema of the lungs, fatty and cirrhosed liver, and fatty kid- 
neys, with subarachnoid serum, hydrothorax, ascites, and ana- 
sarca. The aorta was atheromatous and uniformly dilated. 
The two others will be already referred to under the head of 
vegetations: one, thirteen oz. in weight, had vegetations on 
the aortic and mitral valves, associated with infarctions of the 
spleen, and peritonitis. The other weighed fifteen oz., and 
presented vegetations on the aortic and mitral valves, these 
valves being insufficient at both orifices. 
Lesions of the Aortic and Pulmonary Valves.-These 
valves were found thin and fenestrated in two female patients 
who had died of cholera. Each was thirty-five years of age, 
and had no other cardiac lesion. , 
There was but one other case in which these valves were 
simultaneously affected ; viz., in a male, aged forty-eight years. 
The aortic valves were thickened and rigid, and one leaf of the 
pulmonary valves had a small round rupture. Both ventricles 
were dilated, the left more than the right. Pleurisy, pneu- 
monia, pulmonary apoplexy, and emphysema of the lung co- 
existed in this case. The kidneys were fatty. The pneu- 
monia was of the circumscribed form. With these there was 
considerable serum beneath the arachnoid and in the ventri- 
cles of the brain. 
VEGETATIONS ON THE VALVES OF THE HEART. 
Vegetations were found on the valves of the heart, fourteen 
times ; ten times in males, and four in females. 
They occurred between the age of 20 and 30 years 4 times. 
" " 30 " 40 " 3 " 
" " 40 " 50 " 3 " 
" " 50 " 60 " 2 " 
At 62 years in 1 case. 
They existed on the mitral valves alone three times, and 
on the aortic valves alone six times; while in five instances 
they occurred on both the aortic and mitral, and in one of these 
cases also were attached to the wall of the left auricle. Only 
three times did they attain a large size, twice at the aortic 
orifice, and once at the mitral. This latter was, however, PATHOLOGICAL EEPORT. 
339 
more of a heart-clot than a true vegetation, and was attached 
to one of the chordae tendineae. Three times they existed inde- 
pendently of any valvular lesion. 
In the first of these cases, they were associated with dysen- 
teric ulcers in the colon; in the second, with pneumonia and 
abscess of the lung, and acute meningitis; and in the third, 
with fibrous and cystic kidneys. In two of the cases, where 
they were coexistent with valvular lesions, they were attached 
to the aortic valves, while the disease affected the mitral; 
there being in one case a marked stenosis, and in the other, 
somewhat shortened, thickened, and insufficient valves. In all 
the other cases they were associated with thickened, and in two 
instances, also with calcified valves. In one instance the vege- 
tations were due to a rupture of one leaf of the aortic valves, 
these being thickened, and having attained such a size as al- 
most to occlude the openings. There were also a few vegeta- 
tions on the mitral valves. Six times the heart was hypertro- 
phied, but, with one exception, there were other causes to 
account for the enlargement. In the exceptional case the 
vegetations were sufficient in amount almost to block up the 
aortic orifice, rough, evidently of long duration, and growing 
from valves slightly thickened. The heart weighed one lb. ten 
oz. Coexistent in this case there was an enlarged spleen, 
which displaced the heart in an upward direction somewhat 
to the right. During life the diagnosis in this case had been 
aneurism of the arch of aorta, as there was dulness, impulse, 
and a double murmur situated at the second costal cartilage 
on the right side. 
The following lesions of other organs were found in these 
cases, and have probably some relations to them : 
Abscess of the thyroid gland, one ; pneumonia, one; pneu- 
monia and abscess of the lung, one; acute meningitis, one; 
apoplexy, two ; circumscribed softening of the brain, one ; 
bloody serum, subarachnoid, two; haemorrhagic spots, lung, 
one ; of intestine, one ; infarctus of the spleen, four ; cicatrix 
in the spleen, one; infarctus of the kidney, two; peritonitis, 
one. In this case the peritonitis was due to the rupture of 
a dirty, sloughy-looking cavity in the spleen, which was asso- 
ciated with other evidences of infarction. 340 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
The following diseases were also noticed in these cases : 
Three times the kidneys were fatty, and three times waxy. 
The liver was twice fatty, and twice it and the spleen were 
waxy. Tuberculosis pulmonalis existed in two cases. Inter- 
mittent and remittent fever existed each in one case at the 
time of death. Rheumatism had occurred previously in three 
of the cases. 
VASCULAR POLYPUS OF THE HEART. 
The following case of polypus of the heart it seems best 
also to describe in this connection : 
Mr. , aged about thirty-five years, was picked up in an 
apparently intoxicated state, in the street, December 29,1866. 
He died in the station-house, at 10 p. m. 
Autopsy by Dr. Wooster Beach, Jr. The body was well 
formed and wrell nourished. The brain and its membranes 
were normal. 
Heart.-The pericardium was distended by fluid to such 
an extent as to occupy a large portion of the thorax. There 
was also a large amount of recent inflammatory exudation 
over the whole pericardium. The left auricle and mitral 
valves were normal; the left ventricle normal; and the aortic 
valves, slightly atheromatous. In both there was a moderate 
amount of dark, coagulated blood. The right ventricle was 
much enlarged; the pulmonary valves, normal. The auricular 
ventricular orifice was very large; and the tricuspid valves, 
rough and thickened, wTere folded back against the ventricular 
wall, and adherent. The right auricle was much enlarged. 
Attached to its inner surface, about half an inch from the 
auriculo-ventricular opening, were two polypi. One, of nearly 
spherical form, two and a half inches in its greatest diameter, 
with a very small pedicle, was formed of yellowish, translu- 
cent, elastic tissue, with one or two spots of calcareous degenera- 
tion. It was entirely contained in the auricle. The second, situ- 
ated close to the first, was three and a half inches long, of ovoid 
shape, mostly calcareous, with the lower end broken and rugged, 
and looking as if pieces had been broken off from it. Its lower 
end protruded through the auriculo-ventricular opening into 
the ventricle. On the surface of both, when fresh, vessels filled PATHOLOGICAL REPORT. 
341 
with blood were seen by the naked eye by many observers. 
From the outer surface, a thin membrane could be dissected 
up, consisting of a delicate lace-work of fibres, with a few 
spindle-cells. The mass of the tumors consisted of blood-ves- 
sels, some still containing blood, and cells, spindle-shaped, star- 
shaped, round, and oval, of an inch in diameter, most 
of the cells slightly fatty; fibres, in broad bands; and a transpar- 
ent, homogeneous, finely granular basement-membrane. The 
calcareous portions, on the addition of sulphuric acid, gave off 
bubbles of gas, and presented acicular crystals. One of the 
branches of the pulmonary artery was plugged up by a calcare- 
ous mass. The artery was thinned, as if the mass had been 
there for some time. 
Lungs.-The lungs were adherent to the pericardium and 
costal pleura; otherwise they were normal. 
Kidneys.-1These were fatty. 
Liver.-This organ was in an advanced stage of cirrhosis. 
One case of this lesion was observed. It occurred in a 
male, fifty years of age. He had complained of vomiting, 
debility, and dyspnoea, for seven months previous to his 
death. He had also oedema of the legs, without albuminous 
urine or casts. Later in the history of the case, congestion 
and oedema of the lungs were developed. The heart was en- 
larged, and there was a systolic murmur at the apex. The 
patient died comatose, two days after admission, having been 
in that condition six hours. 
The autopsy was made November 7,1866. 
There was opacity of the arachnoid, with a large amount of 
subarachnoid and ventricular serous effusion. The brain was 
normal. The lungs were somewhat congested. The left lung 
was pushed back by the enlarged heart, and was firmly ad- 
herent to the pericardium and the thoracic wall. Otherwise 
the lungs were normal. The pericardium was adherent to the 
heart over its whole surface. The heart was enlarged, its walls 
thickened, and its cavities somewhat dilated, more markedly in 
the left ventricle. An aneurism, about the size of a man's fist, 
existed at the outer and upper part of the left heart. It was 
ANEURISM OF THE HEART. 342 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
placed against the outer wall of the left ventricle and auricle, 
and extended downward to within two inches of the apex, and 
upward so as to be above the summit of the auricle. The com- 
munication with the heart was situated in the outer wall of 
the left ventricle, one inch from the septum ventriculosum, 
three-quarters of an inch below the aortic valves, and just to 
the outer side of the chordae tendineae going from the ante- 
rior papillary muscle. The opening was 1^ inches long, by 
half an inch wide, its direction being downward and back- 
ward, and its posterior half obstructed by the chordae tendineae 
and the extremities of the musculi papillaries above mentioned. 
The walls of the aneurism were one-eighth of an inch thick, 
and were composed of laminated fibrin and fibrous tissue. It 
was covered by adherent pericardium. The mitral and aortic 
valves were slightly thickened. The aorta was uniformly di- 
lated and markedly atheromatous. 
The liver was much congested, of the appearance described 
as nutmeg. 
The kidneys weighed oz., and did not appear diseased. 
AORTIC ANEURISMS. 
Sacculated aneurism of the aorta was found in five cases. 
In one case there were two aneurisms-one of the thoracic, 
the other of the abdominal aorta. Only one of these six was 
of the true variety. The rest were consecutive. These cases 
were as follows: 
Case I.-Male, aged forty-five. There were two aneu- 
rismal tumors. The first, situated on the descending thoracic 
aorta, was round, three inches in diameter, and reached from 
the seventh to the ninth dorsal vertebra, inclusive. It had con- 
siderably eroded the bodies of the eighth and ninth vertebrae. 
It communicated with the aorta by an opening in its posterior 
wall, the size of the end of the finger. The second was a very 
large tumor which occupied a great part of the left side of the 
abdomen, measuring thirteen inches in length, seven and a 
half in width, and five in thickness. Its apex extended to the 
ninth rib, and its base was at the pelvis. It had eroded the 
bodies of the eleventh and twelfth dorsal, and the first, second, 
and third lumbar vertebrae. The communication with the PATHOLOGICAL REPORT. 
343 
aorta was by an opening in the posterior wall of the vessel, one 
and a half inches long, and about three-eighths of an inch wide. 
It was situated opposite to the point of origin of the cceliac 
axis. 
Case II.-Male, aged thirty-seven years. In this case the 
aneurism formed a large tumor situated partly within and 
partly without the chest, on the right side. The aorta was 
enormously dilated from its origin to the innominate artery. 
The tumor within the chest measured twenty inches in cir- 
cumference. Outside of chest it was twenty-five inches in cir- 
cumference at its base. The portion outside of the chest 
formed a flattened conical projection, occupying the right 
mammary region. The third and fourth ribs were com- 
pletely absorbed for four inches, commencing a little back of 
their cartilages. The direction of the tumor was outward and 
to the right. The heart was normal, and was displaced to the 
left. The right lung was so compressed as to sink in water. 
The left lung was normal, with the exception of a slight hepa- 
tization at the apex. The trachea was merely displaced to 
the left. The liver and kidneys were fatty. 
This aneurism was ascribed by the patient to an injury pro- 
duced by a bale of cotton falling on his back. The aneurism 
involved the whole ascending arch, but was principally 
marked at the point of pericardial attachment. 
Case III.-Female, aged twenty-six years. This was an 
aneurism al tumor of the size of a large orange, situated a little 
to the left of the median line, and extending upward and back- 
ward. It involved the whole of the transverse arch, and was 
firmly adherent to the vertebrae. The left lung was pushed 
back. The only compression was exerted on the pulmonary 
artery, a little above its origin. It would admit the little fin- 
ger with difficulty. The left pneumogastric nerve was em- 
bedded in the tumor. The liver was fatty, and the kidneys 
fibrous. The legs were oedeinatous. 
Case IV.-Male, aged sixty-three years. This was a true, 
fusiform dilatation of the aorta, reaching from one inch above 
its origin to the termination of the transverse arch, was of 
size of a man's fist. The aorta was very atheromatous. The 
pericardium was adherent, with bony plates developed in it. 344 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Adhesions of peritoneal surfaces and small bony plates in the 
capsule of the liver and spleen also existed. The kidneys 
were fibrous and fatty. Death was the result of oedema of 
the lungs. The patient had acute rheumatism three years 
before. 
Case V.-Male, aged thirty-four years. This aneurism was 
situated in the abdomen. It extended from the eleventh dor- 
sal to the third lumbar vertebrae, and there was also a large 
secondary tumor on either side of the spinal column. On the 
right side.it was covered by the psoas muscle, and had for its 
posterior wall, the vertebrae. On the left side, at its lower 
part, it had developed itself in the psoas muscle. Its length 
was four inches, by three in width on either side, and three 
and a half inches long on the vertebral column. The bodies 
of last dorsal and first and second lumbar vertebrae were par- 
tially eroded, but the intervertebral cartilages were intact. 
At its upper part it was covered on either side by the 
diaphragm, and on the right side a rupture had taken place 
into the right pleural sac, capable of admitting two fingers, 
and through this the blood had been discharged, completely 
filling the sac. The communication with the aorta was in its 
posterior wall. It was round, and half an inch in diameter. 
This opening was situated just above the point of origin of 
the coeliac axis. All the other organs were healthy. There 
was merely a slight deposit of atheroma in aorta just above 
the aneurism, and none elsewhere. The liver in this case was 
pressed downward and forward. 
RUPTURE OF THE AORTA. 
This accident was observed in one case, viz.: 
A female, apparently about forty-live years, who was found 
dead in the street, with bruises on her legs and thighs. The 
aorta was ruptured transversely for one-half of its circumfer- 
ence, just above the valves. The pericardium was torn over 
the anterior surface of the heart, from the apex to the base. The 
left pleural sac was nearly full of blood and clots. The aorta 
was atheromatous, and the kidneys were far advanced in fatty 
degeneration. PATHOLOGICAL REPORT. 
345 
There are four cases recorded of ulceration of the larynx. 
In three of these cases the patient died with pulmonary phthisis. 
There were ulcers on the epiglottis and larnyx,' with thick- 
ening of the chordae vocales, and in one case there were also 
ulcers in the trachea. 
The other case occurred in a female presenting symptoms 
of constitutional syphilis. The epiglottis, chordae vocales, and 
nearly the entire internal surface of the larynx, were the seat 
of extensive ulcerative and inflammatory processes, so that the 
parts were completely deformed. 
There is one case recorded of ulceration of the trachea 
alone. It occurred in a female, twenty-one years old, who 
died with pulmonary phthisis. The ulcers were small, round, 
their edges sharply marked, and were found from just below 
the larnyx, down to the commencement of the bronchi. 
There is one case of abscess in the thyroid body. It occurred 
in a female, twenty-three years old, who suffered from exten- 
sive disease of the aortic and mitral valves of the heart, with 
Bright's disease of the kidneys, and died writh oedema of both 
lungs and both pleural cavities nearly full of serum. Ten 
days before her death a tumor was noticed over the trachea 
and just above the notch of the sternum. This tumor was 
painful, tender, and appeared to seriously embarrass respira- 
tion. It gradually increased in size up to the time of her 
death. She died with all the symptoms of impeded respira- 
tion. After death, besides the lesions of the heart, kidneys, 
and lungs mentioned above, the thyroid body wTas found en- 
larged to the size of a child's fist, and in it was an abscess con- 
taining rather more than four ounces of fluid pus. 
LARYNX AND TRACHEA. 
LUNGS PNEUMONIA. 
There are recorded forty-five cases of pneumonia. Of these, 
twenty-six were in males, nineteen in females. Thirteen cases 
were in persons under thirty years old; fourteen cases in per- 
sons between thirty and forty; twelve cases in persons be- 
tween forty and fifty ; four cases in persons between fifty and 
sixty; two cases in persons between sixty and seventy. Six- 346 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
teen cases occurred during the winter months; sixteen cases 
during the spring months; six cases during the summer months; 
and seven cases during the autumn months. There are ten 
cases of pneumonia affecting both lungs, all between the 
ages of nineten and forty-eight. Of these ten cases, in five the 
entire right lung, in four the entire left lung, and in one the 
lower lobe of each lung, was hepatized. In eight of the cases 
the hepatization was both of the red and gray varieties, and in 
two cases it was only of the red variety. Of these two cases, 
one was in a woman, twenty-two years old, who died of puer- 
peral peritonitis, with red hepatization of the lower lobes of 
both lungs and an effusion of purulent serum in both pleural 
cavities. The other was in a boy of nineteen, who died with 
purpura hsemorrhagica, pericarditis, and red hepatization of 
portions of the upper and middle lobes of the right lung, and 
of nearly the entire upper and lower lobes of the left lung, 
the hepatization being of a much darker-red color than is 
usual. In all the cases there were fresh lymph on the pleural 
surfaces of the lungs and variable amounts of serum in the 
pleural cavities. In two cases there was advanced Bright's 
disease of the kidneys. In one case there was marked em- 
physema of both lungs, and two small pulmonary apoplexies 
in the lower part of the upper lobe of the right lung, sur- 
rounded by the hepatized structure. In one case there were 
a number of small, circumscribed, cheesy infiltrations of the 
upper lobe of the left lung. This lobe was not affected by 
the pneumonia. 
There are twenty-seven cases recorded of pneumonia affect- 
ing a single lung. Of these, seventeen occurred in the right 
lung, and ten in the left lung. Of the seventeen cases in which 
the right lung was affected, in seven the upper lobe alone, in 
two the lower lobe alone, and in eight all of the lobes, were 
involved. 
Of the seven cases in which the upper lobe alone was in- 
volved, in five there was both red and gray hepatization, and 
in two, red hepatization alone. Of the two latter cases, one 
was in a man, thirty-four years old, who presented the lesions 
of pericarditis, double pleurisy, and hepatitis gummosa; and 
the other was in a man, thirty-five years old, who presented PATHOLOGICAL REPORT. 
347 
the lesions of double pleurisy and Bright's disease of kidney. 
Of the live cases in which both red and gray hepatization ex- 
isted, all exhibited recent pleuritic exudation; one case died of 
cholera; three cases had Bright's disease; one case presented 
insufficiency of the mitral valves ; one case, pericarditis ; and 
one case, acute meningitis, and in the hepatized lung, four 
small cavities from one-fourth of an inch to one and a half 
inches in diameter, some containing pus, some a grangrenous, 
shreddy material; but no tubercles wTere present. 
Of the two cases in which the right lower lobe alone was 
affected, in one there -was red hepatization alone, in the other, 
red and gray hepatization. The former -was in a woman, thirty 
years old, who died of puerperal peritonitis; and the latter 
w'as in a man, fifty-five years old, who also exhibited the lesions 
of vesicular emphysema, calcification of the aortic valves and 
hypertrophy of the heart, and cystic disease of the kidneys. 
Of the eight cases in which all the lobes of the right lung 
were affected, in all both red and gray hepatization -were found. 
In three of the cases the upper lobe was gray, while the mid- 
dle and lower lobes were red; in one case the middle lower lobes 
w'ere gray, while the upper lobe was red ; and in the other four 
cases both red and gray hepatization were found in each of 
the lobes. In two of these cases there was a fatty liver and 
fatty kidneys; in one, fatty kidneys; in one, calcification of 
the aortic valves; in one, remittent fever; and in two, old 
cheesy, tubercular deposits at the apex of the lung. 
Of the ten cases in which the left lung was affected, in three 
the upper lobe alone, in four the lower lobe alone, and in three 
both the lobes, were involved. 
Of the three cases in which the upper lobe was affected, in 
all there were both red and gray hepatization and recent pleu- 
risy. In one case hypertrophy of the heart and Bright's disease 
were present. 
Of the four cases in which the lower lobe alone was affect- 
ed, in two there was red hepatization alone, and in two, both 
red and gray hepatization. Of the two former, in one there 
■were present, also, vesicular emphysema and Bright's disease, 
and in the other, acute peritonitis. Of the two latter, in one 
there were aortic and mitral insufficiency, fatty liver and fatty 348 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
kidneys; and in the other there were oedema of the lungs, 
cirrhosis of the liver, and Bright's disease. 
Of the three cases in which both the lobes of the left lung 
were affected, one was in a woman, twenty-eight years old, who 
died of metro-peritonitis after child-birth, the entire lung being 
in a condition of red hepatization. One was in a man, twenty - 
nine years old, who died with vesicular emphysema of the lungs 
and waxy degeneration of the liver and kidneys. The entire 
upper and part of the lower lobe were in state of red hepatiza- 
tion, the color was unusually bright, and the cut surface very 
smooth and more granular. Microscopical examination showed 
the air-cells tilled with the usual corpuscles. The third case 
was in a woman, forty-five years old; and here, also, the entire 
upper and part of the lower lobe were in a state of red hepa- 
tization. Old, cheesy, tubercular deposits were found at the 
apex of the right lung. 
Lobular pneumonia has occurred in eight cases, all of them 
adults. The cases were as follows : 
Case I.-A woman, fifty years old, who died with the 
symptoms of pyaemia, had insufficiency of the mitral valves, 
abscesses in the subcutaneous cellular tissue in various parts 
of the body, double pleurisy with serous effusion, infarction 
of both kidneys, and circumscribed spots of pneumonic infil- 
tration, some yellow and cheesy, and some softened in their 
centres, scattered through both lungs. 
Case II.-A man, twenty-four years old, had gangrene of 
both feet after exposure to severe cold. The lower lobe of the 
right lung was hepatized (red), and in the upper lobe of the left 
lung are four small, circumscribed pneumonic infiltrations, 
their centres softened. 
Case III.-A woman, fifty years old, in whom a portion of 
the ilium was necrosed and surrounded by an abscess of some 
size, the abscess passing through the obturator foramen a 
short distance down the thigh. There was thrombosis of the 
internal iliac vein extending up and into the common iliac 
vein. Circumscribed spots of yellow pneumonic infiltration, 
some of them softened, were scattered through both lungs. 
Case IV.-A man, forty years old, having a recent fracture 
of the humerus, acute peritonitis, infarctions of both kidneys, PATHOLOGICAL report. 
349 
pleurisy with serous effusion on both sides, and circumscribed 
pneumonic infiltrations, some cheesy, some softened, in the 
upper lobes of both lungs. 
Case V.-A man, forty years old, having an abscess over 
the lower part of the scapula, infarction of the spleen and kid- 
neys, and circumscribed pneumonic infiltrations, with white 
centres and dark-red edges, in both lungs. 
Case VI.-A man, sixty-two years old, having Bright's 
disease of the kidneys, red hepatization of the lower lobe of 
the right lung and in the upper lobes of both lungs, a number 
of small cavities the size of a chestnut, containing a white, 
puriform fluid, and surrounded by indurated lung-tissue. There 
were no tubercles, gray or yellow, in either lung. 
Case VII.-A man, thirty-two years old, who died of 
acute dysentery and peritonitis. Throughout both his lungs 
were numerous small spots of lobular pneumonia, showing all 
the gradations from red to cheesy hepatization. More of 
them were softened. 
Case VIII.-A man twenty-seven years old, with aortic 
insufficiency, Bright's disease, a large abscess in the cellular 
tissue surrounding one kidney, serous effusion in both pleural 
cavities, gray miliary tubercles in both visceral and costal 
pleura, and in the upper lobe of the left lung and all the 
lobes of the right lung, circumscribed, cheesy, pneumonic in- 
filtrations, more of them softened. There were no gray or 
yellow tubercles of the lungs. 
Exclusive of cases of phthisis pulmonalis, old pleuritic ad- 
hesions were observed in thirty cases, seven times on the left 
side alone, eleven times on the right side alone, and twelve 
times on both sides. They occurred in persons dying of 
diseases having no connection with the pleuritic lesions. The 
coexistence of Bright's disease of the kidneys was observed in 
eleven cases. 
Recent pleurisy, not accompanying pneumonia or phthisis, 
occurred in six cases, twice on the left side alone, twice on the 
right side alone, and twice on both sides. In five of the cases 
there was Bright's disease of the kidneys ; in one case, acute 
PLEURISY. 350 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
pericarditis, in one, acute peritonitis, and in one, pulmonary 
apoplexies in both lungs. In two of the cases the pleural 
cavity was nearly filled with serum, so as to compress the lung 
against the spine. Empyema occurred in three cases, twice on 
the left side, and once on the right side. In one case there were 
pointing and escape of the fluid at a point between the sixth 
and seventh ribs. This case was complicated with pericarditis, 
cirrhosis of the liver, and fibrous degeneration of the kidneys. 
In the second case it was complicated with waxy degeneration 
of the liver and spleen, and Bright's disease. In the third case 
the empyema was subsequent to a pneumonia on the same 
side, and was complicated with pericarditis. 
GANGRENE. 
Gangrene of the lung occurred in two cases. One case was 
in a man, forty years old, in whom nearly the entire upper 
lobe of the left lung was gangrenous. There was no disease of 
any other part of either lung, and no complications, excepting 
atheromatous thickening of the aortic and mitral valves. 
The other case was in a man, forty-three years old, in whom 
nearly all the lower, the middle, and part of the upper lobes 
of the right lung -were gangrenous. Around the gangrenous 
lung, in the lower lobe, there was some gray pneumonic hep- 
atization of the lung-tissue, and on the same side, the pleural 
cavity was full of a reddish, offensive fluid. Part of the lower 
lobe of the left lung was in a condition of red hepatization, 
and there was fatty degeneration of the liver and kidneys. 
PULMONARY APOPLEXY. 
Pulmonary apoplexy occurred in two cases. One was in a 
man, twenty-five years old, in whom there were hypertrophy of 
the heart, calcareous degeneration of the aortic and mitral 
valves, cirrhosis of the liver, and fatty kidneys. There were 
several small apoplectic clots in all the lobes of the right lung, 
but only two in the left lung; and in both pleural cavities 
were serum and fresh lymph. 
The other case was in a man, forty years old, in whom 
there was atheroma of the arch of the aorta and Bright's dis- 
ease of the kidneys. Both lungs were emphysematous, and PATHOLOGICAL REPORT. 
351 
there was pneumonic consolidation of both lungs. In the 
upper lobe of the right lung were two small apoplectic clots 
surrounded by hepatized lung. 
CARCINOMA. 
Carcinoma of the lungs occurred in two cases. One was 
in a man, fifty-one years old, who died with carcinoma of the 
stomach and liver. There were numerous small, whitish, 
cancerous nodules scattered over both lungs, most of them 
in the lung-tissue just beneath the pleura. The other case 
was in a woman, thirty-one years old, in whom the superior 
maxilla had been removed for cancerous disease. The tumor 
had returned at the place of removal, and had been followed 
by infection of the cervical glands, liver, spleen, kidneys, and 
lungs. In the lungs it was in the form of small, white 
nodules, situated just under the pleura. 
EMPHYSEMA. 
Vesicular emphysema of the lungs was observed in twenty- 
seven cases, seventeen males and ten females. Four cases were 
in persons between twenty and thirty years of age; ten cases 
between thirty and forty ; seven between forty and fifty ; three 
between fifty and sixty; and three between sixty and seventy. 
In five cases it occurred in the right lung alone, in two cases, 
in the left lung alone, and in twenty cases, in both. The de- 
gree of the emphysema varied in different cases; in some 
the air-cells were only slightly dilated, in others they were very 
large. In general, it was not confined to any particular lobe, 
but involved the entire lung. The lower lobes were those in 
which the dilatation of the air-cells was usually the greatest. 
In twelve cases it was accompanied by cardiac lesions. 
In two cases the aortic valves alone, in three cases the mitral 
valves alone, and in four cases both aortic and mitral valves, 
were the seat of the disease. In three cases there was simple 
hypertrophy of the heart. In seven cases it was accompanied 
by phthisis pulmonalis, and in five of these the tubercular 
lesions were quite advanced. In twelve cases there was 
Bright's disease of the kidneys; in two cases waxy degenera- 
tion of the liver; in two cases syphilitic gummy tumors of the 352 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
liver; in two cases cirrhosis of the liver; in one case aneurism 
of the arch of the aorta; in one case aneurism of the ab- 
dominal aorta; in five cases pneumonic consolidation ; and in 
one case gangrene of the lung. 
PULMONARY PHTHISIS. 
Pulmonary phthisis occurred in seventy-nine cases-forty 
in males, thirty-nine in females. The deaths occurred at the 
following ages: Below twenty, nine; between twenty and 
thirty, twenty-eight; between thirty and forty, twenty; be- 
tween forty and fifty, thirteen; between fifty and sixty, seven; 
between sixty and seventy, two. 
There were fifteen cases of acute miliary tuberculosis, six 
in young children, and nine in adults, one of these, a man 
sixty years old. In all these cases but one, the tubercles were 
scattered throughout all the lobes of both lungs. In this one 
case, a woman, thirty-four years old, with cystitis, suppurative 
nephritis, and oedema of the lungs, there -were gray miliary 
tubercles in the two upper lobes only, and no tubercle in any 
other organs. 
The tubercles, in all the cases, were in the form of small 
nodules, scattered singly or aggregated into somewhat larger 
nodules, the smallest, gray and semitransparent, the larger, 
with opaque yellow centres. In four of the cases there ex- 
isted also the lesions of chronic phthisis, cavities, and yellow, 
cheesy consolidation of the lung-tissue. In these fifteen cases, 
tuberculosis of other organs occurred as follows: Pia mater, 
five times; brain, twice; ulcer of epiglottis, once; pleura (cos- 
tal), twice ; liver, five times; spleen, seven times; kidneys, 
three times; intestines (with ulceration), four times ; perito- 
naeum, once ; Fallopian tubes and uterine mucous membrane, 
once. 
Of the seventy-nine cases, sixteen were cases of old de- 
posits in the apices of the lungs, which had become cheesy, or 
calcareous, or fibrous. In six cases they were in the right apex 
alone, in four cases in the left apex alone, and in six cases in 
both apices. They occurred in persons who died of the follow- 
ing diseases: of cholera, four; of dysentery, two; of pneumonia, 
two; of cirrhosis and Bright's disease, two; of fatty liver and PATHOLOGICAL REPORT. 
353 
Bright's disease, two; of syphilitic gummy tumors of the liver 
and spleen, and waxy degeneration of the kidneys, one ; of in- 
jury, one; of carcinoma of the stomach, one; of puerperal con- 
vulsions, one. In all the cases there were lesions of the kid- 
neys, either fatty, fibrous, cystic, or waxy. 
There were thirty-one cases in which the yellow consolida- 
tion of the lung known as " infiltrated tubercles," or " tubercu- 
lar pneumonia," or " cheesy hepatization," was the predomi- 
nant lesion, there being very few gray or isolated yellow tu- 
bercles. That is, in larger or smaller lobules of the lung there 
were yellow masses, which, on microscopic examination, were 
found to be caused by the filling of the air-cells with granular 
matter, and small, deformed, shrivelled cells. In one case only 
the upper lobe of the right lung was involved ; and in all the 
other cases all the lobes of both lungs were, in some measure, 
implicated. In twenty-four of the cases there were one or more 
cavities. Around many of the cavities the lung-tissue was in- 
durated, and the fibrous tissue between the air-cells much in- 
creased in quantity. Tubercular lesions of other organs oc- 
curred as follows: Viceration of the larynx, three cases; tu- 
bercles in the pleura, two cases; in the capsule of the liver, 
one case; in the spleen, one case; in the peritonaeum, three 
cases; in the kidneys, four cases; in the intestines (ulcerations), 
twelve cases; in the Fallopian tubes, two cases. In two of the 
cases there was hydro-pneumothorax; in one, emphysema; in 
ten, fatty degeneration of the liver ; in two, waxy degeneration 
of the liver and spleen; in four, cirrhosis of the liver; in fifteen, 
fatty degeneration of the kidneys; in two, fibrous degeneration 
of the kidneys. Waxy degeneration of the vessels of the kid- 
neys was only observed three times, but in many of the cases 
the proper test was not applied. In some of these cases no gray 
tubercles could be seen, but in most of them a few could be 
found scattered here and there. 
There were seventeen cases in which the predominant 
lesion was discrete, scattered, small, yellow tubercular masses, 
usually associated with gray tubercles, often with larger masses 
of cheesy infiltration, often with thickening of the walls of the 
small bronchi, and occlusion of their cavities with cheesy ma- 
terial. In seven of the cases the lesions were confined to the 354 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
upper lobes, in ten cases they involved all the lobes. In nine 
cases there were one or more cavities. Tubercular lesions of 
other organs occurred as follows: Ulceration of the larynx, 
one case ; tubercles in the pleura, two cases; tubercles in the 
capsule of the liver, one case; tubercles in the spleen, three 
cases; tubercles in the peritonaeum, two cases; in the kidneys, 
three cases; ulceration of the intestines, three cases. In two 
cases there was hydro-pneumothorax, in one case emphysema, 
in one case acute pneumonia, in three cases waxy degenera- 
tion of the liver and spleen, in five cases fatty degeneration of 
the kidneys, in three cases waxy degeneration of the vessels of 
the kidneys. 
It has been thought best, in view of the unsettled condi- 
tion of opinions regarding the tubercular process, merely to 
group the cases in the above rough way. 
(ESOPHAGUS. 
There was one case of ulceration of the oesophagus, occur- 
ring in a male, aged fifty-six. The ulceration extended down 
into the cardiac orifice of the stomach. It was not of a can- 
cerous nature. The man had no other organic lesions, and 
died of asthenia. 
STOMACH. 
There were two cases of carcinoma of the stomach: the first 
occurring in a male, aged sixty-four, who died in January. 
The disease was situated along the lesser curvature of the 
stomach, near the pylorus. The liver was also the seat of car- 
cinoma, the other organs being normal. 
The second case occurred in a female aged sixty. The 
walls of the stomach were much thickened throughout their 
whole extent, most markedly at the cardiac orifice. The mucous 
membrane was thickened and of a greenish-white color. The 
muscular coat appeared transformed into a semi-transparent, 
homogeneous-looking tissue, traversed by vertical white trabe- 
culae, placed very closely together and running from the peri- 
tonaeum to the mucous coat. Toward the cardiac orifice the 
whole wall was of a more uniform white appearance. Near 
the cardiac orifice the mucous membrane was gone for a space PATHOLOGICAL REPORT. 
355 
of one and a half inches in diameter, and a sloughy-looking 
mass hung into the cavity of the stomach, about one inch 
long and one-eighth of an inch broad. The glands around 
the stomach were greatly enlarged, firm, and of a white 
color. The peritonaeum presented throughout its whole vis- 
ceral layer, most especially at the mesenteric portion, numer- 
ous white patches. 
Microscopically, the thickening of the mucous membrane 
was seen to be due partly to an increased growth of the nor- 
mal epithelium, the gastric tubules being increased in length 
and diameter, and partly by irregular, polygonal, nucleated 
cells, having no resemblance to cylindrical epithelium. The 
whitish bands underneath the mucous membrane and peritonae- 
um were formed of connective tissue with a few cells. The 
grayish tissue, which made the principal thickness of the walls, 
was composed of smooth muscular fibres in very great quantity, 
running circularly over the stomach, and of cells arranged 
in long follicles between the bundles of muscles. These cells 
were mostly polygonal, nucleated, and from to 7^ of an 
inch in diameter. Many of them were fatty. There were also 
free nuclei and small spindle-cells. The enlarged lymphatic 
glands contained a number of similar cells. 
DYSENTERY. 
NO. 
SEX. 
AGE. 
MONTH. 
MODE OF DEATH. 
COMPLICATIONS. 
1 
Male 
49 
September 
Collapse. 
Asthenia 
Phthisis. 
2 
Male 
32 
September 
3 
Female 
32 
September. 
August 
Collapse. 
Coma. 
Collapse. 
4 
Female. . . 
69 
5 
Female 
28 
August 
6 
Female 
49 
August 
The above table gives at a glance the cases of dysentery. 
INTESTINAL FISTULA. 
There were two cases of intestinal fistula. Case I. was 
associated with uraemia, and is mentioned under the head of 
kidneys. Case II. occurred in a female, aged thirty-two, who 
died in August. The post mortem showed that a loop of the 
transverse colon and a loop of the jejunum were adherent to 356 
BELLEVUE AND CHAEITY HOSPITAL EEPORTS. 
the fistulous opening of the abdomen. The colon commu- 
nicated with this opening, but the jejunum did not. There 
were many firm adhesions between the intestines and the ab- 
dominal walls. In both the large and the small intestines, w'ere a 
number of ulcers. At some of these points of ulceration the gut 
was adherent to the abdominal wall. There were several small 
cheesy masses attached by membraneous pedicles to the gut. 
The lesion of the intestines was accompanied by general tuber- 
culosis. 
PERITONITIS. 
1 NO. 
SEX. 
AGE. 
MONTH. 
CAUSE. 
COMPLICATIONS. 
1... 
Male.... 
17.... 
July.... 
Dysentery. 
«... 
Female. 
ao 
Dec 
Rupture of hsematocele into perito- 
neal cavity. 
3... 
Male.... 
35 
Jan 
Tubercular ulceration 
Phthisis. 
4- 
Female. 
35 
Feb.... 
Tubercules ?. 
Phthisis; waxy liver; 
waxy spleen. 
Thickening of all of the 
valves of the heart. 
5... 
Male.... 
50 
August. 
Rupture of an abscess of the spleen. 
6... 
Female. 
26 
August. 
Rupture of vermiform appendix. 
7... 
Female. 
50 
Dec 
Perforation of the rectum 
Ulceration of the colon. 
8... 
Female. 
Still- 
April... 
Umbilical abscess. 
1 
born. 
HERNIA. 
NO. 
AGE 
SEX 
MONTH. 
VARIETY. 
OPERATION. 
MODE OF DEATH. 
COMPLICATIONS. 
1... 
3... 
56.. 
25.. 
M.. 
M.. 
August. 
April... 
Oblique in- 
guinal en- 
tero-epip- 
locele. 
Ventral en- 
tero-epip- 
locele. 
Sac opened af- 
ter repeated 
attempts at re- 
duction, and 
portion of the 
omentum re- 
moved. 
Collapse from perito- 
nitis, produced by 
the bursting of an 
abscess, formed in 
the surrounding tis- 
sues, into the perito- 
neal cavity. 
Collapse 
Eaceration of 
the abdominal 
walls. Perito- 
nitis. 
FATTY DEGENERATION OF THE LIVER. 
This lesion occurred in twenty-six cases, to a marked de- 
gree. It was found in connection with lesions of other organs 
as follows: Pulmonary phthisis, twelve cases; chronic cardiac 
lesions, four cases; marked fatty degeneration of the kidney, 
eleven cases; other forms of Bright's disease, five cases. In 
one case, where there was fatty degeneration of the kidneys, PATHOLOGICAL REPORT. 
357 
the patient died intensely jaundiced and with all the symp- 
toms of cholsemia. The livers varied in weight from 
pounds to six pounds. 
WAXY DEGENERATION OF THE LIVER. 
This lesion occurred in thirteen cases: four in males and 
nine in females. All the cases were in persons between twenty 
and forty years of age. The livers varied in weight from 3| 
to 7^ pounds. The waxy degeneration varied in extent in the 
different cases; in some only the centres of the lobules were 
changed, in others nearly the entire organ. The degeneration 
in all the cases had attacked the liver-cells, which had as- 
sumed a peculiar, smooth, translucent, homogeneous, shining 
appearance. The cases in which the degeneration affected the 
greatest part of the liver were sufficiently characterized by their 
gross appearances; those in which the degeneration was less 
extensive were readily made evident by the use of the iodine 
test and the microscope. In most of the cases there was also 
fatty degeneration of those of the liver-cells which were not 
waxy. In three cases the livers had been the seat of syphi- 
litic hepatitis, their capsules were thickened, fibrous bands 
extended into the substance of the organ, and in these bands 
were small gummy tumors. 
In five of the cases the patients died of pulmonary phthisis; 
in four of the cases there was a distinct syphilitic history ; in 
one case there was chronic disease of the knee-joint; in one case 
there was chronic cardiac disease ; and in one case, a small 
aneurism of the superior mesenteric artery. Waxy degenera- 
tion of other organs, accompanying that of the liver, was ob- 
served as follows: of the spleen, eleven cases ; of the kidneys, 
ten cases (affecting the Malpighian tufts and small vessels); of 
the vessels of the walls of the heart, one case. 
In one of the cases in which the liver was much degen- 
erated and weighed pounds, but was accompanied by no 
cardiac or kidney disease, there was marked ascites, the ab- 
dominal cavity being nearly full of fluid, and this condition 
had existed for several months before death. 358 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
CIRRHOSIS OF THE LIVER. 
This lesion occurred in twelve cases: nine in males and 
three in females. Eleven cases were in persons between thirty-five 
and sixty years old, and one was in a person twenty-eight years 
old. The livers varied in weight from 1 lb. 14 oz. to 7 lbs. 6 oz. 
In the larger livers there was also marked fatty degenera- 
tion of the liver-cells. Ascites existed only in two cases. The 
spleen varied in size from 5 oz. up to 2 lb. 3 oz. In general, 
its size was in inverse ratio to that of the liver. In eight cases 
there was kidney disease, either granular, fibrous, or fatty. 
One case was of distinctly syphilitic origin. It occurred 
in a woman twenty-eight years old, who had contracted a 
chancre six years before, and since that time had suffered from 
various secondary lesions. The liver weighed 2 lb. 5 oz.; the 
capsule was thickened, fibrous bands passed from the capsule 
into the substance of the organ so as to give it a lobulated ap- 
pearance, and there was an increased amount of fibrous tissue 
between the lobules. 
GUMMY TUMORS OF THE LIVER. 
This lesion occurred in eleven cases : five in males and six 
in females. All were in persons between twenty and forty-five 
years old. In three cases there was a syphilitic history ; in two 
cases the previous life of the patients was such as to render 
syphilis almost a necessity ; and in the other five cases there was 
no syphilitic history, but the patients were not questioned con- 
cerning this point during their stay in the hospital. 
In eight of the cases the capsule of the liver was thick- 
ened, and there were fibrous bands extending from the cap- 
sule into the substance of the organ; in these fibrous bands 
were situated the gummy tumors. In the other three cases 
the tumors were scattered through the substance of the organ. 
The tumors were, small, not larger than a pea, white or yel- 
lowish white, opaque, of firm consistence, and either hard and 
fibrous, or broken down, softened and fluid, most of them 
cheesy in the centre. Those which were neither fibrous nor 
softened consisted of little, round, pale cells, exactly resem- 
bling those found in the fresh granulations of wounds. Those PATHOLOGICAL REPORT. 
359 
which were hard and fibrous consisted of connective-tissue 
fibres and fusiform cells; and those which were cheesy and 
soft consisted of granular matter. In one case the tumors 
reached a large size. This was in a man, thirty-four years old, in 
whom the liver weighed 6 lb. 10 oz., was lobulated, and at the 
middle of the posterior edge was a large white mass, the size of a 
child's fist, made up of a number of smaller tumors. On the 
convex surface of the right lobe near its anterior border was 
another similar mass, the size of a hen's egg. There were other 
smaller tumors scattered through the organ. 
In four of the cases the liver had undergone waxy de- 
generation ; in two cases there were gummy tumors in the 
spleen; and in two cases, waxy degeneration of the spleen. 
In five cases there was waxy degeneration of the vessels of 
the kidneys; and in one case there was waxy degeneration of 
the vessels of the walls of the heart. 
TUBERCULOSIS OF THE LIVER. 
This lesion occurred in seven cases; two in infants, four 
between the ages of five and twenty-three, and one at the age of 
forty-five. In all the cases there was acute general tuberculo- 
sis, attacking the lungs and other organs. The tubercles were 
in the form of small gray granulations, in a few cases yellow, 
situated immediately under the capsule of the liver. 
THE PIGMENT (OR BRONZED) LIVER. 
This lesion was observed in five cases ; all males, between 
the ages of nineteen and fifty. In three of the cases, the pa- 
tients had resided for some time in malarious districts in the 
South. In all the cases the patients died with the symptoms 
of an acute attack of remittent fever. The livers varied in 
weight from 3 lbs. 3 oz. to 4 lbs., were of a dark-olive or 
reddish-brown color, and not at all congested. In all the 
cases the spleen was enlarged, weighing from 12 oz. to 2 lbs., 
and was of the same dark color as the liver. In two cases 
the kidneys were also somewhat pigmented. 
In all the cases, the liver, spleen, and kidneys, in four of 
the cases, the blood from the portal and hepatic veins, and in 
one case, the blood from the lungs and inferior vena cava, were 360 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
subjected to microscopical examination. The results obtained 
in all the cases were the same, and agree essentially with those 
stated by Frerichs. There were found in the blood a num- 
ber of pigmented bodies of various shape, some long and fusi- 
form, others round or oval, and others of irregular caudate shape. 
These bodies were formed of a transparent, finely-granular 
substance, without any thing like a cell-wall, and with badly- 
defined edges. The round and oval bodies measured from 
2 to an inch in diameter; and in a small number of 
them a well-defined small nucleus was seen. In all these bodies 
black pigment was found in the shape of small, black, angular 
particles, but in variable amount. Some of the round bodies 
contained no pigment, while others were nearly filled with it. 
There were also seen solid masses of black pigment of irregular 
shape. All these bodies were found in the greatest numbers in 
the blood of the hepatic and portal veins; and in the blood from 
the lungs and inferior vena cava they were less numerous. 
The livers presented no changes except in their color. 
They were not congested ; there was no increase of the fibrous 
tissue; the gall-bladders contained normal bile; and the liver- 
cells were unchanged. When thin sections were made so as to 
show the lobules, it was evident that the pigment was scattered 
throughout the substance of each lobule. No pigment was seen 
in the inter-lobular or intra-lobular veins, nor was it more abun- 
dant near them, but was scattered uniformly through each of 
the lobules. When looked at in this way, it might easily be 
thought that the pigment was situated in the liver-cells. In 
order to determine more exactly the seat of the pigment, one 
of the livers was injected with Prussian blue. When thin 
sections were made, it was evident that the pigmented bodies 
were situated in the capillary venous plexus of each lobule. 
The hepatic artery was not injected, so that it was not ascer- 
tained whether its branches also contained pigment. When 
portions of the liver were torn with needles, numbers of pig- 
mented bodies, like those in the blood, and especially the round 
forms, were found, and in a few of the specimens several liver- 
cells were seen containing a few black granules. In the 
spleens great numbers of these pigmented bodies were found, 
but their exact situation was not ascertained. In the kidneys PATHOLOGICAL EEPORT. 
361 
there were very plainly pigmented bodies in the capillaries 
of the Malpighian tufts. In none of the cases was there an in- 
creased number of white blood-globules in the specimens 
of blood examined. 
This lesion occurred in five cases ; two in males, three in 
females, at the respective ages of fifty-one, thirty-one, sixty- 
four, fifty-five, and sixty years. In three cases, it was secondary 
to carcinoma of the stomach; in one case to carcinoma of the su- 
perior maxilla ; and in one case it was primary. In two cases, 
the lungs, and in one case, the spleen also contained nodules 
of cancer. In all the cases but one, the cancerous nodules 
were small, scattered through the liver, and this organ not en- 
larged. 
One case, occurring in a female fifty-five years old, pre- 
sented some peculiarities. The liver weighed 6 lbs. 8 oz., and 
contained a number of tumors, from the size of a hen's egg to 
that of an orange. Some of the tumors were solid, with softened 
centres, and others contained large cavities filled with yellow 
serum. The tumors were composed of nucleated cells con- 
tained in regular fibrous alveoli. There was no carcinoma of 
any other organ, but the gall-bladder was small, bound to the 
liver, filled with gall-stones, and its walls thickened with car- 
cinomatous tissue. 
CARCINOMA OF THE LIVER. 
THROMBOSIS OF THE PORTAL VEIN. 
The morbid specimens obtained in this case, together with 
the history, were presented at a meeting of the Pathological 
Society, of this city. 
The following is the history of the case: Thomas Burns, 
forty-seven years of age, was admitted to the Bellevue Hos- 
pital on the 11th of February, 1867. He died on the 22d of 
the same month. His illness began three weeks before his 
admission to the hospital. His first symptoms were pain in 
the right side, and cough. These continued. He had, when 
admitted, a feeble and frequent pulse, and his respiration was 
hurried. 
The percussion-sound was dull over the posterior part of 362 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
the right side of the chest, as high as the angle of the scapula. 
The respiratory murmur and vocal resonance were absent over 
the same part. Eight days later, the symptoms became mark- 
edly typhoid. The abdomen was tender, painful, and tym- 
panitic. The urine contained granular casts, but was free from 
albumen. 
At the autopsy, the brain and its membranes were normal. 
The left pleural surfaces adhered to one another. The 
right pleural sac contained a small amount of serum. Hypo- 
static congestion was observed in both lungs. 
The heart weighed ten ounces, and was normal. The ab- 
domen was very tympanitic. The peritoneal sac contained a 
large amount of serum and lymph. The different viscera were 
adherent to each other and to the abdominal wall. 
The spleen weighed nine ounces, and was normal. The 
kidneys weighed twelve ounces. 
The stomach and intestines were distended with o-as, and, 
with the exception of a small polypus situated in the descend- 
ing colon, their mucous membrane was normal. The bladder 
and the prostate gland were normal. 
The liver weighed 6^ pounds. It was much enlarged, and 
during its removal pus escaped from a superficial abscess. It 
was impossible to decide whether the abscess had been rup- 
tured by the manipulation necessary for the removal of the 
liver, or had opened previous to death. The right lobe con- 
tained a large number of abscesses, many of them super- 
ficial. Only one attained the size of a black walnut. The 
rest of them were of the size of a pea or of a large cherry. 
They contained a thick, white, purulent fluid, which was in 
some stained by bile. Their walls consisted of the liver- 
tissue in a shreddy state. Only two abscesses existed in the 
left lobe. 
On section of the liver, a purulent-looking fluid es- 
caped from the portal veins of each lobe. In the left lobe, 
several of the small portal veins were observed, which were 
obstructed by small, reddish thrombi. The right lobe was too 
much disintegrated to show this appearance. A fish-bone, 
two inches in length, was found, so situated that one-half 
was in the portal, the other half in the superior mesenteric PATHOLOGICAL REPORT. 
363 
vein. The middle portion of the bone was covered by a 
thin, whitish clot, which caused it to adhere to the inner coat 
of the veins. The ends of the bone were free and bare. The 
clot and bone measured only of an inch in thickness. There 
were no signs of inflammation of the veins at this point. 
The external coat of the portal vein at the point of its 
division into its right and left branches was thickened. The left 
branch was filled by a firm, reddish-white thrombus, over an 
inch in length. The right branch was lined by a layer of de- 
colorized fibrin. The internal coat of each branch appeared 
normal. 
The lymphatic glands in the fissure of the liver were 
enlarged. 
HYPERTROPHY OF THE SPLEEN. 
This lesion occurred in four cases, all males between the 
ages of twenty and fifty-one. The spleens varied in weight 
from 1 lb. 7 oz. to 2 lb. 3 oz. Their capsules were much 
thickened, and there were false membranes on their external 
surfaces. In the splenic substance no change could be seen, 
but that of bulk. In one case, the liver was fatty ; in one 
case, cirrhosed ; and, in one case, it contained syphilitic gummy 
tumors. 
WAXY DEGENERATION OF THE SPLEEN. 
This lesion occurred in thirteen cases, five in males, eight 
in females, between the ages of sixteen and forty years. In 
ten of the cases the degeneration affected nearly the whole 
organ, giving a uniform smooth, waxy appearance. In the other 
three cases the degeneration had only affected the Malphighian 
bodies, which looked like gray, transparent grains scattered 
through the organ forming the so-called Lago spleen. The 
spleens varied in weight from 5 oz. to 1 lb. 1 oz. In two of the 
cases there was a syphilitic history; in five cases the pa- 
tients had suffered from pulmonary phthisis; and in one case, 
from chronic joint-disease. 
In eleven of the cases there was also waxy degeneration 
of the liver; in three cases, gummy tumors of the liver; in 
seven cases, waxy degeneration of the blood-vessels of the kid- 
ney ; and in six cases, fatty degeneration of the kidneys. 364 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
GUMMY TUMORS OF THE SPLEEN. 
This lesion occurred in two cases, both males, respectively 
forty and forty-four years of age. In one case the spleen 
weighed 6 oz., and in the other, 1 lb. 6 oz. In both cases the 
gummy tumors were small, opaque, and white, some of them 
softened, and situated in the splenic tissue. In neither case 
was there waxy degeneration of the spleen. In both cases 
there were also gummy tumors in the liver. 
TUBERCLES IN THE SPLEEN. 
This lesion occurred in eight cases, four males and four 
females; three cases in children under one year old ; one case 
at five years; one at twenty-three; one at thirty-two; and 
two at forty-five. In all the cases but one, the tubercles were 
in the form of gray, semitransparent granulations, mostly situ- 
ated immediately under the capsule of the spleen. In one 
case there were two yellow, cheesy tumors the size of a pea. 
In all the cases the patients died with general tuberculosis. 
CARCINOMA OF THE SPLEEN. 
This lesion occurred in one case, a female, thirty-one years 
of age. The tumors in the spleen were secondary to primary 
carcinoma of the superior maxilla, and were associated with 
other secondary tumors in the liver and lungs. The spleen 
was not much enlarged, and the cancerous nodules were small. 
CYSTS IN THE SPLEEN. 
This lesion occurred in two cases, both in males, forty- 
five and fifty-six years old respectively. In one case the spleen 
weighed 3 oz., and there was a cyst the size of a chestnut 
near its lower edge, containing clear serum. In the other 
case the spleen weighed 8 oz. The cyst was rather larger than 
a chestnut, and contained serum and cholesterine. 
INFARCTI OF THE SPLEEN. 
This lesion occurred in five cases, three males and two fe- 
males, all between the ages of twenty-two and fifty years. The PATHOLOGICAL EEPORT. 
365 
spleens weighed respectively 1 oz., 7 oz., 9 oz., 15 oz., 5 lbs. 
There were found in the spleens, circumscribed portions of 
opaque, white tissue, usually surrounded by splenic tissue of a 
deep-red color, sometimes partially separated from the surround- 
ing tissue, and sometimes having more the shape and consistence 
of cicatrices, varying in size from a pea to a hen's egg. When 
examined with a microscope, these bodies were found to consist 
of exactly the same elements as the surrounding spleen-tissue, 
except that in some there was more granular matter, and in 
some more fibrous tissue. In one case, one of these white 
masses was surrounded by a thin layer of gangrenous tissue, 
the capsule of the spleen was perforated, and some of the dead 
tissue had escaped into the peritoneal cavity, causing peritoni- 
tis and death. 
In three of the cases there were vegetations on the aortic 
valves; in one case on the mitral valves; and in one case on 
both the aortic and mitral valves. These vegetations were large 
and rough in all the cases. In one case there was caries of 
the ilium and a large abscess. In one case there was an apo- 
plectic effusion at the base of the brain. In one case there was 
atheroma of the splenic artery and of some of its branches. 366 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
NO. 
AGE. 
SEX. 
MONTH. 
WEIGHT. 
MODE OF DEATH. 
COMPLICATIONS. 
URINE. 
1.. 
2.. 
3.. 
4.. 
5.. 
6.. 
7.. 
8.. 
9.. 
10.. 
11.. 
12.. 
13.. 
14.. 
15.. 
16.. 
17.. 
18.. 
19.. 
20.. 
21.. 
22.. 
23.. 
2-1.. 
25.. 
50.... 
48.... 
23.... 
50.... 
40.... 
30.... 
35.... 
17.... 
36.... 
40.... 
60.... 
29.... 
14.... 
38.... 
55.... 
40.... 
27 ... 
21.... 
45.... 
34.... 
40.... 
48.... 
45.... 
36... 
23.... 
Male.... 
Male.... 
Male.... 
Female. 
Female. 
Female. 
Female. 
Male.... 
Male.... 
Female. 
Female. 
Male.... 
Female. 
Female. 
Female. 
Female. 
Male.... 
Female. 
Male.... 
Male.... 
Female. 
Male.... 
Female. 
Female. 
Male.... 
May 
May 
May 
May 
June 
June 
July 
June 
June 
November.. 
November.. 
January.... 
February... 
March 
August 
April 
May 
December.. 
January.... 
February... 
March 
May 
May 
August 
August 
13 ounces... 
12 ounces... 
17 ounces... 
12 ounces... 
14 ounces... 
14 ounces... 
14 ounces... 
15 ounces... 
7 ounces... 
12 ounces... 
13% ounces. 
15% ounces. 
11 ounces... 
13 ounces... 
11 ounces... 
14 ounces... 
12% ounces. 
8 ounces... 
11 ounces... 
15 ounces... 
9 ounces... 
10 ounces... 
6 ounces... 
14 ounces... 
16 ounces... 
Asthenia 
Asthenia 
Convulsions 
Coma 
Exhaustion 
Convulsions 
Coma 
Coma 
Asthenia 
Coma 
Asthenia 
Coma 
Coma 
Coma 
Asthenia 
Asthenia 
Asthenia 
Coroner's case.... 
Not stated 
Coma 
Not stated 
Not stated 
Peritonitis ; aortic and mitral disease ; calcareous plates on 
inner coats of splenic and portal veins. 
Pleuro-pneumonia 
Iliac abscess ; subacute meningitis 
Double pneumonia ; spots of gangrene on both legs. 
Phthisis 
Pregnancy , 
Fatty liver; phthisis 
Mitral disease 
Fatty liver 
Fatty liver 
Pleuro-pneumonia; phlegmonous erysipelas 
General anasarca; effusion into abdominal cavity; erysipelas 
(Edema of lungs ; effusion into peritoneal cavity; disease of 
aortic and mitral valves. 
Phthisis 
General oedema 
(Edema of legs; aortic disease; pleuro-pneumonia; pyone- 
phrosis. 
Pysemia 
Cirrhosis; general oedema. 
Aortic and mitral disease ; general oedema 
Endocarditis; fatty liver. 
Phthisis 
Carcinoma uteri 
Fatty liver. 
Phthisis; cardiac disease ; infarction of spleen. 
Not examined. 
Not examined. 
Albumen and casts. 
Albumen and casts. 
Albumen and casts. 
Albumen; fatty casts. 
No albumen; granular casts. 
Not examined. 
No albumen; granular casts. 
Albumen; fatty and granular 
casts. 
Albumen; pus ; fatty casts. 
Albumen; casts. 
Suppressed. 
Albumen; granular, fatty, and 
hyaline casts. 
Albumen ; hyaline and granu- 
lar casts. 
Hyaline casts. 
Albumen; casts. 
Fatty and hyaline casts. 
Albumen. 
FATTY KIDNEY. PATHOLOGICAL EEPORT. 
367 
NO. 
AGE. 
SEX. 
MONTH. 
WEIGHT. 
MODE OF DEATH. 
COMPLICATIONS. 
URINE. 
1.. 
45.... 
Male.... 
February... 
8% ounces. 
Unknown 
Hydrothorax; oedema of lung; pneumonia; endo- and peri- 
carditis. 
2.. 
50.... 
Female. 
April 
6 ounces... 
Convulsions 
Small cysts in kidneys; disease of the mitral valves. 
Small cysts in kidney ; general oedema ; erysipelas. 
Waxy liver: oedema of lung; mitral disease. 
Small cysts in kidney; general oedema, and effusion into all 
the cavities; remains of an apoplectic clot. 
3.. 
49.... 
Male.... 
May 
8 ounces... 
Asthenia 
4. 
38.... 
Female. 
June 
10X ounces. 
6X ounces. 
5.. 
56.... 
Male.... 
July 
Convulsions 
Albumen ; granular casts. 
6.. 
40.... 
Female. 
October.... 
6^ ounces. 
10 ounces... 
Coma 
Mitral disease 
Normal. 
7.. 
15.... 
Male.... 
June 
Convulsions . 
Cysts in kidney. 
Cancer of uterus; dysentery 
8.. 
38.... 
Female. 
August 
May 
14 ounces... 
Coma 
Not examined. 
9.. 
62.... 
Male.. 
6 ounces... 
Asthenia 
Phthisis; pneumonia. 
10.. 
39.... 
Female. 
July 
4 ounces... 
Coma 
General oedema ; mitral and aortic disease 
Albumen; granular casts. 
No albumen ; no casts. 
11.. 
27.... 
Female. 
September.. 
December.. 
16 ounces... 
Convulsions 
Tubo-rectal fistula 
12.. 
56 ... 
Male.... 
6^ ounces. 
5 ounces... 
Asthenia 
Phthisis ; erysipelas; general oedema. 
Pleuro-pneumonia 
13.. 
35.... 
Male.... 
February... 
July. 
Asthenia 
Albumen; casts. 
14.. 
62.... 
Male.... 
6% ounces. 
Coma 
(Edema* of the lungs; fatty liver. 
NO. 
AGE. 
SEX. 
MONTH. 
WEIGHT. 
MODE OF DEATH. 
COMPLICATIONS. 
URINE. 
1... 
22.... 
Female. 
April 
12 ounces... 
Waxy liver; waxy spleen; apoplexy; aortic and mitral dis- 
No albumen ; no casts. 
2 
35.... 
Female. 
June 
20 ounces. 
Asthenia 
ease. 
Aortic disease; waxy liver; waxy spleen ; diarrhoea; facial 
3... 
23.... 
Female. 
October.... 
12 ounces... 
Asthenia 
erysipelas. 
Waxy liver; waxy spleen ; disease of all the valves of the 
Albumen ; granular and fatty 
heart; general oedema. 
casts. 
4... 
22.... 
Male... 
March 
8 ounces... 
Convulsions 
General oedema; effusion in all the serous cavities. 
5... 
44.... 
Male... 
February... 
11 ounces... 
Convulsions 
Waxy liver; waxy spleen; slight oedema of the lower ex- 
tremities. 
6... 
22.... 
Male... 
February... 
8 ounces... 
Convulsions 
Waxy liver; waxy spleen ; general oedema 
Albumen: hyaline, granular, and 
blood casts. 
7 . 
38 . 
Female, 
June 
10X ounces. 
Mitral disease; waxy liver. 
8 
35 
TTpynnlp 
.Tnnnnrv . 
14 ounces. 
Coma 
Waxy liver; waxy spleen 
Suppression of the urine. 
37.... 
Female. September.. 
8 ounces... 
Asthenia 
Waxy liver; waxy spleen; phthisis 
Not'examined. 
FIBROUS KIDNEY 
WAXY KIDNEY. 368 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
ABSCESS OF THE KIDNEY. 
There were three cases of abscess of the kidney: two in 
males, and one in a female. The age of each of the males was 
forty years. The age of the female was twenty-one years. The 
two cases in which the disease was found in males occurred in 
October, the other in August. 
The weight of the kidneys was respectively twenty, fif- 
teen, and ten ounces. Asthenia caused death in two of the cases, 
and the cause was not stated in the remaining case. 
The complications were pyaemia, pregnancy, and peritoni- 
tis. Albumen and hyaline casts were found in the urine in 
one case. 
CARCINOMA OF THE KIDNEY. 
There was one case of carcinoma of the kidney, in a male, 
thirty-five years of age. The disease of the kidney was com- 
plicated by cardiac disease and oedema of the lungs. The 
carcinoma was situated in the right kidney. 
Twelve examinations were made, where death occurred at 
a short period after labor, and the pelvic viscera or the perito- 
naeum exhibited inflammatory lesions. 
The following is a list of the parts involved: 
One case of simple peritonitis. 
Seven cases of metro-peritonitis. 
Two cases of endo-metritis. 
One case of endo-metritis and pelvic cellulitis. 
One case of abscess of the uterus. 
PERITONITIS. 
The woman in this, the only case of death from peritonitis 
without endo-metritis or parenchymatous metritis, was twenty- 
three years of age. The total duration of labor had been forty- 
two and a half hours. The duration of the second stage had been 
thirteen hours. The history stated that the woman had had 
symptoms of peritonitis the day after labor; that these symp- 
toms had disappeared on the following day, and had only re- 
turned twelve hours before her death. She died on the seventh PATHOLOGICAL REPORT. 
369 
day after labor, in July, 1866. The peritoneal sac contained 
fresh lymph and a purulent fluid. The kidneys were granular. 
METKO-PEKITONITIS. 
The autopsies of the seven patients dying of metro-perito- 
nitis were made in July and December, 1866, and in January, 
March, April, May, and September, 1867. 
The ages of the patients were between twenty and 
twenty-eight years, with one exception ; viz., thirty-five years. 
The disease had developed itself in five cases between the 
twelfth hour and the sixth day after the labor had been com- 
pleted. Death occurred between the thirty-sixth hour and the 
fourth day after the symptoms had manifested themselves, and 
between the third and the ninth day after the termination of 
labor. 
The following is a brief detail of some particulars of the 
different cases: 
Case I.-The second stage of labor had lasted thirty-six 
hours. The disease commenced on the second, and death oc- 
curred on the fifth day after labor. Pneumonia and fatty 
kidneys were complications. 
Case II.-The disease commeficed on the sixth, and death 
occurred on the ninth day after labor. Fatty liver and kid- 
neys and double pleuro-pneumonia were complications. 
Case III.-The second stage in this case was eight and 
three quarters hours in duration. Mania had occurred, which 
had masked the symptoms of peritonitis. The complications 
were fatty liver, congestion of both kidneys, small abscesses in 
the right kidney, and purulent infiltration of the broad liga- 
ments. 
Case IV.-The labor was natural. The disease commenced 
on the third day after labor, and death occurred in thirty-six 
hours. The complications were cystitis, pyelitis, and conges- 
tion of the kidneys. 
Case V.-The second stage of labor lasted eighteen hours. 
Forceps were used for the delivery of the child. Metro-peri- 
tonitis developed on the twelfth hour after delivery, and death 
occurred three days later. The following were the diameters 
of the inlet of the pelvis : antero-posterior, three and a half 370 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
inches; transverse, four and a half inches; oblique, four and 
three quarters inches. The complications were a fistulous open- 
in<r between the neck of the uterus and the bladder, situated 
one inch above the external os and measuring one and one 
eighth inches in diameter, and intense cystitis. 
Case VI.-The death occurred on the fourth day after la- 
bor. Pneumonia and thickening of the heart-valves were 
complications. 
Case VII.-The placenta was delivered by the hand on 
account of adhesions. The disease commenced on the sixth 
day after labor, and death occurred in thirty-six hours. The 
other organs were normal. 
ENDO-METRITIS. 
Case I.-A woman, aged twenty-eight years, died eight 
and a half days after labor, of post-partum convulsions, which 
had commenced twelve hours before death. There were endo- 
metritis and parenchymatous metritis. With the exception of 
the kidneys, which were too far decomposed for examination, 
the other organs of the body were normal. The examination 
was made in July, 1867. 
Case II.-The patient was nineteen years of age, single, 
and primipara. She had mania of eight days' duration, com- 
mencing two days after labor. On examination, July, 1866, 
there was found endo-metritis. The kidneys were fatty, and 
the other organs normal. 
PELVIC CELLULITIS AND METRITIS. 
In this case the woman w'as eighteen years of age, and de- 
veloped puerperal mania seven days after labor. In her case 
there was metritis associated with inflammation of the broad 
ligaments and of the cellular tissue of the pelvis in proximity 
to the veins. The other organs were normal. The kidneys 
were too much decomposed for examination. The autopsy 
was made in July, 1867. 
ABSCESS OF THE UTERUS. 
The patient was twenty-one years of age, and showed 
symptoms of pyaemia six weeks after labor. She died at the 
expiration of two weeks after these symptoms had developed. 
The uterus was of normal size, and in its walls was a small PATHOLOGICAL BEPOET. 
371 
abscess. The kidneys were fatty. There was no lesion of any 
other organ. 
NON-PUERPERAL PERITONITIS. 
Peritonitis due to inflammation of the genito-urinary or- 
gans of the female occurred in three cases, independently of 
parturition. 
Case I.-The patient was twenty-three years of age. The 
autopsy was made in September, 1866. The bladder was the 
seat of a severe inflammation ; its mucous membrane was in- 
tensely congested, thickened, and the seat of ulcerations; and 
its walls were also thickened in some parts. There was recent 
exudation of lymph upon the peritoneal surface of the bladder 
and of the neighboring intestines, gluing them together. In 
addition there was suppuration in the cellular tissue around 
the right kidney. ' The pelvis of each kidney was inflamed. 
The kidney-structure seemed normal, as did also the ureters. 
The uterus was normal. 
Case II.-The patient was twenty years of age. She had 
had symptoms of peri-uterine haematocele two months pre- 
vious to her death, and she,had apparently recovered from 
this, when the symptoms of peritonitis were developed. 
A large abscess was found between the posterior wall of the 
vagina and uterus and the rectum. There was a small open- 
ing leading from this into the peritoneal sac. The abscess 
contained merely a purulent fluid, and no clots. The abdom- 
inal cavity also contained purulent fluid. 
Case III.-The patient was thirty years of age. In this 
case the os externum was almost occluded. There was dila- 
tation of the cavity of the body and of the neck of the uterus, 
with inflammation of the mucous membrane. The Fallopian 
tubes were dilated, convoluted on themselves, and adherent to 
the ovary and to the uterus. In the left there was a dirty sero- 
purulent fluid ; while the right was thickened, lined by a layer 
of false membrane, and empty. The latte/ circumstance was 
due to its having been cut in its removal. There was no point 
of rupture to be made out. The tubes communicated with 
the uterus. There was a considerable exudation of lymph on 
the peritonaeum, especially in the pelvis. 372 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
UTERO-TUBO-RECTAL FISTULA. 
This condition was found in the body of a female, twenty- 
seven years of age, who died of convulsions. The kidneys 
were fatty and the lungs tuberculous. 
The os uteri externum was occluded. Both Fallopian tubes 
were dilated, containing a muco-purulent fluid, as did also 
the uterus. There was no communication between the right 
tube and the uterus, but the latter communicated with the rec- 
tum, by means of a small fistulous opening situated in the upper 
posterior part of the right side of the fundus. The uterine 
orifice of the left tube was pervious, while on the other side it 
communicated with a small cavity in the ovary, and this latter 
was connected by a narrow fistulous opening with the rectum. 
Each ovary contained in its substance a clot of dark-red blood, 
about half an inch in diameter. 
PELVIC ABSCESS COMMUNICATING WITH THE UPPER PART OF THE 
VAGINA. 
The autopsy was made in January, 1867. The patient 
was fifty years of age. During life she had a profuse purulent 
discharge from the vagina, and developed symptoms of pyaemia. 
She died of asthenia. 
There was on the right side of the pelvis a large abscess, 
situated both beneath the obturator interims muscle and be- 
tween it and the fascia. It extended into the thigh through 
the obturator foramen, and beneath the obturator externus 
muscle, as far as its points of attachment to the femur. It also 
accompanied the femoral vessels as far as the cribriform fascia. 
A small piece of pubic bone, forming the margin of the ob- 
turator foramen, was eroded. There was a narrow fistulous 
communication between the abscess and the upper part of the 
vagina, on the right side near the cervix uteri. The uterine 
cavity was enlarged and was lined by a layer of false membrane. 
The external and internal iliac veins of this side were sur- 
rounded by indurated tissue. The interior of the external 
vein was normal. The internal iliac was lined by a layer of 
whitish, buff-colored fibrin, and in the centre of this was a 
small quantity of a thick, whitish fluid. The common iliac 
vein contained a loose fibrinous clot, one fourth of an inch long. PATHOLOGICAL REPORT. 
373 
There were small abscesses in both lungs. The other organs 
were normal. 
There was one case of fracture of the skull by a pistol-ball, 
in a male, aged forty-eight. The fracture was situated at the 
postero-inferior angle of the parietal bone. He had been tre- 
phined, and the dura mater opened ; and at this point a fun- 
gous growth developed from the brain. At this point, also, the 
brain-tissue was much disorganized. There was another pistol- 
ball received on the parietal boss of the same bone, leaving 
no external trace of any note, but internally there was a 
slight effusion of blood separating the dura mater from the 
skull. There was also a laceration of the brain, exactly cor- 
responding to the external injury. This was a case of suicide ; 
and the man, after shooting himself twice, jumped out of a 
fifth-story window, breaking both bones of both legs. When 
he had fallen to the ground he drank about a gill of sulphuric 
acid. He died on the third day after the receipt of his inju- 
ries, from the brain-trouble. 
FRACTURES. 
FRACTURE OF THE NECK OF EACH FEMUR. 
The patient, a male, sixty years of age, was treated in the 
hospital, in 1863, for fracture' of the right cervix femoris, and 
in December, 1866, was admitted with fracture of the left cervix 
femoris. Three days later he died suddenly of a cerebral 
clot. The following is a description of the specimens : There 
was a fracture of the left cervix femoris, intra-capsular, with 
the exception of a small portion anteriorly, where the fracture 
became extra-capsular. The sides and posterior surface of the 
head of the bone within the capsule and the fractured surfaces 
without the capsule had become rounded and smooth, so as to 
form a false joint admitting of considerable motion. There 
was a recent fracture of the right cervix femoris, partly intra- 
capsular and partly extra-capsular. 
CARCINOMA OF THE SUPERIOR MAXILLA. 
There was one case of carcinoma of the superior maxilla, 
in a female, aged thirty-one years. The bone was removed, 
and at the same time the carotid artery of that side was liga- 
tured. This ligature was followed by marked cerebral symp- 374 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
toms and hemiplegia. The patient died about seventy days 
after the operation, from abscess of the brain. The heart, liver, 
and kidneys presented carcinomatous growths. 
MORBUS COXARIUS. 
There was one case of morbus coxarius, in a female, 
aged twenty-one years, who died of general tuberculosis. 
Several small abscesses were found around the joint, but not 
communicating with it. The capsule was thickened, and the 
cartilage covering the head of the bone was displaced by a 
thick layer of firm, cheesy substance, under which the bone was 
denuded. The cartilage was still present, but displaced and 
thinned. On the acetabulum were several spots of denuded 
bone. The whole cavity of the joint was filled with the same 
cheesy matter. 
pott's disease of the spine. 
There was one case of Pott's disease, situated in the dorsal 
vertebrae, in a female, thirty-one years of age. The disease of 
the spine was accompanied by a psoas abscess pointing in 
Scarpa's triangle. The cause of death was asthenia, accom- 
panied with diarrhoea. 
The number of post-mortem examinations made on pa- 
tients who had died of cholera was twenty-two. These all 
occurred during the summer and the early part of the fall of 
1866. They were distributed over the different months in the 
following order: one in June, five in July, thirteen in August, 
two in September, and one in October. Of the patients, three 
were males and nineteen, females. Fifteen (two males and 
thirteen females) died in collapse. The remaining seven 
died during the period of reaction. The following table will 
show the age at which death occurred in these patients: 
ASIATIC CHOLERA. 
No. in Collapse. 
Reaction. 
Total. 
Between 
10 and 20 
years,.... 
1 
1 
2 
44 
20 and 30 
44 
4 
7 
44 
30 and 40 
44 
. . . . 4 
1 
5 
a 
40 and 50 
44 
.... 3 
4 
44 
50 and 60 
44 
.... 3 
3 
41 
60 and 70 
44 
1 
1 PATHOLOGICAL EEPORT. 
375 
The eldest was a woman sixty-nine years of age, and 
the youngest, a boy of ten years. 
Of those dying in collapse, the death occurred in one case 
on the first, in five cases on the second, in three cases on the 
third, in two cases on the fourth and on the fifth, and in one 
case on the seventh and on the tenth day of the disease (these 
periods including the preliminary stage). During reaction the 
deaths occurred, one case each on the second, third, sixth, sev- 
enth, and eighth, and two cases on the ninth day. Five, dur- 
ing the period of reaction, died comatose, while the mode of 
death in the other two cases dying during this period is not 
mentioned. 
LESIONS FOUND IN THOSE DYING IN COLLAPSE. 
Brain and Membranes.-In six cases these parts presented 
nothing abnormal. In three cases there was a considerable 
amount of serous effusion, both sub-arachnoid and ventricular, 
which in one instance was bloody, and in another was. associ- 
ated with an old apoplectic cyst in the brain. In one case 
there was a slight abnormal congestion of the vessels of the 
pia mater, and a small amount of subarachnoid effusion. Nei- 
ther the age, the duration of the illness, nor the length of time 
lapsing between the time of death and that of the autopsy, 
seems to have had any connection with these differences. 
Heart.-1There was either fluid blood or clots in the right 
cavities and none in the left, in seven of the cases, while in 
one instance there were clots in the left cavities and none in 
the right. In three cases there was a slight valvular thicken- 
ing on the left side; and in one, an adherent pericardium of 
long standing. 
Lungs.-These organs were anaemic in eight cases. The 
weight of both lungs in one instance being reduced to nineteen 
ounces, and in another to twenty-six and a half ounces. In 
no case was there marked congestion, without some disease 
of the lung. Pneumonia, small in amount, occurred once. 
Tubercles were found in four cases, the lungs in one case 
having cavities, and in one case there was merely a small, 
cheesy deposit. Slight emphysema of the lungs was found 
twice. 
Liver.-Only once was the liver markedly congested. 376 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Twice it was cirrhotic, once fatty, and once the seat of gum- 
mata. Its average weight in thirteen cases was three pounds. 
Spleen.-This organ was twice found enlarged, but in each 
of these cases there had been intermittent fever. 
Kidneys.-These organs were fibrous in three cases, in two 
cases small cysts also existed. In three cases they were fatty, 
and once there was pyelitis. In the other cases they are re- 
corded as being normal. The average weight of both kidneys, 
in ten cases, was seven and four-tenths ounces. 
Intestines.-In all except one of the cases there was con- 
gestion in some part of the alimentary canal, while in six cases 
it extended throughout. In eight of the cases the stomach 
was not markedly congested. Only in three eases was conges- 
tion absent from the small intestine. In four cases the solitary 
glands of this part and Peyer's patches were enlarged. Ecchy- 
moses are also mentioned as occurring in three cases. The 
so-called diphtheritic exudation occurred only once. It was 
colored green, and was found in the lower part of the ilium. 
The colon was more or less congested, with but two exceptions. 
Ecchymoses occurred in this portion of the canal in eight 
cases. Exudation was only once found, and in a different case 
from the one noticed above. In four cases the mucous mem- 
brane was ulcerated, which was due in one instance to a dys- 
entery becoming complicated by cholera. The contents of 
the intestine varied in its different portions somewhat. In 
five cases the fluid in the small intestine was stained by bile, 
in six cases it was a thin liquid resembling gruel, and in one 
case it was colored deep brown. In three cases the fluid in 
the large intestine was stained with blood, and in each of these 
cases there were ulcers in this part of the intestine. 
Bladder.-This viscus contained a small amount of urine 
in two instances. 
The diseases with which cholera-collapse was associated 
were as follows: chronic rheumatism, one ; pneumonia, one ; 
pelvic cellulitis, one; Bright's disease, as marked by symp- 
toms during life, one; dysentery, one; and visceral syphilitis, 
one. PATHOLOGICAL EEPORT. 
377 
In four of the seven cases the brain was examined. Twice 
it was found congested. Once it was normal. In the remain- 
ing case there was a considerable quantity of serum under 
the arachnoid. The heart was normal in all the cases. 
Lungs.-They were normal in three instances. In three 
cases they were the seat of tubercle, which was in one merely a 
small, cheesy deposit. In one case there was marked hypo- 
static congestion of the lungs. 
Liver.-In two cases this organ was fatty, while in the 
others it was normal. Its average weight in five cases was 
three pounds. 
Lntestines.-The intestines were found congested in all the 
cases. In three the solitary glands and Peyer's patches 
were enlarged. The diphtheritic exudation occurred once in 
the lower part of the ileum. Ecchymosis existed in the colon 
in one case. Ulcers were found in the intestines twice, in one 
case, tubercular, in the other they were situated in the duode- 
num and colon. The kidneys were in two cases congested, 
and in two, fatty. Their average weight (for both) was nine 
and four-fifths ounces. 
Spleen.-This gland was normal in all the cases. 
Bladder.-The bladder is mentioned as having been empty 
in three cases. 
Besides the associated diseases noticed above, cholera oc- 
curred once in a patient suffering from rheumatism. 
LESIONS FOUND IN THOSE DYING DURING REACTION. XIII.-EFFECTS OF EXCESSIVE INTELLECTUAL 
EXERTION. 
On some of the Effects of Excessive Intellectual Exertion. By 
William A. Hammond, M. D., Professor of Diseases of 
the Mind and Nervous System, and of Clinical Medicine 
in the Bellevue Hospital Medical College, etc. 
The condition in which the brain is left after very intense 
or protracted mental application, or as a consequence of pow- 
erful emotional disturbance, is one of very great importance, 
both as regards the immediate results to the individual and as 
predisposing to subsequent disease. Nevertheless, the subject 
is almost unstudied except in its incidental relations. In fact, 
the difficulties which surround it are, so far as we can per- 
ceive, insurmountable, wim our present opportunities and ap- 
pliances for research. 
That an increased amount of blood flows through the cere- 
bral vessels during mental activity, that these vessels may be- 
come permanently over-distended, and that profound intersti- 
tial changes are produced in the brain-substance, are facts very 
generally admitted. The first two are capable of actual de- 
monstration, the last is a matter of inference, but of inference 
so very decided in its character as scarcely to allow of the ex- 
istence of a doubt. What these changes are, and what exact 
relations they bear to the kind and degree of cerebral action, 
we are far from being able to determine. 
Helmholtz,1 several years ago, ascertained for muscles, 
1 Muller's Archiv. 1843, p. 72. Also, Die Chemie der Gewebe, von Ju- 
lius Eugen Schlossberger. Erster Band, Leipzig & Heidelberg, 1856, p. 
186. 380 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
what we cannot, with any degree of fulness, determine for 
the brain. He amputated the legs of a frog, and, leaving one 
of them in a state of rest, excited the other to contractions by 
means of galvanism, and continued the action so long as the 
muscles retained their irritability. The flesh of the two limbs 
was then submitted to chemical examination, with the result 
that the water-extractive was found to be from twenty to twen- 
ty-four per cent, less in the exercised limb than in the other, 
while the alcoholic extract was correspondingly increased. 
I have recently repeated Helmholtz's experiment, and have 
obtained similar results. 
Gulliver's1 observations lead to no important conclusion, ex- 
cept that muscular rigidity ensued at a comparatively recent 
period in animals hunted to death. 
The effect of emotion over the solids and fluids of the body 
has long been known. Scarcely an organ resists this influence 
altogether, and some exhibit it in a very marked degree. Even 
the muscles are subject to it, and may be profoundly changed 
in chemical constitution, through emotional disturbance or 
physical suffering. Doubtless the primary effect is, in such 
cases, produced upon the blood, but this does not lessen the 
value of the example as analogical to what we have ample as- 
surance takes place in the structure of the brain from similar 
causes. 
The influence of bodily suffering, in rendering the flesh of 
animals poisonous, is very strikingly shown in the following 
account: 
" In order to procure a roast for Easter," says Dr. Bbser, " C. 
in K. desired his family to set a snare for a roebuck. Ac- 
cordingly one of these poor animals was caught in the snare, 
which, as its head and breast had passed through, held it by 
the hinder parts of the body, the abdomen and pelvis being 
enclosed in the cord, so that it must have succumbed after a 
most agonizing struo-o-le. It was found dead the next day. 
" The master and mistress of the family ate, on Easter-day, 
the best part of this dainty; the servants had little; the re- 
mainder was laid in vinegar, but not eaten. 
1 Edinburgh Medical and Surgical Journal, October, 1848. EXCESSIVE INTELLECTUAL EXERTION. 
381 
" On the same day, all of the family who had eaten of the 
venison observed a striking dryness of the mouth, oppression 
at the stomach, and nausea; all complained of oppression of 
the head, giddiness, and great weariness of the limbs. The 
master lost his sight for several days, and, in short, there now 
began a series of remarkable symptoms, requiring in many 
ways the assistance of Dr. Rbser. The husband was only re- 
stored to health in July, but the wife never recovered; she 
lingered more than two years, and at last died after severe 
sufferings. The daughter, the man-servant, and the maid, 
who had eaten little of the tortured animal, were soon cured. 
The symptoms, in many respects, resembled those of the effects 
of the bite of rabid animals (and of the sausage-poison of Wiir- 
temberg ?)." , 
Dr. Rbser concludes his communication in these words: 
" Many an animal (for example in hunting) is tortured to 
death in the most barbarous manner, like the roebuck in the 
snare. Ought not, then, the medical police to be led by cases 
like this to adopt the strictest regulations to prevent the use, 
as food, of animals which have in any way been tortured to 
death, and to insure that the animals intended for food are not 
tortured before being slaughtered."1 
Every one, too, has noticed the feeling of fatigue experienced 
after severe physical exertion. This is of course due to struc- 
tural changes in the muscles as well as to nervous exhaustion. 
It is also well known that the flesh of animals hunted to death 
is stringy, unsavory, and that microscopical examination 
shows the fibrillae of the muscles to be ruptured, and separated 
from each other by minute extravasations of blood. In addi- 
tion to these evidences of muscular change, we have that af- 
forded by the waste of the muscular tissue-the debris, as it 
were-which appears in the urine, and which enables us to 
measure with considerable accuracy the extent of the decom- 
position, just as we can, by weighing the ashes, ascertain how 
much wood has been burnt. 
Now, in regard to the brain, somewhat similar results ensue 
1 Dr. 0. G. Carus, in Der Menschenfreund in seiner Beziehungen zur 
belebten Welt, quoted by Liebig in his Familiar Letters on Chemistry, etc. 
Third edition. London: 1851. Appendix No. 4, page 531. 382 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
from intellectual exertion, and although, as I have said, we can- 
not determine, with any degree of exactness, the nature of the 
change produced, we are not altogether without important 
data which tend to give us some ideas on the subject. These 
data I propose to make the basis of the present memoir, divid- 
ing them into two classes : those which relate to the circulation 
within the cranium, and thus to the diminished or increased 
amount of blood in the cerebral vessels, and those which refer 
to interstitial alterations of the brain-tissue. 
I. That one of the primary effects of intellectual exertion 
is an increase in the quantity of blood circulating through the 
brain, does not admit of a doubt, except from those who contend 
that the cerebral circulation is not subject to variation under 
any circumstances. Experimental physiology has, however, 
determined this point so positively in the affirmative, that it 
is scarcely necessary to adduce the evidence in its support. It 
will be sufficient to recall the numerous facts observed, and ex- 
periments performed by others and myself, with reference to 
the immediate cause of sleep, by which it is shown that, during 
the condition of wakefulness, the quantity of blood in the brain 
is much greater than it is during sleep, the first being a state 
of intellectual activity, the latter one of almost complete rest 
for the brain.1 
Excessive mental exercise inordinately augments the ac- 
tivity of the cerebral circulation. The blood-vessels become 
over-distended, and, if the brain be long kept in a condition of 
extraordinary action, they may be rendered incapable of re- 
turning to their normal dimensions. Like a bladder filled to re- 
pletion with urine, they become in a measure paralyzed, and 
unable to contract upon their contents. A state of cerebral 
congestion is thus induced which gives rise to a set of symp- 
toms perfectly characteristic, and fraught with peril to those in 
whom they occur. 
Among the primary symptoms of this condition, wakeful- 
ness occupies a prominent place, and indeed for a time is often 
the only circumstance which attracts the attention of the pa- 
1 Those who desire to examine further into this question are referred to 
the writer's monograph entitled Sleep and its Derangements. EXCESSIVE INTELLECTUAL EXERTION. 
383 
tient. He remains awake the greater part of the night, his 
mind either active with the affairs which have engaged it dur- 
ing the day, or else filled with the most preposterous ideas. 
Toward morning he obtains a little sleep, but he rises unre- 
freshed and ill prepared for the labors of the day. Indeed, 
when the affection is well established, mental or physical 
activity is almost impossible. So far as the mind is concerned, 
there is an indisposition to give the attention to any subject 
requiring much thought, and at times an absolute want of 
power to get correct ideas of any subject. This is especially 
seen in those who have arithmetical questions to solve, or long 
columns of figures to add up. 
Before long, the mental symptoms become more evident. 
The ideas are confused and without logical arrangement, 
the memory begins to fail in regard to recent occurrences, and 
there is often a special disposition to omit words in conversa- 
tiou or writing, and to substitute others having a similar sound 
or appearance. The judgment is weak and vacillating, as 
shown by the difficulty experienced in making up the mind to 
any determinate course. Thus, a gentleman laboring under 
symptoms of cerebral congestion, induced by almost un- 
remitting application to a very engrossing business, and who 
in good health was remarkable for his decision and firmness 
of character, told me that he had gone down to Wall Street 
several times every day, for many weeks, with a large sum of 
money in his pocket to invest, and always returned home with- 
out having been able to decide what to do with it. Any 
effort at continuous or severe thought increases the difficulties 
of the mind, and sometimes induces pain or uneasiness in the 
head. The intelligence becomes enfeebled, and it is frequently 
impossible for the patient to understand things which in his 
normal condition he easily comprehended. Illusions and de- 
lusions may both be present, but are not usually fixed, and the 
individual will himself often laugh at the absurd images he 
has seen, or ideas he has entertained, not five minutes before. 
Patients thus affected will often reason clearly in regard to 
apparitions or voices, of the unreality of which they are fully 
sensible. 
In conjunction with these mental phenomena there are cer- 384 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
tain important physical symptoms of disordered cerebral ac- 
tion. Vertigo is very generally complained of, and there are 
likewise heat, pain, and a feeling of fulness in the head. In 
some cases the headache constitutes the principal feature of 
the disorder, and is almost constantly present. There are noises 
-such as roaring, rumbling, and ringing-in the ears; and 
sometimes bright flashes, at others dark specks before the eyes. 
Ophthalmoscopic examination, which should never be omitted, 
shows the veins of the retina to be increased in number, di- 
ameter, and tortuosity, and occasionally the optic disk is found 
more or less congested. The conjunctivae are suffused; there 
is intolerance of light, and motion of the eyeballs is painful. 
Loud noises are likewise disagreeable. The face is flushed 
and the carotids throb with more than ordinary force. 
Sensation and the power of motion are more or less 
affected, and generally, though not always, on one side of the 
body only. Thus the arm or leg feels heavy, and a sensation 
as of ants crawling over it, pins and needles sticking in it, 
or as if the limb was " asleep," is experienced. Examination 
with the aesthesiometer shows that the ability to distinguish 
the two points of the instrument at the normal distance apart 
is less on the affected side than on the other, and that thus, to 
get the sensation of two points, they must be more widely 
separated when applied to the diseased side than is necessary 
for the corresponding parts of the sound side. The muscular 
strength is also lessened generally, but sometimes the difficulty 
is especially noticed in particular muscles, such as the tibialis 
anticus or the deltoid, which, losing a portion of their con- 
tractile power, cause the patient to experience an awkwardness 
in raising the foot, or elevating the arm from the side. The 
face, however, is rarely affected, even when the muscular power 
is diminished on all the rest of one side of the body, and the 
tongue when protruded comes out straight. Careful observa- 
tion will generally detect some difficulty, perhaps slight, about 
the speech. Words are not pronounced with the same distinct- 
ness as before, especially when the patient is fatigued, or has been 
speaking for some time. The linguals and labials among let- 
ters are particularly troublesome, as well as all words which 
require the nice management of the end of the tongue for their EXCESSIVE INTELLECTUAL EXERTION. 
385 
enunciation. The articulation is thick, and sometimes whole 
syllables are slurred over in a slovenly way. 
The other organs of the body are more or less deranged. 
The pulse is unusually slow and full, the appetite capricious, 
the digestion imperfect, the bowels costive, and the urine 
scanty and high colored. 
The foregoing constitute the ordinary assemblage of symp- 
toms which are first met with in congestion of the brain, the 
consequence of excessive intellectual exertion, or the long-con- 
tinued action of some powerful emotion. Some of them may 
be absent, others so slightly manifested as to escape ordinary 
observation, and others again so strongly exhibited as to ex- 
cite the grave apprehensions of the patient and his friends, 
and to require him to keep his bed. Generally, however, they 
are not so severe as to prevent him attending, in a measure, 
to his ordinary avocations, and they may altogether disappear 
either by removal of the cause or in consequence of appropri- 
ate treatment. 
Without suitable medical and hygienic treatment, they fre- 
quently precede a much more decided condition of cerebral 
derangement, and especially is this the case when some intense 
mental or physical cause, capable of suddenly increasing the 
amount of blood in the brain, is brought into action. This 
fully-developed condition may, in its general features, resemble 
apoplexy or epilepsy, or may be characterized by some of the 
phenomena of both these conditions. Attack after attack 
supervenes at intervals of a few dqys, weeks, months, or even 
years-each one leaving the patient more exhausted and en- 
feebled, bodily and mentally, than the immediately preceding 
seizure, until, at last, softening of the brain-tissue or disease 
of the blood-vessels, leads to imbecility, general paralysis, com- 
plete hemiplegia, or sudden death from extravasation of blood. 
II. The symptoms characteristic of cerebral exhaustion are 
likewise well marked. Owing to excessive use, the brain- 
substance is metamorphosed into lower grades of matter faster 
than new tissue can be found to take its place. As a conse- 
quence the mind is enfeebled-for, to possess a strong and well- 
balanced mind, a sound brain is indispensable. 386 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Now, one of the first effects of debility, whether in the brain 
or other organs, is rapidity of action at the expense of strength 
and completeness. A weak heart beats with great frequency, 
but with little force; an overtasked muscle is in a constant state 
of tremor from incomplete contractions, and feeble lungs inhale 
the requisite amount of air by frequent and shallow inspirations, 
instead of the slow and profound expansions which indicate 
strength in these organs. Similar facts are observed as regards 
brains. Even within the limits of health they may be noticed. 
Thus we often see persons with weak brain-power, and inca- 
pable of intense thought on any subject, giving evidence of 
great mental activity. Their brains, without thoroughly mas- 
tering any subject, take up an infinity of matters, and drop 
them, one after the other, after the most superficial considera- 
tion. Such persons, though remarkable for their vivacity, are 
really of very irritable dispositions. Their minds are like a 
piece of machinery without the balance-wheel. A brain may be 
originally of great power. This power proceeds not only from 
quantity but from quality. By over-exertion this latter is de- 
teriorated, and imperfect mental manifestations are the result. 
Individuals who have tasked their brains beyond the normal 
limits, lose the capacity for deep and well-regulated thought; 
they become inconstant in their studies, their pursuits, and 
their ideas. Their opinions are as fickle as the winds, and 
their mental impressions, though numerous, are as transient as 
characters written in sand-at the same time it is observed 
that their dispositions are, undergoing change. Trifling cir- 
cumstances give them great annoyance, and the little troubles 
of life, which in their normal condition were scarcely noticed, 
now render them miserable. Radical changes of character 
may also supervene. 
Of course the several intellectual faculties are more or less 
deranged, and the will suffers more than any other, unless, 
indeed, it be the memory. 
The special senses are enfeebled, the general sensibility of 
the body lessened, and the motorial power considerably re- 
duced. A long-sustained muscular contraction, as of the fin- EXCESSIVE INTELLECTUAL EXERTION. 
387 
gers for instance, cannot be maintained; and hence a straight 
line cannot be made with the dynamograph. 
As the cerebral condition becomes worse, the evidences df 
mental and physical decay become more palpable, and even- 
tually dementia, as the result of softening, precedes the last 
stage-death. We know, with tolerable certainty, that increased 
intellectual exertion leads to an augmentation of the amount 
of phosphatic salts nominally present in the urine. Whether 
the group of symptoms just described is due essentially to the 
too rapid removal of phosphorus from the brain, without a cor- 
responding assimilation of this substance into the cerebral 
tissue, is more questionable. Certain therapeutical facts, to 
which allusion will presently be made, would seem to indicate 
that it is no unimportant circumstance. It is probable, how- 
ever, that defective nutrition of the brain, as regards other con- 
stituents, is not without great influence in causing derangement 
of its functions. Certainly this is the case where the stage of 
softening is reached. 
Generally the two series of symptoms-those due to hyppr- 
semia and those the result of mal-nutrition-coexist in the 
same patient. Cases are, however, occasionally met with in 
which they are distinct. In the case of a gentleman recently 
under my charge, the state^first observed was that of conges- 
tion-gradually this disappeared, and the symptoms of defec- 
tive nutrition supervened. The retinae were anaemic, and there 
was atrophy of the optic disks, indicating a deficient circulation 
of blood through the cerebral vessels. 
In the treatment of the effects of excessive intellectual ex- 
ertion, it is of the first importance to insist upon as complete a 
state of rest for the brain as it is possible to obtain. This, with 
a change of the current of thought, travel, exercise in the open 
air, and a full and nutritious diet, will often result in great al- 
leviation of the symptoms, and sometimes in a perfect cure. 
Ordinarily, however, medical treatment must also be adopted, 
and this depends in a great measure upon the condition which 
exists in the brain. If the phenomena of congestion predomi- 
nate, the administration of bromide of potassium cannot be ad- 388 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
vantageously omitted. I have ascertained,1 by experiments 
upon living animals, as well as by observation of individuals 
who have taken it in large doses, that one of the principal ef- 
fects of this substance is to lessen the amount of blood circula- 
ting through the brain. This it probably does by its action 
on the sympathetic nerve, whereby the calibre of the cerebral 
blood-vessels is diminished. To be efficacious it should be 
given in doses of at least twenty grains, and preferably thirty 
grains, three times a day. Under its use the symptoms of cere- 
bral congestion, as described in this paper, disappear. Its ad- 
ministration should not be too. long continued, and we have in 
the ophthalmoscope a ready means of ascertaining when its use 
should cease. 
Along with it strychnia and phosphorus should be given, 
and especially if we have reason to suspect defective nutrition. 
The former I usually administer in solution in dilute phosphoric 
acid, one-thirtieth of a grain of strychnia to half a drachm of 
the acid, three times a day. The phosphorus may be given 
either in the form of phosphorated oil, of which the dose is 
from five to ten drops, or as phosphide of zinc, in doses of the 
tenth of a grain, three times a day. Cod-liver oil is also a very 
eligible agent, but I would not like to be deprived of phosphor- 
us in any condition of the brain the result of mal-nutrition 
from over-exertion. Its effects are almost invariably decided 
and permanent, provided the patient can be brought to com- 
prehend the danger he is in, unless he consents to use his brain 
in accordance with the principles I have laid down. 
In addition, great benefit is to be derived from the prudent 
use of the primary galvanic current, both in contracting the 
diameter of the blood-vessels, and in improving the nutrition 
of the brain. To produce the former result, the positive pole 
should be applied over the sympathetic nerve in the neck, and 
the negative to the nucha. The same effect is also caused by 
placing one pole over each mastoid process, and thus passing 
the current directly through the brain. The instant the cir- 
cuit is closed in either case, but especially in the latter, a feel- 
1 On Sleep and its Derangements, 1869. Also, Sleep and Insomnia, in 
New York Medical Journal, May and June, 1865. EXCESSIVE INTELLECTUAL EXERTION. 
389 
ing of vertigo is experienced. If the retina be viewed with 
the ophthalmoscope at the time, the vessels will be seen to be- 
come smaller and less numerous. The employment of the cur- 
rent, so as to improve the nutrition of the brain, is best effected 
by placing one pole on the nape of the neck and the other on the 
forehead. Not more than sixteen elements should be used, and 
care must be exercised, even with this number, that the passage 
of the current be stopped as soon as the least sign of fatigue is 
experienced. XIV.-OVARIOTOMY. 
The History of Eight Cases of Ovariotomy. By T. Gaillard 
Thomas, M. D., Professor of Obstetrics and the Diseases of 
Women and Children in the College of Physicians and 
Surgeons, New York; Physician to Bellevue Hospital. 
It is now just sixty years since the operation of ovariotomy 
was first introduced to the medical profession by an American 
surgeon. Dr. Ephraim McDowell, of Kentucky, performed 
this operation in 1809, the patient recovering from it and living 
twenty-five years afterward. Since that period, the most con- 
stant and acrimonious discussion has been, until within a few 
years, kept up, as to the propriety, I may even say the legiti- 
macy, of the procedure. In spite of all opposition, supported 
as it has too often been by unfair argument and absolute mis- 
representation, the operation has steadily advanced, and at 
the present time has reached a position so sure and unassail- 
able in the esteem of the profession, that no one who desires 
to see his name stand in the list of those who favor advance in 
medical science ventures to depreciate it. 
It is true that here and there will be found those who even 
now declare that the procedure is one too hazardous in its steps 
and too fruitless in its results to warrant its adoption. But 
these will almost invariably be found to stand upon the same 
level with the men who systematically vilify the speculum 
and anaesthesia, and depreciate the value of the microscope 
and ophthalmoscope. 
Although this be true, the operation of ovariotomy is as 
yet too recent not to require the light which can be thrown 392 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
upon it by honestly reported statistics, and by them alone. 
Amputation of the thigh has been so often performed, for so 
many years, and in so wide an extent of territory, that the 
surgeon who now performs it is excusable if he does not report 
every case for the critical examination of his peers. All ques- 
tions as to the value and results of the operation are at rest; 
and, although statistics with regard to it will always be of value, 
the profession no longer demands them as essential for its ulti- 
mate position as a surgical resource. With ovariotomy it is 
otherwise. Every case should be carefully and frankly re- 
ported, in order that it may serve to swell the numbers from 
which conclusions, whether favorable or unfavorable to the 
procedure, are to be drawn. 
There are many influences at work at present which tend 
to keep up the mortality attendant upon this operation. Some 
of these are inherent to the operation itself, and will always 
exist; others, as knowledge increases with experience, and the 
basis upon which it rests becomes more stable and assured, will 
greatly diminish or entirely disappear. First among these 
must be mentioned the necessity for cutting into the perito- 
naeum, exposing this delicate and important structure for a 
long time, and often leaving vessels open upon its surface, or 
within its cavity, which pour out blood that serves as mate- 
rial for putrefaction. Second, the difficulty of diagnosis must 
not be lost sight of. It is safe to say that in no pathological 
condition for which surgical procedure is adopted, not except- 
ing that of internal aneurism, is this difficulty equalled. But 
it is not my intention to enumerate all the influences to which 
I have made allusion, and I shall content myself with the men- 
tion of a third. The observation of others may not agree 
with mine, and many may dissent from what I am about to 
advance, but to me it stands forth clearly as an influence 
which has done, and is doing, much to injure the position of 
ovariotomy as a surgical resource. It is this: the operation 
of ovariotomy is at present often performed by men inexperi- 
enced in the diagnosis and treatment of ovarian tumors. The 
statistics of some of the best operators prove that they have 
been progressively successful, as they have advanced in experi- 
ence, and learned to avoid the dangers attendant upon the pro- OVARIOTOMY. 
393 
cedure, and we must conclude that they who operate for the 
first or second time, must damage the array of reported cases 
and increase the rate of mortality. I know full well that it 
may be objected to this statement, that if inexperienced men 
never operated, where would our supply of new surgeons come 
from ? In reply to this I would remark, that if the profes- 
sional relations of any man make it likely that he will be fre- 
quently called upon to perform this or any other operation, he 
should prepare himself to meet the demand upon him; but I 
cannot think it incumbent on any practitioner, upon whom 
no such demand is likely to be made, to have performed one or 
two operations of ovariotomy. I sincerely believe, as the re- 
sult of observation, that the third influence which I have stated 
as marring the statistics of the subject, is by no means an 
insignificant one. With these remarks, I proceed to the his- 
tory of, 
Case I.-Large single cyst, with numerous small ones at base, 
of eighteen months1 standing; removal by ovariotomy; 
recovery. 
Eliza B., native of Ireland, aged thirty-five years, by occu- 
pation a child's nurse, of perfectly temperate habits, single, and 
previously in good health, consulted me on the 1st of November, 
1863, on account of an abdominal enlargement which she sup- 
posed to be " dropsy." About eighteen months before the 
date which I have recorded, she was startled by observing an 
enlargement about the size of a child's head low down in the 
abdomen on the right side. At first she kept the fact secret, 
but so rapidly did the swelling increase, that she sought the 
advice of her mistress, who requested a neighboring physician 
to see her. The examination of this physician led the patient 
to believe that he suspected pregnancy, although he made no 
such statement, and, being of rather a morbid disposition, she 
subsequently refused to see him or any other physician, until 
she came under my observation. 
When I saw her she was in good health, her color was 
good, appetite moderate, spirits not depressed, and pulse nor- 
mal. She stated, however, that for three months she had been 394 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
losing strength and flesh gradually, and that she was becom- 
ing troubled in respiration. 
Physical examination revealed a large globular tumor fill- 
ing the whole abdomen, and evidently pressing upward against 
the diaphragm. Fluctuation was obtained readily and clearly. 
Over the anterior face of the mass, dulness upon percussion 
existed, and the intestines were found displaced upward and 
laterally. The uterus was elevated, and anterior to the tumor. 
Regarding the case as one of ovarian cyst, I informed the pa- 
tient of my conclusion as to the diagnosis, and advised her at 
once to submit to the operation of ovariotomy. To this she 
readily consented, and all was made ready for its performance. 
A good room was procured for her, as well as a skilful nurse, 
and the 1st of December was appointed for the operation. 
The operation was performed at half-past 12, p. m. ; the 
weather was cool, snow having fallen heavily on the day pre- 
vious, but clear and bracing. 
I was assisted by Drs. T. A. Emmet, George T. Elliot, 
J. S. Thebaud, Foster Swift, and G. S. Winston. Dr. Win- 
ston having produced anaesthesia by Squibb's ether, the patient 
was placed on a table, and, after evacuation of the bladder, 
the operation commenced with an incision by a bistoury in the 
median line, midway between the umbilicus and symphysis 
pubis, involving the skin and adipose tissue. This incision 
was two and a half inches in length, my intention being to 
prolong it if I found it necessary to do so. 
Having cut down to the fibrous expansion formed by the 
conjoined sheaths of the recti, this was picked up by a tenacu- 
lum, and a very small opening made by scissors into the peri- 
tonaeum, and a grooved director inserted, upon which this 
fibrous sheath and the parietal peritonaeum were slit upward 
by the bistoury. The sac was now exposed, presenting a 
white, shining, fibrous surface. A small amount of straw- 
colored serum escaped from the peritoneal cavity, the result 
of congestion of the vessels compressed by the tumor. The 
hands having been carefully washed in warm water, two fin- 
gers were now passed into the peritonaeum and swept over the 
surface of the tumor, ascertaining the fact that no adhesions 
existed, at least in its upper part. Firm pressure being now OVARIOTOMY. 
395 
made on the sides of the incision, by the hands of an assist- 
ant, a large trocar and canula were plunged into the cyst. 
Upon the withdrawal of the trocar, there rushed from the 
canula with great violence a little less than six quarts of a fluid 
looking like the rinsings of a vessel which had contained milk, 
and having floating upon its surface some little pellets, like fat. 
The edges of the incision in the cyst were now seized by the 
fingers, and in this way the sac was drawn out of the abdominal 
cavity. It came forth without resistance, no adhesions exist- 
ing. The cyst was a degeneration of the right ovary, and at 
its base the Fallopian tube could be distinctly traced. In ad- 
dition to one large cyst, were discovered, upon inspection, six 
or eight small ones, about the size of pigeons' eggs, and one 
the size of the foetal head was emptied as the large cyst was 
drawn forth. 
A double thread of strong silver wire was now passed 
through the centre of the pedicle by means of a large needle, 
separated and twisted so as to ligate both sides of the pedicle, 
one of the ligatures encircling the right and the other the left 
portion. Another needle, similarly armed, was then passed at 
right angles to the first, and the two ligatures which it carried 
were disposed of in the same way. After this a strong ligature, 
composed of trout-line,'was fastened above the silver ligatures, 
and the sac cut off by the bistoury just above it. 
The abdominal incision was then closed by silver sutures 
one inch distant from each other. The pedicle was placed 
at the inferior angle of the wound, and kept from returning to 
the abdominal cavity by a darning-needle passed through it, 
and left with the point broken off and the extremities guarded 
by cork, at right angles to the pedicle, and flat upon the ab- 
dominal walls. A piece of patent lint, soaked in tepid water, 
was then laid over the wound, the whole abdomen covered 
with warm cotton batting, and an obstetric bandage applied 
with moderate tightness. 
After the operation the pulse was found to be 76 to the 
minute, and as voluminous as before. The patient, who was 
not yet conscious, was then placed in a warm bed, hot bottles 
were put to her feet, she was covered carefully with warm 
blankets, and in fifteen minutes had ten drops of Magendie's 396 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
solution of morphine injected into the areolar tissue of the 
arm by the hypodermic syringe. 
After this she slept quietly for between five and six hours. 
Upon awakening, she suffered slightly from nausea, but this 
soon passed off, the pulse rose to 96, but never went above 
it, and on the fourth day the bladder was emptied without 
the use of the catheter. The diet consisted almost entirely 
of milk for four days, when animal broths and farina-gruel 
were added to this. During the entire convalescence, pain 
and restlessness were quieted by the use of the hypodermic 
syringe ; and pellets of ice, iced champagne and soda-water 
were freely given for the relief of the nausea which it created. 
Seven days after the operation all the stitches were re- 
moved, except those immediately in contact with the pedicle, 
and on the eleventh day the patient, contrary to orders, sat 
up out of bed for a little while during the absence of the 
nurse. This produced no evil effect whatever; and on the 
next day the end of the stump was cut off, two remaining su- 
tures removed, the abdominal bandage tightened, and the 
patient allowed to sit up for a short time. This was now re- 
peated every day until she soon walked about the room. 
At the time of "writing this, it is six years since the opera- 
tion, and I frequently see my patient in my visits to the chil- 
dren under her charge. She is in perfect health, and has never 
suffered from the operation, the only vestige of which is, a 
cicatricial line on the linea alba that is scarcely visible. 
The fluid discharged from this sac was milky in hue, as I 
have said, and about six quarts in amount. Tested by heat 
and nitric acid, it behaved precisely like highly-albuminous 
urine, and, "when rubbed between the fingers, gave the tenacious 
sensation experienced by smearing them with thin syrup and 
water. The specific gravity of this fluid was 1012. 
Case II.-Fibro-cystic tumor, weighing 17 lbs., removed by 
abdominal section ; death from shock in forty hours. 
Mary M., a native of Ireland, aged about thirty-two years, 
married eight years, never pregnant, applied to me in Sep- 
tember, 1864, on account of an abdominal tumor accompanied 
by profuse menorrhagia. She stated that she had noticed an OVARIOTOMY. 
397 
enlargement of the abdomen about four or four and a half 
years before, but had paid no attention to it at first, as it gave 
her no inconvenience except mental anxiety on account of its 
presence. As it went on steadily increasing in size, however, 
she began to flow very freely at her menstrual epochs. This 
exhausted her to such a degree, and she had of late suffered 
so constantly from pain, distention, dyspnoea, and vesical irri- 
tation, that she strongly desired operative interference. 
I kept the patient under observation for two months, en- 
deavoring by palliative means to give her relief. At the end 
of this time, she and her husband urgently desired some more 
decided interference, and, as it appeared to me that her life 
would be sacrificed by the continuance of the symptoms which 
existed, I determined upon operating. 
At this time, physical examination revealed a large globular 
mass in the abdomen, which appeared to yield fluctuation very 
perfectly. The intestines were pressed upward and laterally, 
and percussion over the whole anterior face of the abdomen 
yielded dulness. The uterus was normal in size, and to all 
appearance unattached to the tumor, a point which was 
carefully noted. Before operation, the patient was examined 
with me by Drs. Peaslee, Budd, and Loomis, all of whom 
agreed with me, that the case was one of ovarian cyst, that 
operation was legitimate, and that the prospect of recovery 
was ordinarily good. 
The operation was performed in presence of Drs. Peaslee, 
Budd, and Loomis, the house-staff of Bellevue Hospital, and a 
large number of medical students, at 3 p. m., in a ward of Belle- 
vue Hospital which had just undergone complete renovation, 
and which contained no other patients. An incision two inches 
in length was made over the median line, midway between 
the symphysis pubis and umbilicus. When the conjoined 
sheaths of the recti were reached, the operation was arrested 
until all oozing had ceased; then the sheath was caught up 
by a tenaculum, a small opening cut, a grooved director passed, 
and upon it a bistoury slid up so as to open the peritonaeum. 
The anterior wall of the tumor being then exposed to view, a 
steel sound was dipped in warm water and passed around it 
in search of adhesions, but none wTere discovered. 398 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Palpation of the tumor was now practised by myself and 
the gentlemen who aided me, and, as it appeared to us all cer- 
tain that it consisted of a sac filled with fluid, I plunged in a 
large trocar and canula. To my surprise, instead of a gush of 
fluid, a free flow of blood occurred, and, withdrawing the trocar, 
I found that the tumor was not a sac filled with fluid, but a 
cystic sarcoma. The flow of blood from the deep wound made 
w'ith the trocar was so free, that it was thought best not to 
abandon the operation, but to extirpate the tumor. Accord- 
ingly, I enlarged the incision to about five inches in length, 
and very readily turned it out of the abdomen. The pedicle 
was soon discovered on the left side ; it w'as small, but very 
short. Ligating this with a strong cord made of silk threads, 
I cut it close off, and returned it to the abdomen. The wound 
was then closed by interrupted silver sutures which involved 
the peritonaeum, and dressed with cold-water dressing, held in 
place by the obstetric bandage. The patient, who had been 
kept under the influence of ether not quite an hour, was now 
put to bed, and warm bottles were applied to her feet, and ten 
drops of Magendie's solution of morphine were thrown into the 
areolar tissue of the arm by the hypodermic syringe. 
Just after the operation I felt the pulse, found it beating at 
the rate of 160 to the minute, and so feebly as to give me great 
apprehension as to whether the patient would not die on the 
table. After she had slept for an hour, the pulse sank to 
140, and became stronger, but it never became less frequent. 
When consciousness was restored, the patient seemed much 
depressed in mind, declared that she knew she was going to 
die (she had been quite sanguine before the operation), moaned 
constantly, and looked wild and unsettled. Throughout the 
next day this singular condition continued. She took milk- 
punch when urged, but desired no food, and nothing to drink 
except ice water. I saw her at midnight on the second night 
after the operation, and it was then evident that collapse was 
approaching. In spite of continued dry warmth kept up at 
the feet, and as high as the knees, the extremities became cold; 
a clammy perspiration broke out over the whole surface, and 
toward morning the patient died. OVARIOTOMY. 
399 
A post-mortem examination revealed no trace of perito- 
nitis and no secondary haemorrhage. 
The tumor, when placed upon a table and palpated, was 
so deceptive in its apparent yielding of fluctuation, that it was 
even then declared to contain fluid which had not been 
reached by the trocar, and this view was entertained until it 
was bisected. It was found that it consisted of loose fibrous 
elements, forming numerous loculi, about the size of a hickory- 
nut, which were filled with a honey-like material. After sec- 
tion had allowed what was computed as about three pounds 
of this material to flow away, the tumor weighed a little 
more than fourteen pounds. 
To one not familiar with the difficulties attendant upon the 
diagnosis of these cases, and their differentiation from cystic 
disease, it may appear astonishing that so grave an error 
should have been made in this case. They who have encoun- 
tered them will readily agree that not only is diagnosis very 
difficult, but often impossible, without exposing the patient to 
the risks of paracentesis. In this case I did not resort to this 
explorative procedure, because my mind did not admit a 
doubt as to the true nature of the tumor. On two other occa- 
sions I was, with others, similarly deceived: one was a case, 
that I saw in consultation with Dr. Peaslee, and in which he 
subsequently made an explorative incision that proved fatal; 
the other was removed by a long abdominal incision by Dr. 
O'Reilly, the patient dying on the seventh or eighth day. 
Case III.-Alveolar cancer of left ovary; ascites ; removal 
of cancer ; return of pedicle to abdomen ; death of patient 
on eighth day.fr om septicaemia. 
Mary McC., aged twenty-one years, single, a cook by occu- 
pation, was sent to me by her employer on account of an ab- 
dominal enlargement. Upon examination I found her very 
sallow, almost jaundiced in appearance, very large about the 
abdomen, and exceedingly weak. She informed me that just 
one year before that time, she had noticed a slight abdominal 
enlargement, which had steadily and rapidly increased. At 
the same time she had emaciated rapidly, grown very weak 400 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
and low-spirited, and now felt that, unless relieved very soon, 
she would die from exhaustion. 
Physical exploration revealed a large accumulation of 
fluid in the peritongeum, and, in addition, a round tumor oc- 
cupying the whole of the left side of the abdomen. 
Although the case was not looked upon as a favorable one 
for operation, it was determined that, since extirpation offered 
the best chance for the saving of life, it should be resorted to. 
Accordingly, in the presence of Drs. Otis, Swift, Reynolds, 
Finnell, and Hull, I undertook the operation. 
The patient having been anaesthetized with ether, I cut 
down slowly through the abdominal walls into, the perito- 
naeum. Instantly a large amount of peritoneal fluid escaped, 
a much larger amount, indeed, than had been computed in 
the diagnosis. After its escape, I found in the left side of the 
abdomen a solid mass about the size of a large cabbage, 
and resembling in feel and appearance an ordinary cauli- 
flower. This was attached to the broad ligament at about the 
point ordinarily occupied by the ovary. It was too large for 
removal through the small opening which I had made, but 
this being enlarged, it was readily turned out. Securing the 
pedicle, which was short, by two strong hempen ligatures 
passed through its centre, it was returned, after removal of the 
growth, to the abdomen, and the abdominal incision closed by 
interrupted silver sutures. 
The patient rallied well after the operation. She was kept 
upon beef-tea, milk, and gruels, and quieted by administration 
of opium. Her pulse kept up to about 100, respiration was 
normal, and nothing existed to excite alarm except the ex- 
treme nervous depression of the patient. She asserted that 
she would certainly die, and really seemed convinced that 
such would be the case. With the exception of this symptom 
she appeared to be progressing favorably until the seventh 
night. Then she seemed more than usually nervous and ex- 
citable, and desired to see the priest, who was accordingly 
sent for. 
On visiting her early on the morning of the eighth day, 
I found that a great change had come over her during the 
night. Her eyes were wild and haggard, her face maniacal, OVARIOTOMY. 
401 
her tongue red and dry, and she constantly talked in an inco- 
herent and violent manner, as is so often found to be the case 
in puerperal mania. As I entered the room, she covered her 
head with the bedclothes, and screamed out that I had 
leagued with the priest to murder her. Nothing would pacify 
her, or dissuade her from this view. After soothing her for 
some time, I succeeded in getting near enough to her to find 
that the pulse was beating at 160 to the minute, and that the 
breath yielded a sweetish odor like sugar-cane. I was now 
convinced that she was suffering from septicaemia, and that the 
mania which had supervened was due to it. But, even with 
this knowledge, nothing could be done in the excited state of 
the patient. She remained in the maniacal state which I 
have described till evening, when she sunk into coma and 
died, post-mortem examination could be obtained. 
Case IV.-Multilocular ovarian cyst; removal by short in- 
cision ; pedicle ligated with silk, and returned to the ab- 
dominal cavity • recovery. History recorded by Dr. Jas. 
L. Brown. 
Miss C. W., twenty-two years of age, consulted Dr. Thomas 
in the early part of December, 1867, with reference to an ab- 
dominal tumor which she had first noticed nearly a year pre- 
viously, and which had been growing rapidly during the past 
six or seven months. 
She stated that her general health had been excellent until 
September, 1866, when there began to be some irregularity in 
her menses. The periods became more frequent, occurring at 
intervals varying from eight days to a fortnight, the duration 
and quantity of the flow being about the same as before. In 
a short time her general health began to be impaired, and 
medical advice was sought on account of the menorrhagia 
which was supposed to be the cause of her ill health. Failing 
to receive any benefit from the physician first consulted, other 
advice was sought, and no less than twelve physicians, nearly 
all of them homoeopathic practitioners, were consulted with- 
out avail, before Dr. Thomas was asked to see the case. No 
vaginal or other physical examination was ever made or pro- 
posed by any of these gentlemen. The existence of the tu- 402 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
mor in the abdomen was first noticed by Miss W. some three 
or four months after the disturbance of the menses. At first 
she merely observed a hardness, which seemed to make its ap- 
pearance with the menstrual flow and subside with its cessation. 
In a few weeks, however, this hardness was found to be persist- 
ent and to be steadily increasing in area. With the growth of 
the tumor there was a corresponding depreciation of the pa- 
tient's health, which had become very greatly impaired when she 
first was seen by Dr. Thomas. The menorrhagia was persistent 
during the whole of this period, the intervals never exceeding 
two weeks, and rarely extending beyond ten or twelve days. On 
examining the case, Dr. Thomas found no difficulty in recog- 
nizing the presence of a cystic tumor of the ovary, and recom- 
mended its removal by ovariotomy. The recommendation 
was accepted by the patient and her friends, and the opera- 
tion performed December 15,1867, by Dr. Thomas, with the 
assistance of Drs. E. R. Peaslee, J. B. Reynolds, Mintzer (of 
Philadelphia), and J. L. Brown. The external incision through 
the integuments was about three and a half inches in length, 
the internal incision through the peritonaeum being about half 
an inch less. The tumor was found to be multilocular, and 
the main cyst on being tapped discharged a chocolate-colored 
fluid of about the consistence of cream. A second cyst about 
half as large contained a clear gelatinous fluid of much greater 
consistency. After evacuating these and several smaller cysts, 
the sac was readily removed through the opening, no adhesions 
existing anywhere. The pedicle, which sprang from the 
right side, was transfixed by a needle armed with a double 
silk ligature and tied in segments, each ligature including one- 
half of it. The actual cautery was then applied to the cut 
edge, and the charred portions pared off with a scalpel, after 
which the pedicle was returned to the abdomen. 
A small quantity of blood which had found its way into 
the pelvic cavity was then carefully sponged out, and the 
wound was closed with six wire sutures, between which were 
inserted five pins after the manner practised in operations for 
harelip. A layer of soft cotton was placed over the wound, 
and an ordinary obstetrical bandage around the abdomen. 
The patient was then placed in bed, and ten drops of Magen- OVARIOTOMY. 
403 
die's solution of morphine administered. The whole dura- 
tion of the operation, including the anaesthetizing, was just 
two hours. 
8 p. m.-Patient entirely recovered from the effects of the 
ether. No pain or nausea. Pulse 84, and tolerably full. 
16^, 9 a. m.-Passed a comfortable night, but did not 
sleep much. Pulse 86. No pain or nausea. Used catheter. 
8| p. m.-Begins to be troubled with flatus. Otherwise com- 
fortable. Pulse 108. No nourishment except two tumbler- 
fuls of milk. Has been kept moderately under the influence 
of morphine. Used catheter. 
17^4, 8^ a. m.-Passed a good night. No morphine since 
9 last evening. Pulse 84. Skin cool and comfortable. Mind 
bright and cheerful.-12 p. m. Condition about the same as 
in the morning. Has thus far taken no nourishment but 
milk, of which she drank about a quart to-day. No trouble 
from flatus since yesterday. Still obliged to use catheter. 
18&4, 9 a. m.-Passed a good night. Pulse 84. Condition 
about the same as yesterday morning.-11 p. m. Has taken 
no morphine in twenty-four hours. Begins to suffer from irri- 
tability of the bladder; otherwise quite comfortable. Pulse 
88. Milk diet only. 
19/A.-Suffering some distress from irritability of the blad- 
der ; otherwise comfortable. In the evening was able to evac- 
uate the bladder without the catheter for the first time since 
the operation. All the pins were removed to-day. Pulse 90. 
20^4.-Pulse 96. All the sutures taken out to-day. Pa- 
tient comfortable, but quite weak. Ordered egg-nogg, sherry 
wine, and quinine. Pulse rose in evening to 108. 
21sA-Better in every respect. Pulse 86, and full. 
The convalescence of the patient 5^as now uninterrupted 
until the 31st of December, when she was taken with an at- 
tack of peritonitis, which was confined to the right iliac region, 
and which, although it assumed quite a threatening aspect for 
two or three days, finally yielded to treatment, and the patient 
made a good recovery. The menstrual function was reestab- 
lished about two months after the operation, and has since 
been perfectly regular in every respect. 404 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
P. S.-Since the foregoing account was written, the patient 
has been married. 
Case V.-Multilocular ovarian tumor ; removal by short in- 
cision ; pedicle treated by clamp • recovery. 
Mrs. Y., aged forty years, a native of New Jersey, married, 
and the mother of a large family, consulted me in the month 
of March, 1869, by advice of Dr. Van Riper, of Passaic, under 
whose care she had been. The patient was a thin, wiry, and 
enduring woman, who had enjoyed good health up to one year 
before the time at which I saw her. At that time she noticed 
an abdominal enlargement. This gave her no anxiety, as she 
supposed it to be due to pregnancy. She was somewhat sur- 
prised, however, to find that, in spite of its steady increase, 
she still menstruated, and as her periods occurred every two 
weeks after the sixth month was passed, she became alarmed 
and sought medical advice. For about six weeks before the 
operation which I am about to. describe, she suffered from 
abdominal pain, but until that time she had not done so. 
About the same time she lost appetite, became somewhat de- 
pressed in spirits, and failure in strength and flesh was ob- 
served. 
When I saw the patient in March, I found an irregular 
nodulated tumor filling the abdomen. Toward the left 
lateral surface of the mass a protuberance, equal in size to the 
head of a newly-born infant, was formed, and below this 
others of less size could be discovered. Percussion over the 
abdominal surface yielded dulness, and palpation gave fluctu- 
ation distinctly. Vaginal touch revealed the uterus pressed 
forward and upward, and discovered no protrusion in Doug- 
las's cul-de-sac. , 
I looked upon the case as one of multilocular ovarian cyst, 
and advised operation, which was determined upon, and ac- 
cordingly performed on the 26th of April, 1869, in presence of 
Drs. Willard Parker, C. Van Riper, Robert Stewart, W. J. 
Cadmus, J. II. Kenworthy, Garnet Terhune, R. A. Terhune, 
James L. Brown, and W. Linsley. 
The day was clear and the weather very comfortable. The 
patient being placed upon her back, on a firm table, before a OVARIOTOMY. 
405 
window admitting a good light, ether was administered by 
Dr. Stewart. I then made an incision of two inches in 
length in the median line, exposed the tumor, and plunged in 
a large trocar and canula. There instantly gushed forth an 
albuminous looking fluid, which flowed until the largest cyst 
was emptied. Then turning the canula so as to plunge it into 
two others, which were quite large, I emptied these, and. easily 
withdrew the sac, which was free from adhesions. The pedicle 
was then secured by a clamp, and the wound closed by inter- 
rupted silver sutures. 
The time occupied in the operation was forty-five minutes ; 
the weight of the tumor twenty pounds; and the amount of 
fluid removed from it a little over two gallons. 
Subsequent to the operation the case was carefully watched 
by Drs. Van Riper and Stewart, and the details which follow 
are taken from notes by the latter gentleman. 
" Three hours after the operation, pulse 60, slightly inter- 
mittent ; surface cold; expression natural; no pain; says she 
feels happy; urine voided naturally; slight nausea. One 
grain of opium was given in pill. 
27?A.-Rested well; expression good; no pain; 
pulse 70; tongue clean; urine voided naturally; respirations 
20 to the minute. She was given to-day beef-tea and milk, 
and just enough opium to quiet restlessness. 
"April ^th.-Called to patient on account of great pain 
down left thigh ; drew off urine with catheter, and gave one 
grain of opium, which relieved her. Pulse 60; respiration 20. 
" April -Pulse 72 ; respiration 20 ; stump dressed 
with carbolic acid." 
From this time onward the notes vary so little from those 
just given that it is useless to state them. The patient went 
on to recovery without an unfavorable symptom. On the 
seventh day after the operation the clamp was removed and 
the sutures withdrawn. The whole abdominal wound was 
found closed by first intention, except just around the pedicle. 
In a fortnight after removal of the tumor, the patient sat up in 
bed. Now, six months after the operation, she declares her- 
self to be in better health than she has experienced for many 
years. 406 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
Case VI.-^Lultilocular ovarian tumor ; firm adhesions; 
pedicle treated hy clamp ; recovery. Notes by Dr. Benja- 
min Biggs. 
Johanna Murphy, aged forty, born in Ireland, a widow, 
was admitted to Bellevue Hospital, April 29, 1869. 
The patient states that she has borne three children ; that 
all her confinements were natural, and without bad results. 
She menstruated regularly till September, 1868, when she 
was seized with flooding two weeks before the proper time of 
menstruation. During the three months following she did not 
menstruate at all. In October, 1868, she first noticed a swell- 
ing of the abdomen, which since that time has steadily in- 
creased, but she does not know that it commenced on either 
side. From January to March, 1869, she menstruated regu- 
larly. In March she had a second attack of flooding, lasting 
six days, and leaving her very weak. Two weeks before ad- 
mission was flooding for about a week, and was much reduced 
in strength. 
Physical Signs on Admission.-The patient has a tumor 
of the abdomen, fluctuating at all points, dull on percussion, 
excepting tympanitic resonance on the left side, extending from 
the ensiform-cartilage to the pubes. Measurement between 
anterior-superior spinous process through the umbilicus twenty 
and a half inches, largest girth thirty-five and a half inches. 
On vaginal examination, the uterus is found movable, and 
no fluid seems to fill the cul-de-sac. The tumor does not seem 
to sag much in the flanks when the patient lies down. Some 
abdominal pain is complained of, and the patient is low-spirit- 
ed, wanting in appetite, and somewhat emaciated, though al- 
ways of spare habit. There seems to be some mental derange- 
ment : she attributes her tumor to a rattlesnake which she sup- 
poses she swallowed while drinking from a pool some time 
ago. 
In May diuretics were tried without effect upon the tu- 
mor, which increased steadily though very slowly. During the 
early part of June a tonic treatment was adopted, and a gen- 
erous diet with some stimulants allowed, preparatory to an 
operation. In May and June there were several irregular 
and small discharges of blood from the uterus. OVARIOTOMY. 
407 
On the 18th of June, the patient was in fair condition and 
spirits, and Dr. Thomas decided to operate. An anaesthetic 
being given, an incision about two inches long was made in 
the median line between the umbilicus and the pubes. On 
reaching the sac, a trocar was introduced with a canula of such 
construction that the sac and external coverings were clamped 
together, and leakage into the peritonaeum prevented. Sev- 
eral cysts were now discovered and successively emptied. The 
large one, which was first reached, contained clear, viscid fluid 
in large quantity. Two others contained grumous fluid full of 
flocculent lymph. The whole tumor was but slightly adherent 
in front, more strongly attached behind and below. 
After evacuating all fluid contents and separating the at- 
tachments, the mass was withdrawn through the original open- 
ing, which was slightly enlarged before this could be done. 
The pedicle, of considerable length, was cut and retained by a 
clamp outside the wound, which was sewn up so as to grasp it 
tightly. Immediately after the operation there was consider- 
able shock. About thirty minims of Magendie's solution of 
morphine were given hypodermically through the night, and 
eight ounces of whiskey by the mouth. Next day the pulse was 
full and under 100, no pain or restlessness. Urine drawn 
off every four hours. Wound dressed with weak solution 
of carbolic acid. In the evening there were restlessness and 
some vomiting; skin hot and pulse rapid. Fifteen minims of 
Magendie's solution of morphine were given as before. 
June 26 th, a. m.-Slept badly. Stomach irritable all 
night. Fifteen minims of the morphine solution were given 
hypodermically. 
June 21s^.-Better, pulse about 80. Ilas some appetite. 
June 22d.-Pulse 80. Scarcely any pain. Condition im- 
proving. 
June 23d and 2Mh.-Pulse about 100. Appetite and gen- 
eral condition still improving. 
June 25th.-A week, less five hours, after the operation, 
the clamp was removed. A small abscess in the abdominal 
walls opening into the wound, treated by charcoal poultices. 
June 26th.-Bowels moved twice spontaneously. From 
this time convalescence went on rapidly without a bad symp- 408 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
tom, and the patient was discharged perfectly well about the 
end of July. No abnormal increase in the size of the abdo- 
men occurred from the time of operation until that of dis 
charge. 
Case VII.-Niultilocular ovarian cyst; removal of four- 
fifths of the sac ; pedicle and ligatures left in the vagina ; 
death from peritonitis. 
Mrs. Van T., a native of Holland, forty-five years old, 
married, mother of one child ; was seen by me in consultation 
with Dr. N. S. Drake, of Brooklyn, in June, 1869. 
The tumor had been first observed about eighteen months 
before I saw her, and had steadily increased in spite of a va- 
riety of plans of local and general treatment which had been 
pursued under the advice of physicians whom she had con- 
sulted before calling upon Dr. Drake. No diagnosis had 
been made before Dr. Drake saw her. He at once recognized 
the nature of the case, and requested me to see her in reference 
to operation. 
The patient, at the time I first saw her, was in good gen- 
eral condition, not emaciated, and cpiite hopeful as to the issue. 
The abdominal surface yielded dulness on percussion, and the 
sense of fluctuation could be readily appreciated. As there 
were no obscure points to be settled by paracentesis, I pro- 
posed operation at an early day. This was gladly acceded to, 
and accordingly on Sunday, June 27th, ovariotomy was per- 
formed in presence of Drs. Drake, Hutchison, G. K. Smith, 
Turner, Simmes, and Mulhallan, of Brooklyn; and Drs. Peas- 
lee, Sands, and Jas. L. Brown, of New York. 
The patient having been brought fully under the influence 
of ether, an incision three inches long was made over the me- 
dian line between the symphysis pubis and the umbilicus. The 
peritonaeum being reached, a steel sound was swept over the 
circumference of the tumor, and by it universal, though very 
delicate, adhesions were found to exist. These were readily 
broken down, and a large trocar and canula were plunged into 
the cyst. A clear fluid like spring-water flowed away, and the 
cyst collapsed. This fluid was found to be slightly albumi- 
nous by the tests of heat and nitric acid. It resembled pre- OVARIOTOMY. 
409 
cisely that which flows from cysts of the broad ligaments, al- 
though this cyst was certainly one of ovarian character. 
Traction being made upon the emptied sac, it came forth 
for about four-fifths of its extent, but farther than this it 
could not be drawm. I then enlarged the abdominal opening, 
and found that from the pelvis sprang extensive and powerful 
adhesions which bound down the whole base of the sac. I 
strove to break these, but it was slow and painful work, and in 
the end I was forced to leave in the abdomen about one-fifth of 
the sac. The pedicle was so short that I could not employ a 
clamp, and so large that I dared not leave it in the abdomen. 
I therefore secured it with a strong hempen cord, cut an open- 
ing into the vagina through Douglas's cul-de-sac, and left cord 
and pedicle in the vagina. 
The peritoneal cavity was now so filled with clots of blood, 
that I did not wish to keep the patient anaesthetized for so 
long a time as sponging them out would require, so I intro- 
duced through the abdominal opening the long nozzle of a 
Davidson's syringe, and cleansed the abdomen by a stream of 
warm water which swept all accumulations before it as it es- 
caped into the vagina. 
The patient was under the influence of ether from 3 to 5 
o'clock. The pulse, which wTas 80 to the minute at the com- 
mencement of the operation, remained so until the evening of 
the next day, about twenty-four hours, when it rose to 112. 
Symptoms of peritonitis then developed themselves, and she 
died on Wednesday at 5 p. m., precisely seventy-two hours after 
the operation. Subsequent to the operation she wras fed on 
beef-tea and milk, pain relieved by opium, and the bladder 
kept empty by the catheter. 
Case VIII.-Alveolar cancer of both ovaries; removal 
by ovariotomy ; pedicles treated by actual cautery ; death 
from peritonitis. Notes by Dr.BENjamin Riggs. 
" Elizabeth Harrison, aged twenty-seven, born in New York, 
married, was admitted into Bellevue Hospital, April 28, 1869. 
" Patient is a remarkably robust woman. Has been married 
for two years, but has never been pregnant. She menstruated 
regularly every three weeks till January, 1869. Since January 410 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
menstruation lias been irregular and painful, occurring, on an 
average, about once in two weeks, with a greatly increased 
loss of blood. In January she first noticed a swelling in the 
left iliac fossa. Pain in the same region commenced about a 
week later. This swelling has rapidly increased, accompanied 
by a good deal of pain. The tumor is pyriform ; no sagging 
in the flanks. Obscure fluctuation only can be felt. June 9th, 
the abdomen is very full and tense, and there is excessive pain. 
The fluctuation is very obscure, and Dr. Thomas thinks the 
tumor may be colloid cancer. An exploratory trocar brought 
away fluid. Tapping was at once resorted to, and from four to 
five gallons of clear fluid were evacuated, to the patient's great 
relief. The fluid was alkaline, viscid, and highly albuminous. 
For four days the patient was kept quiet by opiates, some 
soreness being complained of in left iliac fossa. This had dis- 
appeared on the fifth day, and the bowels were moved by enema. 
It was determined, with patient's consent, to perform an oper- 
ation for the removal of the tumor, now presumed to be an 
ovarian cyst. 
"June 26th.-Bowels thoroughly moved. June 27th, one 
grain of opium night and morning. June 28th, a. m., one grain 
of opium. 2£ p. m., after freezing the parts, an incision was 
made down to the sheath of the rectus muscle, extending in the 
median line from an inch below the umbilicus nearly to the 
pubes. The fat through which the incision was made was fully 
three inches thick. By 3^ p. m. all oozing from the wound hav- 
ing ceased, the patient was anaesthetized, and the incision car- 
ried down to the peritonaeum, which since the tapping had par- 
tially refilled, but the abdominal walls were by no means tense. 
On opening this membrane, there was a gush of clear yellow 
fluid, and exploration showed that no ovarian cyst existed ; the 
fluid present being contained in the peritoneal sac. Attached 
to each ovary were found soft fungous growths-these were re- 
moved, and the parts from which they sprang seared with a 
red-hot iron. The peritonaeum was washed with a weak so- 
lution of common salt, and, all haemorrhage having apparently 
ceased, the wound was closed. Deep quill sutures were used, 
and the superficial edges of the wound were held together by 
pins and twisted silk at some points, at others by ordinary in- OVARIOTOMY. 
411 
terrupted wire sutures. Anaesthesia -was continued, in all, one 
hour and a half. Immediately before the administration of 
the anaesthetic, ten minims of Magendie's solution of mor- 
phine were given hypodermically. 
" After the operation, the patient slept through the after- 
noon and evening till about midnight, when there was some 
vomiting. Toward morning there was recurrence of vomit- 
ing, and she suffered pain in the abdomen. Her pulse was 105. 
About half a grain of morphine Was given during the night. 
" June ^th, 10 a. m.-Abdominal pain is complained of. 
Pulse 120; quarter-grain of morphine given ; 2 p. m., vomits 
considerably. Later in the afternoon febrile excitement ran 
high, but she complained less of pain. During the night mor- 
phine was given. 
" June 3Qth, A. m.-Pulse diminished in frequency and hard- 
ness ; skin cooler. At night she grew worse again, pulse 140 ; 
skin hot and dry. Toward midnight she became quieter, and 
slept. 
" July \st.-Vomits a good deal this morning ; p. m., vom- 
iting persistent; pulse 120. She takes nothing but a wine- 
glassful of champagne every half hour, followed by a little 
carbonic-acid water. 
" July ^d.-Vomiting persisted, and pulse remained about 
120 till 3 a. m., when the patient began to fail in strength, 
the pulse increasing in frequency. The extremities became 
cold, and her face was covered with a clammy sweat. At 
noon the pulse was 140, and irregular; at 2 p. m., 165; at 
4 p. m., she died. 
" Autopsy, July 3d.-Brain not examined. Heart 11 oz. in 
wreight; flabby; valves normal. Lungs-hypostatic conges- 
tion at their bases; the right lung adherent. Liver, 3 lb. 
10 oz. in weight; adherent to diaphragm and stomach by old 
false membrane. Kidneys-nothing noticeable; weight 10 oz. 
Spleen, 3 oz. Bladder-mucous membrane congested. 
"An incision 74 inches long, extended through the abdomi- 
nal walls and peritonaeum. Peritonaeum separated from rectus 
muscle at its lower portion, and the cellular tissue at this point 
partly gangrenous. All the intestines adherent to each other 
and to the abdominal walls by recent lymph. Peritoneal cavity 412 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
contains about 8 oz. of dirty-brownish sero-purulent fluid. 
There is considerable injection of peritoneal vessels. 
" The organs in, the pelvis adherent to one another by old 
false membranes. Left ovary gone, its site marked by lacerated 
tissue. Right ovary lacerated at one point, the major part of 
it remains in situ, it is swollen and vascular, and its vesicles 
for the most part contain small clots of blood. 
"Fallopian tubes, convoluted, dilated, adherent; the left 
contains bloody muco-pus. 'Uterus contains nothing but a 
small mucous polypus in its body." 
I have spoken of this case and of Case III., as instances of 
alveolar cancer, not because I regard them as being true car- 
cinomatous disease, but because the question of their pathology 
is not settled, and I prefer rather to abide by the old nomen- 
clature than to discuss the matter. From a clinical stand-point, 
they certainly do not appear to belong to the family of true 
cancer. The appearance of the patient, the hue of the com- 
plexion, and the constitutional condition of those who are 
affected by them, seem to contradict such a supposition. To 
the touch and sight they resemble very closely cauliflower 
growths of the cervix uteri, and seem to belong to the family of 
vegetating epithelioma. My colleague, Dr. H. B. Sands, kindly 
examined for me a portion of the growth taken from Case VIII., 
and thus describes its appearance under the microscope. 
" Sections of the tumor, when examined under the micro- 
scope, exhibited the following elements: 1. Connective tis- 
sue, slightly vascular, arranged in the form of villi, either club- 
shaped or conical. 2. Flat epithelium, in several layers, 
covering the villi, but not present in their interior. The ap- 
pearances observed were those commonly seen in epithelial or 
cauliflower growth." 
Case IX.1-^Lultilocular cyst, containing numerous large 
cysts; removed by short incision ' pedicle treated by 
clamp ; recovery. Notes by Dr. C. S. Ward. 
Annie Farrell, aged fifteen years, single, presented herself 
at the clinic at the College of Physicians and Surgeons, Octo- 
ber 15, 1869, on account of an abnormal enlargement, which 
1 This case received while passing through the press. OVARIOTOMY. 
413 
she first noticed about one year and a half before, and which 
had been steadily increasing until it had now attained a size 
exceeding that of the uterus at full term of pregnancy. At 
the age of thirteen she menstruated once, since which time 
there has been no menstrual flow. Owing to this circumstance 
she had been led to believe that her increased size might be 
due to retention of the menses; in fact, she stated that this 
opinion had been expressed by some physician whom she had 
consulted. She first noticed the tumor in the left iliac region ; 
it appeared to be smooth, and globular in shape. Five or six 
months later she noticed that it began to be irregular in out- 
line and nodulated. Within the last three months her general 
health had begun to fail, and she became much reduced both 
in flesh and strength. Her face was pale and sallowT, and her 
general appearance cachectic. On physical examination the 
abdomen was found distended with a fluctuating tumor, im- 
bedded in which could be felt three smaller tumors of firm 
consistence. These were on the left side, and conveyed the 
impression of being solid masses. With a view to facilitate 
diagnosis as wTell as to afford temporary relief to the patient, 
Dr. Thomas tapped the tumor on the following day ; about a 
gallon of clear fluid, of the consistence of thick mucilage, was 
discharged, which greatly relieved the patient. The seem- 
ingly solid tumors could now be felt more distinctly, and con- 
veyed the feeling of obscure fluctuation. 
The girl's general condition became much improved, al- 
though the tumor began to refill, and at the end of three weeks 
was again as large as before. Ovariotomy now being the only 
resource, this operation wTas resorted to on the 4th of Novem- 
ber, 1869, in the presence of Drs. Peaslee, Budd, Norcom (of 
N. C.), Burgess, Bowe, James L. Brown, H. F. Walker, and 
C. S. Ward. The patient being fully anaesthetized, an incision 
three inches in length w'as made in the median line, midway 
between the umbilicus and symphysis pubis, down to the peri- 
tonaeum ; after all haemorrhage had ceased, this was lifted, 
snipped, and slit upon a director, allowing a slight flowr of 
serum, and exposing the tumor. A sound was swept around 
the tumor, and only one or two slight adhesions found, which 
were gently broken. A trocar was then plunged into the 414 
BELLEVUE AND CHARITY HOSPITAL REPORTS. 
principal sac, which discharged a clear fluid like that drawn 
off at the previous tapping, and through this sac about a dozen 
other cysts of various sizes w'ere punctured and the contents 
evacuated. The fluid in all these sacs was clear and limpid, 
but in some of much greater consistence than in others. All 
the cysts being emptied, the sac was readily drawn out and the 
pedicle secured by a clamp; the tumor was then separated and 
the actual cautery applied to the cut surface of the pedicle. 
The other ovary was examined and found normal. The peri- 
toneal cavity was carefully cleansed by soft sponges squeezed 
out of warm water. The wound was closed by five sutures of 
iron wire passed through the skin and peritomeum, the pedicle 
being left at the lower angle of the incision; a pledget of lint 
soaked in a carbolic-acid solution was laid over it, and a binder 
applied, as after parturition. Five minims of Magendie's solu- 
tion were injected subcutaneously and the patient placed in 
bed. Time of operation forty minutes. 
Progress of Case.-November ^th.-At 4.30 (immediately 
after operation) pulse 88 ; 10.30 p. m., 104; f gr. morphia given. 
November 5th.-9 a. m., pulse 100 ; rested well during the 
night; 6 p. m., pulse 122; skin moist, sleeping quietly, has had 
no pain. 
November ^th.-9 a. m., pulse 120; took £ gr. morphia last 
night and rested well; 6 p. m., pulse 104; patient cheerful 
and comfortable, has taken three pints of milk and six ounces 
of beef-tea to-day. 
November 7th.-10 a. m., pulse 102; rested well during 
the night; no morphia given; 6 p. m., pulse 100; patient in 
fine spirits ; has taken milk, toast, beef-tea and steak. 
The patient has complained of no pain since the operation, 
no tenderness on pressure, no tympanites, wound looking well. 
Subsequent to this period the patient has gone on steadily im- 
proving until the date at which this manuscript goes to press, 
November 8. 
In this report are embodied nine cases of ovariotomy. Five 
of them resulted favorably and four unfavorably. Out of the 
four unfavorable cases, two were instances of so called alveolar 
cancer, one a solid tumor, and one a cyst, the whole of which 
could not be removed. Six cysts were operated upon. Of OVARIOTOMY. 
415 
these, five recovered, and that which ended fatally was a case 
in which one-fifth of the sac had to be left in the abdomen. 
The operation of ovariotomy was only in two cases preceded 
by that of paracentesis. This was due to my desire to avoid 
an additional risk to my patients. I believe, however, that, in 
thus avoiding paracentesis, I committed a grave error. A 
more frequent resort to it would have cleared up many obscuri- 
ties as to diagnosis, and thus prevented resort being had to 
ovariotomy in at least one of my fatal cases. My experience 
thus far will induce me, in the future, to resort to it much 
more generally than I have done in the past. 
Case IX. recovered without an unfavorable symptom. 
The clamp was removed and sutures withdrawn on the eighth 
day. ADDENDUM. 
To the article by Professor Taylor, On Amputation of the 
Cervix Uteri in Certain Forms of Procidentia, and Remarks 
on the Complete Eversion of the Cervix Uteri, page 33, add 
the following: 
Since this paper was prepared for publication, eighteen 
months ago, eight more cases have been operated upon, mak- 
ing, in all, eighty-four cases, with thirty-four favorable results. 
Some of these last cases have been retained in the Bellevue and 
the Charity Hospital for several months, and have been seen 
by those interested in the results. The uterus retains a nor- 
mal position, the os tincae being two and a half inches from 
the vulva.